as it were, upon the normal energies of the system, or taking their place, such as we find to be the character of malignant disease; nor, on the other hand, is it identical with the effusions of blood-constituents which result from an exaltation of the normal energies, and continue in possession of their vitality, by which they are susceptible of organisation. This we do not see in tubercular deposit, which must be viewed as bearing to the diathesis giving rise to it, very nearly the same relation as, to use the strongest comparison that suggests itself to us, calculus in the bladder bears to the calculous diathesis to which it is due. There is, unfortunately, no such emunctory for the effete protein compounds, as there is for the excess of saline constituents of the blood; or tubercle might accumulate, as the latter do, at a given point, and the product be removed by operative proceedings, or by chemical solution. The Jungs and the skin have this duty to perform; but I need not stop to point out to you why we have not yet succeeded in destroying the tubercular product in the former, and removing it from them, by direct applications. I do not myself despair of a remedy being discovered which, in a gaseous form, may be conveyed to the deposit in the lungs, and, by dissolving it, enable the patient to expectorate it; but this would only affect a single organ. The cachexia leading to the local product will ever remain the real malady to deal with, so that we may anticipate its local effects.

The changes which take place in the deposit itself, and which have been the source of much discussion, and of some very wild speculations, are, as I have already observed, closely allied to what we see taking place out of the human body in inorganic substances. They seem to follow the laws regulating crystallisation and chemical decomposition rather than those of vital action.

The earliest form in which tubercle presents itself to the eye is that of a faintly granular blastema, in which we are only just able to trace a tendency to aggregation into circular forms.

The next form which we find tubercle presenting is that of more definite corpuscles; they offer an oval form, with a more or less sharp outline, and a granular surface. These corpuscles are surrounded by the granular blastema before mentioned, which now becomes more definitely marked, and by and by appears to eliminate oil-globules in a greater or less quantity. The tubercular corpuscle does not present a nucleus as its normal constituent; it is, in fact, regarded by some, among whom I may be allowed to mention Dr. H. Jones, as itself a nucleus. We occasionally find cells with nuclei in tubercular matter, but I am inclined to think that they are generally, if not always, derived from the normal tissues of the organs in which the deposit has taken place.

A term has of late been brought into vogue by the authority of great names, to which, before concluding this brief sketch, it is necessary that I should allude, as the subject to which it refers is closely associated with tubercular disease. I refer to fibrinous deposits. Many of the cases which are thus denominated present no differences perceptible, either to the naked eye or under the microscope, by which we can distinguish the product from tubercle; and in such it is scarcely in accordance with sound induction to assume a different disease, until we are able to demonstrate a distinct primary lesion in the blood.-Association Med. Journal, May 27, 1853, p. 451.

35.-ON THE TYMPANITIC SOUND, PRODUCED BY PERCUSSION OF THE LUNG, WHEN PARTIALLY CONDENSED.

By DR. W. O. MARKHAM, Assistant Physician and Curator to St. Mary's Hospital. [Dr. Markham observes, that two cases have convinced him of the fact that the percussion sound of a partially condensed lung is clearer than that of an healthy lung.]

In the one case, the left lung was found reduced by the pressure of pleuritic effusion to about one-fourth or fifth of its natural size; its lower lobe being completely, and its upper lobe partially, consolidated.

In the other case, the partial consolidation was general throughout both lungs; it was caused by the effusion within them of the products of inflammation, excited

by the rapid and extensive deposition of miliary tubercles. Now, when in these two cases the lungs, thus differently circumstanced as regards the nature of the disease affecting them, were removed from the bodies after death, placed side by side, and percussed, it was observed: That the partially condensed upper lobe of the pleuritic case, and every part of the lungs invaded by inflammation in the otherespecially the posterior parts, where the consolidation was most advanced, and the lungs contained the least amount of air-yielded a remarkably clear percussion sound, which, in both cases, as far as the ear could judge, was exactly alike in its characters; the sound was that to which, for want of a better, I have affixed the term "hollow;" it is clear, high-pitched, empty, of a tympanitic character, and somewhat metallic; the vibrations of sound producing it appear superficially distributed, ceasing quickly, and not passing deeply. Perhaps it would be most convenient to designate the sound as "tympanitic," for I believe that this word is rarely in practice used to indicate merely a drum-like sound, as its origin would require; the term "hollow" is objectionable, and for an evident reason.

