The first column exhibits the arrangement which I propose; the second, the corresponding terms in most frequent use; the third, contains brief descriptions of the distinctive characteristics of each sound; the fourth notes the occurrence of the sound, whether chiefly in inspiration or expiration, or in both; the fifth, shows the most common seat of each sound; and the sixth, the principal disease in which each sound is manifested.

1. Bubbling sounds are produced by air passing through secretion in the bronchial tubes, as peculiarly occurs in bronchitis; in those of moderate calibre constituting what has been usually designated mucous rhonchus. The smaller bubbling rhonchus produced in the capillary bronchi, commonly known as subcrepitant, should rather be termed sub-mucous, if, from respect to long usage, the somewhat questionable term "mucous" be retained. To these bubbling sounds the term rhonchus is appropriate; but I do not dignify with this title sounds probably produced externally to the cells, such as crackle and true crepitation, which are not proved to have any relation to the passage of air through secretion or vibrating tubes.

2. Clicking consists of a series of sounds, few in number, exactly corresponding to the term, audible in some degree during expiration as well as inspiration, and probably never existing except when softened tubercle is present.

3. Crackling a term which itself defines the sound-consists of a few (not more than three or four) crackles, limited to the period of inspiration, seeming to arise at a distance from the ear, probably produced externally to the cells, and characteristic of the first stage of phthisis, although not invariably present under such circumstances.

4. Crepitation consists of more numerous and finer sounds than crackling. It is also confined to the period of inspiration, and is probably due to viscid secretion in the cell-walls, occasioning difficulty in their expansion. It is peculiar to pneumonia. 5. Vibrations. Of sonorous, grave or cooing, and sibilant, shrill or whistling rhonchus, sounds resulting mainly from vibration, and indicating flattening or narrowing of tubes, such as is common in chronic bronchitis, it may be sufficient to remark that, when occurring interruptedly, these rhonchi may be occasioned by vibrations of air produced by pellets of mucus, as is sometimes observed in pertussis'; but that in proportion to the continuousness of these sounds, there is reason to suspect turgescence or thickening of the membrane, or effusion in the submucous tissue.

A few incidental remarks may here be expedient, in order to explain a little more particularly the modifications which are suggested in this communication.

The term subcrepitant rhonchus has been so long and extensively employed, that the attempt to displace it may seem a bold and doubtful experiment; but I scarcely know a medical expression which has tended to more danger in practice. The term conveys to the mind the idea of a sound analogous to that usually designated crepitant rhonchus (but which I propose to call crepitation); and has in consequence led to injurious depletion. If asked to specify the greatest abuse of auscultation with which I am conversant, I should instance the leeching and antimonializing of children, in certain pectoral affections, of which the subcrepitant rhonchus is a prominent symptom. Under the cover of a pedantic numerism, the cure of pneumonia without depletion has, on the continent especially, been assumed to be common, because this so-called subcrepitant rhonchus, although really differing in character of sound, as well as in cause, has been mistaken for the rhonchus characteristic of pneumonia. A reference to the table will show the marked difference between these sounds.

As respects diagnosis and treatment, I cannot but think that great importance may be advantageously attached to the co-existence of certain sounds with expiration as well as inspiration, with certain qualifications, particularly in reference to vibratory rhonchi; the presence of a morbid sound during expiration affording evidence of the presence of secretion within the cells or tubes. This view is supported by the concurrence of clicking, from softened tubercle, with both respiratory actions, as contrasted with the inspiratory crackle of the first stage of phthisis. The same peculiarity distinguishes the small bubbling (submucous rhonchus) from true crepitation (crepitant rhonchus), which resembles the noise produced by rubbing a lock of hair between the fingers, and conveys to the mind an idea (probably in harmony with the fact) of the abrupt forcing open of cells rendered less yielding by glutinous deposition in their walls. If the cause commonly assigned for "crepitant rhonchus

-namely, air passing through secretion-were correct, the air in repassing should produce a rhonchus during expiration also. The presence of viscid secretion within the pulmonary cells in pneumonia may be acknowledged, without conceding that this secretion is concerned in the production of crepitation; indeed, its tenacity may be a reason why bubbles are not produced, the calibre of the capillary tubes to a certain extent remaining free. When, in the resolution of pneumonia, the secretion becomes less viscid, and occasionally more copious, the rhonchus changes in character, and the sound which has been designated the redux crepitant rhonchus, having more of a bubbling character, and more or less audible during expiration, is produced. The sound sometimes termed continuous subcrepitant rhonchus, existing only during inspiration, and accompanying pulmonary congestion such as attends some forms of fever, I should regard as a subcrepitation, not a rhonchus.

