more sparingly used than in the syphilitic, and the constitutional effect of mercury is not required. Conium sometimes exerts great influence over this form of disease when given in doses of five or ten grains thrice daily. An early recourse to tonics and alkalies is generally requisite.

The paper is illustrated by several well-narrated and instructive cases. IV. Account of a specimen of partial fracture of the neck of the thighbone, and of the proper source of nutrition of the head of the bone; by J. Wilkinson King. With two plates.

V. On paracentesis thoracis. Additional cases; by H. M. Hughes, M.D. The whole number of cases now amounts to 25. Of these 13 have fairly recovered, 2 have at least partially recovered, and ten have ultimately died of other diseases, generally connected with that for which the operation was performed, but entirely independent of its performance. VI-and No. VI, VIII. Select clinical reports, with observations; by George H. Barlow, M.A., M.D. We join these two valuable communications together, because the facts and arguments in both are directed to the establishment of the same general principles; and we may state, in limine, that we have rarely met with a better specimen of the application of sound inductive reasoning to the elucidation of any point in pathology.

The first portion is occupied with the narration of two cases of fatal obstruction of the bowels. In the first case, the seat of obstruction was in the colon, the sigmoid flexure of which twisted upon itself, so as to cause two points of constriction. In the second, the jejunum was compressed by a band of false membrane, which also narrowed the cavity of a portion of ileum passing under it. In neither case was the cavity of the gut entirely closed. But, though the pathological conditions were so similar in nature, the symptoms varied in some important respects. In the first case there was little or no abdominal pain at the commencement; in the second it was one of the earliest symptoms. In the first case there was great flatulent distension of the abdomen; in the second there was none. In the first the urine was abundant in quantity; in the second that secretion was almost entirely suppressed. In the first case the circulation was well maintained in the extremities, until symptoms of perforation manifested themselves; in the second there was early collapse. Now these differences were clearly dependent upon the variation in the seat of obstruction, and accordingly, from a consideration of them and the results of other case, Dr. Barlow has grounded upon them the following rules of diagnosis in these often obscure cases :

"It appears, then, that in cases of constipation, where there is great abdominal distension, with little or no sickness till a late period of the disease, and an abundant secretion of urine, the seat of the obstruction is in the colon or rectum; and if there be no great degree of pain or tenderness, this obstruction is probably dependent upon some mechanical cause. When, on the other hand, the abdomen appears empty, or but moderately distended-when there is early vomiting and great deficiency of urine-and, more especially, when to these symptoms there are added considerable pain, with a tendency to collapse, the affection is probably in the course of the small intestines, and, for the most part, near the pylorus; but when the last-named symptoms are present, with the exception of deficient urine, the disease is either in the cæcum or lower part of the small intestine."

In respect of treatment, Dr. Barlow most wisely deprecates the perse

vering use of drastic purgatives, as being inefficient in themselves, and calculated to produce serious mischief.

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Supposing, then," he says, " in a case of constipation which has lasted several days, that it appears probable, from the distension of the abdomen, the absence of sickness, and an abundant secretion of urine, that the obstruction is situated in the lower bowels, the first step should be to exhibit some efficient but not irritating purgative, such as a full dose of calomel with half a grain of opium, followed, in a few hours, by castor-oil, which may be again repeated-or four or five grains of compound extract of colocynth, with one of extract of hyoscyamus, may be given every hour, for six or eight hours; or, should time be allowed by the absence of any very urgent symptoms, both the above means may be tried. Copious enemata should also be administered once or twice in the twenty-four hours; and where there exists the slightest suspicion of any inflammatory action, a full bleeding should be early had recourse to.

"Should no evacuation be obtained by these means, it may be well to explore the rectum with a finger or a bougie, or both, with a view to ascertaining the existence of any obstruction in that part of the bowel. The flexible tube should next be cautiously introduced, and the lower part of the bowel well washed out by copious injections of warm water, which may be drawn off by the stomachpump. After this has been done two or three times, there will generally be an opportunity of feeling the extremity of the tube through the abdominal parietes, by which its direction and the position of the bowel may be ascertained... Should there be a simple distension, it is probable that the upper portion of the intestine will empty itself into the distended part; and, with a view of promoting this, a moderate purgative may again be administered, and a turpentine enema thrown up by the flexible tube. But, should no evacuation be procured in this manner, it will become probable that there is a second obstruction above the distended portion. The farther exhibition of purgatives by the mouth will then be useless, or even injurious, and our efforts should be limited to the persevering washing out of the lower bowels, and the occasional exhibition of calomel and opium; as it may happen even yet, that, by diminishing the distension, the pressure at the points may be so far diminished as to allow of the passage of the contents of the bowel."

Should, however, all these means fail, it will be advisable to open the colon in the loins.

We now come to the inquiry, how does obstruction of the upper part of the intestinal canal influence the secretion of urine? And this leads our author into a very interesting discussion, in which he attempts, and we think successfully, to prove the truth of the following proposition:

"If a sufficient quantity of water cannot be received into the small intestines, or the circuit through the portal system into the vena cava ascendens, or thence through the lungs and heart into the systemic circulation, be obstructed, or if there be extensive disorganization of the kidneys, the due secretion of urine cannot be effected."