The left side of the thorax of the patient attacked by the pleuritic effusion yielded, two days before her death, a completely dull percussion sound at every part; and the heart was found beating to the right of the sternum. To relieve the great difficulty of breathing induced by this copious and sudden effusion of serum, a very fine trocar was introduced into the pleural cavity, and about twenty ounces of fluid withdrawn therefrom, by the aid of an exhausting syringe. Great care was taken that no air entered into the pleura, and that none did I am satisfied, having assisted at the operation. Temporary relief was thus afforded the patient; and now, immediately after the operation, on percussion beneath the clavicle, we found, instead of the completely dull percussion sound observed previously, a remarkably loud, clear, tympanitic sound-so marked, indeed, as to lead an observer to suppose that air had found its way into the chest. That there was no necessity for our thus calling in the presence of air to give reason for the sound, we had the demonstrative proof after the patient's death, when the body was examined. No air escaped from the pleura, but on puncturing the left thorax a large amount of fluid gushed forth, and when a certain amount had escaped, the partially condensed lung floated forwards against the upper and anterior walls, and its percussion now both within, and when removed from the thorax, yielded a character of percussion sound, exactly similar to that which it had offered during life, after a portion of the pleuritic fluid had been withdrawn.

I did not observe, during life, the nature of the percussion sound of the thorax in the case of partial consolidation, produced by tubercular inflammation, but it nevertheless well illustrates the fact I am alluding to.

The conclusions which I am justified in drawing from these cases are:

1st, That Skoda's assertion, that a partially condensed lung yields a clearer and more tympanitic percussion sound than a healthily inflated lung, is correct.

2ndly, That Dr. Williams' mode of accounting for this "tracheal" sound, as he calls it, viz., by supposing that the upper part of the lung is compressed against the anterior walls of the thorax by the fluid behind, and thus being consolidated, transmits, when percussed, the hollow sounds of the large tubes, is not correct, at least in all cases, for here was an instance in which every part of the partially consolidated upper lobe yielded equally well the tympanitic percussion sound, and so also when divided to show the absence of all hollowness or large tubes.

3rdly, That the sound, so far from of necessity indicating the presence of air in the pleura, is a sign that the lung contains less than its normal amount of air.

One important practical deduction, if I am not mistaken, naturally flows from these facts, viz., that in certain cases of pneumonia, if not in all, when the consolidation of the lung has reached a particular stage, but not yet that of hepatization, the percussion sound over the affected portion, so far from being duller, is actually clearer than natural. The error of diagnosis into which a misinterpretation of this fact may lead the physician, is manifest enough; it may induce him at a critical period of the disease, viz., when the lung is on the eve of complete consolidation, to prognosticate a commencing return to its healthy condition.—Monthly Journal of Med. Science, Aug. 1853, p. 173.

36.-Tannate of Quinine in the Night-Sweats of Phthisis.-In the Union Médicale' for April 12th, M. DELIOUX describes several cases in which he has administered tannate of quinine with the effect of arresting night-sweats in cases of pulmonary consumption. He says that, though it is sometimes inferior to pure tannin, it is superior to disulphate of quinine; and that it combines the action of a tonic and antiperiodic. He gives it in powder, the quantity taken daily being from half a gramme to a gramme (seven and a half to fifteen grains), in three or four doses, taken at intervals during the afternoon or evening, so that the last may be administered three or four hours before sleep.-Association Med. Journal, Sept. 2, 1853, P. 778.

37.-OBSERVATIONS ON EMPHYSEMA PULMONUM.
By DR. GEORGE CORFE.

[Dr. Corfe is of opinion that any one going constantly round the wards of large hospitals would come to the conclusion that emphysema pulmonum and bronchitis are essentially blood diseases. The first disease especially occurs in people who for some time have lived upon poor vegetable food, and then, perhaps, on obtaining employment have worked hard for a few days, when they have been seized with dyspnoea, cough, and expectoration. Dr. Corfe has noticed this particularly to be the case in washerwomen and navigators. In examining the physical condition of the air and the pulmonary blood, he observes:]

The specific gravity of a cubic inch of air is 185, that of water is 1000, and that of blood 1050. Forty cubic inches of air weigh about 12.980 grains; the same amount of blood weighs about 10,653 3 grains. Thus the latter fluid is somewhat 865 times heavier than air; or, as 185 is to 1050. The amount of air, as it passes into the lungs, is opposed by a column of blood coming from the heart, in the proportion of one inspiration to four pulsations of the right ventricle. Each inspiration carries into the pulmonary cells 40 cubic inches of air, and the average number of inspirations in an adult is 20 per minute. Each ventricular contraction throws two ounces of venous blood into the pulmonary cells; and, as there are four contractions to one inspiration, about eight ounces of blood is therefore dispersed through the pulmonary capillaries, from minute to minute.