As respects the treatment of inflammatory affections of the lungs, in proportion as sounds are confined to inspiration, they afford reason for depletion; in proportion as the rhonchi become bubbling, they indicate secretion, and suggest a discontinuance of antiphlogistic treatment.

The advantage of introducing terms so diverse as is suggested in the present plan is obvious. If we speak of crackle, the first stage of phthisis is indicated; if of clicking, the stage of softening; if of crepitation, pneumonia is known to be present; if of bubbling or of small bubbling rhonchus, secretion more or less copious is known to be present in the difierent orders of bronchial tubes.-Association Med. Journal, April 29, 1853, p. 364.

32.-ON TUBERCULOSIS, THE CONSTITUTIONAL ORIGIN OF CONSUMPTION AND SCROFULA.

By HENRY ANCELL, Esq., late Surgeon to the Western General Dispensary, &c. [The German pathologists express by the term 'tuberculosis' that diathesis or change in the constitution, producing and accompanying the tubercular exudation.' Mr. Ancell limits it to the constitutional disorder, and the local results he styles 'tubercular diseases.' First, on a few points with regard to the blood.]

The general composition of the blood in tuberculosis, according to the various analyses collected by Mr. Ancell, is altered from its normal condition. The corpuscles are diminished, and the albumen increased in quantity. The fibrin is below rather than above the normal amount, and, it may be inferred, is also defective in its nature. Elsner, and some other analysts, have found the fatty principles diminished. Dr. Fricke's analyses indicate an increase above the standard of health, in the lime, and a decrease in the phosphates; while l'Héritier states, that in scrofula, the earthy salts are diminished. Hence the blood may be stated generally to be degraded in quality, and endowed with a low degree of vitality.

Whether such be the real changes which occur in the blood, however, is not yet determined with anything like certainty. Thus Andral, in his earlier contributions to hematology, showed that the fibrin was augmented in phthisis pulmonalis; and there can be little doubt that in many cases of that disease, especially where intercurrent pneumonia prevails, it is so. Again, Dr. Glover of Newcastle, from his analyses, maintained that the fats were not diminished in the blood. The fact is, the blood is continually undergoing changes, is constantly receiving matters from the primary and secondary digestions, and as constantly giving off matters by the processes of secretion and excretion. Hence diet, exercise, time of the day, and a multitude of circumstances, so affect the circulating fluid as to render it very difficult to decide as to its typical composition in any particular disease. On the whole, however, we have no doubt that the blood corpuscles and fatty principles are diminished in quantity, whilst the albumen is comparatively augmented, a condition that seems to us made out by all the chemical, physiological, and pathological researches with which we are as yet acquainted.

Such an altered physical condition of the blood is necessarily accompanied by deviations from the perfect physiological standard of the corporeal functions. This is evinced by a greater or less degree of constitutional debility, a deficiency of vital powers, and weakness of all growth in the ultimate nutrition of the body. Hence

the waste which takes place from the beginning, first, in the coloured corpuscles of the blood, and secondly, in the muscles and other tissues. Thus the whole phenomena of the predisposition and the symptoms of the disease show-1st, That from the earliest invasion the sum of the vital force is either below the standard of health, or it is relatively low as respects the structure and organization of the individual; 2d, That this diminution in the sum of the vital force is dependent on the imperfect blastema of the diseased blood causing perversion of the tissues; 3d, That as tuberculosis advances, the sum of the vital force for the whole system continues to diminish; 4th, That the nutritive powers of the blood, as respects the nervous tissue, frequently remain undiminished, this tissue not requiring for its nutrition compound principles identical with it to be introduced into the blood with the food, and having a nutrition peculiar to itself, differing from that of the cellular and muscular struc

tures.

These general propositions will, we believe, be readily agreed to, and the hypothesis advanced to explain the integrity of the function of innervation, whilst that of nutrition is lowered, if not demonstrated to be true, must at least be regarded as ingenious, and consistent with the humoral pathology of the day. Mr. Ancell, however, derives from them some practical inferences, not the least important of which is that in reference to the general disease. The diagnostic object here is not to determine whether a local tuberculous development exists-a pulmonary or abdominal tuberculosis-but rather to determine whether the patient is truly affected with the blood disease, and thereby threatened with its local manifestation. He considers the successful treatment of the disease of the blood in this stage, based on a knowledge of its nature and causes, is in many instances certain. The successful treatment of the disease, after it has localised itself, is frequently impossible.

Now we consider this to be remarkably sound theory; but the difficulty is to carry it out practically. How are we to distinguish such a preliminary condition, one in which the blood only is affected, before the local disease comes on? Mr. Ancell admits that, in estimating the symptoms of tuberculosis, that is the blood disorder in a practical point of view, their absolute value, taken singly, is comparatively little, since one and all occur in other diseases. He considers that it is their relative value-the association of several, or the harmony of many in one case, the manner in which they arise, and their mode of succession, which distinguish them from the symptoms of other diseases, and assist us in the differential diagnosis. Many of these symptoms are found associated in chlorosis, simple anæmic debility from venereal excesses, and other conditions of the economy.

With regard to the structure of tubercle itself, the author cites the opinions of various histologists, who have resolved it into molecules, granules, and imperfectly developed cytoblasts and cells-the latter being in general very defective, of an irregular shape, rarely round or oval, frequently angular. From this description, those corpuscles are evidently meant which contain no nuclei, and which, in point of fact, are not cells at all.

[As to the causes of tuberculosis, though he enters into an elaborate statement, he yet encounters some difficulties.]

Mr. Ancell, in following out his view, with regard to tuberculosis being the blood disease, is under the necessity of throwing the causation a step further back as it were, and, in doing so, experiences unusual difliculties. Then, as he considers statistics to be the only ground for arriving at satisfactory results, and as these are very loose materials to work with, no very solid or well-formed reselt has been arrived at. Hence, so far as we can make out, Mr. Ancell attributes vast influence to an hereditary taint; and, as respects the individual, supposes the disease to be the result of combined rather than of particular causes. We have long been persuaded, that the only cause is an imperfect nutrition, and that the principal origin of this is a derangement in the primary digestion. Mr. Ancell, on the other hand, maintains, that the most powerful causes are a vitiated atmosphere, insufficient muscular exercise, and the depressing passions, all of which he thinks meet, as it were, at one common point, and have probably one essential modus operandi, viz., an insufficient renewal of pure atmospheric air, or an abnormal condition of the air habitually contained within the chest. But Mr. Phillips, whose work on Scrofula was also based, to a great extent, on statistical details, as elaborate and careful as those of Mr. An

cell, came to the conclusion that improper food holds the first place in the production of tubercular diseases, whilst a vitiated atmosphere is scarcely appreciable.

[The chapter on 'The Essential Nature and General Pathology of Tuberculosis' is more satisfactory. Mr. Ancell observes:]

"The theories of Buffalini, Canstatt, Mr. Simon, and Dr. Hughes Bennett, undoubtedly approximate more closely to the real question of the essential nature of the disease than either of the others, ancient or modern. There is also no doubt that the whole, however theoretical, and however in some points they may differ from each other, are founded upon the facts of modern science. After all the attention I have been able to bestow upon the subject, I have no hesitation in declaring my opinion, that Dr. Hughes Bennett has advanced the farthest in this investigation; and I believe that the pursuit of the inquiry in the direction indicated by these pathologists, and especially by the latter, will ultimately lead ns to a knowledge both of the modus operandi of the causes, and of the essential nature of the disease."

He concludes the discussion of this subject as follows:

"We thus trace this fatal disease to a primary error or defect in the blood-making process. Vitiated air, or air stagnating or insufficiently renewed within the chest, and probably other anti-hygienic influences-as a vitiated or defective diet-acting singly, coetaneously, or as respects each other ancillary, produces, slowly under ordinary circumstances, but occasionally with great rapidity, some unknown change in a portion of the proteiniform principle of recently formed liquor sanguinis; this change may consist in hyper-oxidation, but whether so or not, it deteriorates its properties, rendering it more or less, or altogether, unsuitable as a material for organisation. At the same time, the oily principle of nutrition, circulating with a diminished number of red corpuscles, is, in part, converted into a fatty substance of a lower degree of oxidation. These modified proteiniform and oleaginous principles are exuded in the blastema, and are either employed in the assimilating processes, deranging the nutrition of many of the organic structures, and giving the tubercu lous or scrofulous character to various pathological processes; or, in the more advanced stage of the morbid process, they are deposited in particular tissues and accumulate, generally in the form of turbercle, but sometimes both as tubercle and morbid fat; substances, for the most part, incapable of organisation.

"In the present state of pathological science, confining ourselves to its legitimate object, the study of phenomena, apart from any metaphysical views of final causes relating to the powers of nature, this appears to us the most accurate definition that can be given of the most essential nature of tuberculosis."

[In the chapter on Treatment, he considers the baneful effects of vitiated air, and enters upon the subject of a proper diet and other hygienic measures.]