The ordinary amount of atmospheric pressure on the human body, at the level of the sea, is about fifteen pounds on every square inch of surface; but the air which pervades the body balances and counteracts this pressure from without, so that the elasticity of the air within and the external weight of this fluid over the whole body are exactly and equally poised; and thus it is that we are not conscious of any pressure. But if there should occur any diminution of weight in the columns of air which we breathe, this equipoise is altered-these opposing forces are unequalthe even balance is destroyed, so that one is relatively stronger, and the other is relatively weaker, than each was before any alteration took place. The effect of such diminution of weight in the air is experienced by those individuals who have ascended into a more subtle and rarefied atmosphere, as aëronauts and visitors to Mont Blanc, &c. ; in such cases, the resisting power of the blood in the lungs has not been counterpoised by an equally heavy column of inspired air; so that the pulmonary capillaries have given way, the cells have broken, and blood has burst forth, and has been freely coughed up. But, in order to follow up our present inquiry, let us reverse the change, and consider the effects which may ensue upon an alteration in the other fluid, namely, the blood. This vital fluid in health contains from 778 to 853 of water, and from 57 to 78 of albumen, and from 1·360 to 2.236 of dry fibrine in every 1000 parts. In order, then, for an individual to continue in a robust and healthy state, it is needful that the blood should be duly supplied with a given quantity of albumen and of fibrine. This supply is exclusively derived from azotized substances, such as animal food, &c. If this supply is deficient, the blood loses in weight and in vigour, its watery elements are increased, and its solid contents are decreased, and thus the absolute specific gravity of this fluid approaches nearer to that of water than it does to that of healthy blood. Under these changes it cannot act as a resisting medium to a given quantity of inspired air; for if its specific gravity is reduced, for example, from 1050 to 1025, and a column of air

charged with an unusual amount of moisture is respired, the resisting force is unequal to support the weight, the air-cells burst, and the foundation of inter-lobular pulmonary emphysema is immediately established. The sense of dyspnoea now begins, and, from a small spot of such breaking up of pulmonary vesicles, an entire lobe may shortly become emphysematous. The fact, that this disease ordinarily sets in at the margins of the lower lobes, and not in the centre of the upper lobes, will further explain the mode in which emphysema occurs, namely, from the feeble resistance which a column of blood, spread over the area of the pulmonary cells, offers to the increased weight of the columns of air. Dr. Goodfellow informs me that emphysema pulmonum is very common among the coalwhippers in the east part of London. These men drink largely of porter, and eat animal food sparingly. When they raise the coal from the hold of the ship, they fill their lungs by a forced deep inspiration, grasp the rope, and leap from the steps to the deck, and then as suddenly expel the air from their over-inflated lungs. This action mechanically breaks down the delicate pulmonary areolæ, just as we should burst a thin paperbag, by forcing a large column of air into it. This fact is mentioned in order to show that, if undue force is brought to bear upon the areas of the pulmonary cells, and that force is not met by an equal antagonistic rssistance from within, the cells must necessarily break down.

When a confirmed state of emphysema pulmonum is established, dilatation of the right chambers of the heart eventually comes on. When this change is superadded to the pulmonary disease, the attacks of dyspnoea will usually be most severe at the turn of the night, i.e., from twelve to two. The circulation is then at the minimum of its twenty-four hours' cycle; and the delay which a lung bloated with pent-up air, causes to the flow of blood through it, also produces a tardy supply of blood to the left side of the heart, so that the ventricle is not roused to action by a due amount of arterial fluid. The patient now will be suddenly awoke by a sense of impending suffocation; he sits up in bed, gasping for breath, and is often many hours struggling in this distressing paroxysm, until, at length, the pulmonary circulation has become poised, the left ventricle duly supplied with blood, the cardiac muscular fibres soothed, and the dyspnoea gradually assuaged, and he once more falls into a doze.

These few observations have been founded on the pathological facts connected with the onset of emphysema pulmonum; and the practical deductions which may be made from them are the following:

1st. That, in the majority of such cases which occur in our large towns, in overcrowded localities, or, indeed, in any vitiated atmosphere, and where the artisan or labourer is insufficiently nourished with a generous animal diet, it is a blood disease in its origin, and that this form of toxæmia is further asthenic in its character; the amount of fibrine, albumen, and red globules of the blood, is below the average standard of robust health.