These are 1st, to supply the blood with its constituent materials in a state of purity, in sufficient quantity, and in due proportion; 2nd, To adopt all such measures as are calculated to promote the elaboration of the materials of nutrition, the formation of healthy blood, and the elimination of effete matter; 3rd, To promote healthy cell growth, and a consequent vigorous nutrition of the organic structures, a symmetrical growth and development of every part and of the whole bodily frame, and a healthful waste and repair. Our limits prevent us entering into the various means indicated by the author for accomplishing these ends; we would, however, call attention to the following judicious observations, because we fear that they are far too little attended to in practice:

"The indisposition to muscular exertion in a majority of tuberculous subjects, and to both mental and muscular exertion in others, has been described. The proceedings adopted to counteract this tendency require to be based upon the most judicious principles. We have to bear in mind, that we are dealing with a state of health in which there is direct debility, or a very inadequate development of vital force. At the same time there is morbid excitability, and accordingly, by injudicious proceedings, a great risk of exhausting the little power that exists. The effect of that exhaustion is, necessarily, to arrest all those processes upon which the system is dependent for the renewal of muscular power. Violent temporary exertions, under these circumstances, can but be most injurious, and it is in this way that occupations of life attended with such exertions prove injurious. They tend to a still smaller production of vital power, and confirm the debility of the disease. Many an indiXXVIII.-6.

vidual who might have lived for a long period, or recovered, has had the disease irretrievably precipitated by such exertions. At the same time, moderate, continuous exercise, which expends a portion of the available vital force without exhausting it, induces the natural reactions by which it is renewed. That is to say, it excites the action of the heart and arteries-the nutritive processes in all the tissues-the demand for supply or the appetite-the digestive and respiratory functions-and the reciprocal actions of organising molecules, and the physical agents essential to life. Keeping these principles steadily in view, they may be made to operate as unerring guides in regulating the exercise of tuberculous subjects. It must not be overlooked, that in turberculous subjects the heart is most frequently small and weak, and that it is often especially so in relation to the voluntary muscles and muscular power; rendering it excitable and liable to palpitation and exhaustion.

"The vital force should never be exhausted. The rule usually laid down, is 'to encourage as much exercise as can be borne without fatigue.' A better rule would be, to allow of as much exercise as the patient can bear without producing a greater degree of fatigue than will be entirely recovered from after moderate rest. This distinction may appear trivial, but the best test of the injurious or beneficial tendency of muscular exercise, is found in the state of the muscular and other manifestations of vital power after subsequent rest.

"If a tuberculous subject retire at night fatigued, this is but natural, but if he rise also fatigued after a proper amount of sleep, either the exercise of the previous day has been excessive, or it has not been of a proper kind in relation to his state of debility and the slowness with which his system recruits its vital force. If the same amount of expenditure of force be kept up from day to day with the same results, the exercise he takes is increasing his debility; assimilation, and particularly cell-growth and nutrition, becomes less and less perfect, the destructive exceed the assimilative processes in the organic tissues, and atrophy sets in or progresses. Diminished nutrition is the result of this exhaustion; and thus, the labours of the day, which ought to sustain the vital force, absolutely destroy the very source of its supply."

[Speaking of the medicinal treatment of tuberculosis, Mr. Ancell considers cod liver oil to be the most important therapeutical agent.]-Monthly Journal of Med. Science, July, 1853, p. 64.

33.-ON ACUTE TUBERCULOSIS.

By DR. WILLIAM JENNER.

[This disease very often similates typhoid fever, and like it rarely affects people above the middle period of life. It generally assumes one of three forms-the insidious, the active febrile, and the adynamic.]

The first form occurs almost exclusively in children; the patient often after measles, or scarlet fever, but not unfrequently without known cause, is observed to be languid; unwilling to make any exertion; complains of headache; lies about; seeks quiet, leaving its companions; is heavy, dull, or irritable in temper; the skin is hot and dry; the pulse frequent; the tongue moist, and slightly furred; the appetite lost, or variable; the bowels confined, or irregular; the stools more or less claylike, putty-like, or party-coloured; the abdomen free from tenderness, and of its normal form; there is trifling cough, and a little sonorous or sibilous râle, or the respiratory murmur is simply rough or harsh, and the expiration rather loud and prolonged, or, it may be, perfectly natural. Some time usually elapses before advice is sought, so indefinite are the symptoms of the illness; and, after it is sought, the physician is occasionally some time in attendance before the gravity of the affection is comprehended; for the febrile symptoms often remit during the day, the skin being little above its natural temperature, and the pulse only a little quicker than natural, when he makes his visit. Thus the disease proceeds for two, three, or four weeks, when the functions of some one organ become disturbed in an extreme degree, and the patient dies with all the symptoms of acute hydrocephalus, tubercular meningitis, bronchitis, pneumonia, or peritonitis.

After death, in such a case, grey granulations, or yellow tubercles, are found in