2nd. That the disease is not remedied by antiphlogistic treatment, nor by bloodletting, expectorants, &c. &c., but that it is relieved by small doses of iron, quinine, and tonics, together with a generous diet of animal food and porter. Among the most useful forms of steel, that of the sulphate seems to rank the first: one grain of this salt and one of quinine in the compound infusion of roses, with syrup of ginger, is as valuable as any I know of in this distressing malady. Dry cupping between the shoulders, the inhalation of creosote in the proportion of twenty drops to a pint of boiling water each night, the occasional use of a stramonium cigarette, or twelve drops of chloric ether, have severally been known to ward off an attack of nocturnal dyspnoea. The fumes from a slip of lighted nitre touch-paper have long been a favourite remedy in the wards of this hospital for cutting short an attack. A gentleman of my acquaintance is always greatly relieved by a large dose of the hydrochlorate of ammonia, which he takes as soon as he feels the paroxysm approaching. -Med. Times and Gazette, July 23, 1853, p. 86.

38.-CREOSOTE INHALATION IN PHTHISIS AND BRONCHITIS. By DR. THOMAS INMAN, Liverpool.

[In a letter to the editor of the Medical Times and Gazette,' Dr. Inman speaks of

the benefit derived in these diseases from the inhalation of creosote, combined with steam. His first experiment with it was in a case of phthisis, when it succeeded in relieving the irritating cough, after a host of opiates and other remedies had been tried in vain. He says:]

Encouraged by the success attending this, I determined to try it in other cases, some of chronic bronchitis, the majority of phthisis. In all I have found it most useful in allaying cough, and checking secretion and expectoration. By allaying the cough, and thus increasing the comfort of the patient, it seems in some degree to increase the strength; at any rate, it saves its diminution. It does not of itself appear to possess any curative power. As a palliative, it is useful in all cases; and I have heard it spoken of most gratefully by a patient who only lived to use it for three or four days.

The mode of using it is very simple. I direct from four to ten drops of creosote to be placed in the bottom of an old teapot, and a small quantity of boiling water to be poured over it. The spout is to be protected by a piece of flannel, and the steam inhaled through that until it begins to feel cool. Care must be taken, of course, not to put too much water in. This answers well enough in poor practice. In hospital and private practice, more elegant apparatus may be used. An inhaler made by Weiss answers remarkably well. It consists of a closed tin can, holding about three pints: at the top are two large tubes, which communicate with the interior; one is furnished with an ivory mouth-piece, to prevent the lips being burned by the hot metal; the other is turned upwards, and, through this, the creosote and water are readily introduced. The size of the tubes makes the inhalation of the steam peculiarly easy. When this is employed, I find that the temperature of the water should not exceed 150°. The immediate effects are, a feeling of warmth about the throat, and a sensation "as if you had lungs under your ribs," followed by reduced irritability of the mucous membrane, and, subsequently, by evidence of the creosote having entered the blood.

It would take up too much space were I to detail all the cases in which I have employed it in hospital and private practice; one will suffice, and will serve to indicate the routine treatment I have adopted in phthisis.

A. B., seaman, aged 30, was admitted into the Northern Hospital with severe cough, dyspnoea, and profuse expectoration. He had been ill for three months, during which he had emaciated considerably. The pulse was 130, and there were copious night sweats. On examining the chest, I found solidification of the apex of the left lung, and coarse mucous râles all over the same side, both anteriorly and posteriorly. At the apex of the right lung there was tubular breathing in one spot, and prolonged expiration in another. The expectoration was of thick, semi-transparent mucus, free from air-bubbles, and mixed here and there with grey tubercular patches. He was ordered to have creosote inhalation three or four times, and to take internally half an ounce of cod-liver oil, with twenty-five minims of tincture of iron, three times daily. The severity of the symptoms abated in the course of a week, and, in six weeks, the man was convalescent. The right lung now seems perfectly healthy; all traces of solidification have disappeared from the apex of the left; the respiration there, and over the whole of that lung, has become natural. The pulse has come steadily down to 72. The man has gained flesh, and the capacity of the chest, as evidenced by the power to take in a deep inspiration, has signally increased.

I may mention, that the use of iron has been adopted in consequence of the effect it had on a little girl, who had been previously employing creosote inhalation and cod-liver oil for some weeks without any indication of improvement. In her case the whole of the left, and the upper part of the right lung were implicated; but I could not detect any cavities. The case seemed hopeless, when she began with the tincture of the sesquichloride, in addition to her other medicine. In two days an improvement was seen; in four it was confirmed; and, in less than six weeks after, she was running about the wards rosy and well, and has continued so up to the present time-about two months more.-Med. Times and Gazette, May 14, 1853, p. 507.