Into the steps of his argument we have not space to enter: they consist of a series of cases, illustrating in succession the effects of obstruction in the several parts of the circuit above noticed, and the existence, in each, of an abnormal condition of the urinary secretion. Thus, in the case already alluded to, the sickness prevented the reception of a sufficient quantity of water into the system; in case 4, the ascending cava was filled with morbid deposit; in cases 5 and 6, there was obstruction to the circulation of blood through the lungs ; in case 7, obstruction to the return of blood from the lungs; in case 8, obstruction to the passage of blood

through the heart; and in case 9, obstruction to the passage of blood from the heart. In all these the one constant symptom was a great deficiency in the quantity of urine. The series is completed by the narration of a very remarkable case, in which, from extensive disorganization of the kidney, scarcely any solid matters were eliminated by that organ, and the patient died comatose, though a large quantity of watery fluid was passed daily. We strongly recommend these papers to the careful attention of our readers. They are illustrated by five plates.

VII. Medical reports from the books of the clinical wards, with remarks; by J. C. Brereton. These are interesting, and well worth reading; but do not admit of analysis.

VIII. Report of cases of injuries to the abdomen.

IX. An abstract of the two half-yearly Reports of the Clinical Society, for 1843; by E. L. Birkett, M.B.

No. V.

I. On the pathology of phthisis; by T. Addison, M.D., Senior Physician to the Hospital. With five coloured plates.

In this paper the author pursues the course of his former investigations, bringing forward additional evidence in support of his position, that indurations of the substance of the lungs may give rise to all the ordinary signs of tubercular phthisis, and prove fatal, without there being a single tubercle in any part of those organs. To this form of disease he gives the name of pneumonic phthisis.

This pneumonic phthisis may be acute; the deposits and inflamed tissue softening down and disorganizing at once, without any attempt whatever being made at induration or repair, thereby constituting one form of acute or galloping consumption. It may be acuto-chronic; of which there are three varieties. 1. The inflammation, though more or less acute, is slower and more insidious in its course, and manifests some attempts at repair, as indicated by various stages and degrees of induration. The induration, nevertheless, is not complete; the pulmonary tissue continues to be friable; and sooner or later, that is to say, in a few weeks or months, softens down and gives rise to excavation; most frequently by a slow ulcerative process; more rarely by an actual slough of greater or less portions of the indurated but still friable pulmonary tissue. 2. Inflammation may supervene upon or around ancient induration, leading to disorganization either of the newly-inflamed tissue, of the old induration itself, or of both at the same time. Lastly, pneumonic phthisis may be chronic; of which, also, there are two varieties: first, that in which old indurations undergo a slow progress of disintegration, giving rise to vomica; and, secondly, that very rare form of the disease, in which an insidious inflammation proceeds very slowly to convert a considerable portion of pulmonary tissue into gray induration, without any necessary excavation whatever.

Tuberculo-pneumonic phthisis. By this is meant a very common form of the complaint, in which, although tubercles are present, the really efficient cause of the phthisical mischief is pulmonic inflammation.

Dr. Addison distinguishes two forms of simple pulmonary tubercle, which he designates by the names sthenic and asthenic: the former being

usually of a gray colour, and semi-transparent; the latter, from the very first, and however minute, of an opaque white, or boiled-rice colour, sometimes with a faint tinge of yellow. It is the sthenic variety that usually preponderates in the form of phthisis we are now considering.

"Pulmonary tubercle has its seat in the delicate filamentous tissue which forms the slight filmy parietes of the air-cells, and bears the same relation to these parietes that tubercle does to serous memorane.

"The apparent growth and increase of size of simple pulmonary tubercle depend upon changes taking place in adjacent cells, either from the development of additional tubercles, or from inflammation. The so-called enlarged tubercles, therefore, are in reality either aggregations of simple tubercles, or simple tubercles inclosed in the products of inflammation. To the former I would apply the term compound tubercles, which, of course, are made up of two distinct elements, viz. the abnormal product, tubercles, and the tissue of the air-cells in which that tubercle is developed. The latter element of compound tubercle, although little considered, probably plays a by no means unimportant part in some of the most serious changes observed to take place in tuberculated lungs. Compound are at all times more liable to disintegration than simple tubercles.

"When tubercles are present, and especially when numerous, in clusters, or compounded, but still quiescent, the neighbouring pulinonary cells pretty uniformly afford indication of compensatory or excessive function; the cells being more or less enlarged, as observed in pulmonary emphysema. This compensatory change probably increases the difficulty of recognizing simple tubercles in the lungs; it being rarely, if ever, possible to detect them, either by dullness of sound or percussion, or by diminished respiratory murmur, as determined by auscultation-unless, perhaps, they exist in great numbers, and in groups of considerable size.

"In general, the only physical indication worthy of the smallest confidence at a very early period is a certain degree of inequality in the respiratory murmur; it being a little more loud or puerile at certain points, or in one lung than the

other.

"When tubercles are present in the pulmonary tissue, there exists a great proneness to increased vascular action, congestion, or inflammation in the lungs themselves, and their appendages, the larynx, trachea, bronchi, bronchial glands, and pleuræ. This tendency is, however, most strongly marked in the immediate vicinity of the tubercles. Unless subjected to causes calculated to aggravate such tendency to congestion or inflammation, an individual may experience little or no inconvenience from the presence of tubercles;—a pathological principle applicable to sthenic tubercles generally, whether situated in the lungs, the pleuræ, peritoneum, or arachnoid. The inflammation which supervenes upon tuberculated lungs is commonly of the low and insidious kind observed in scrofulous and cachectic constitutions; and, unless under aggravation, is rarely attended with sufficient serous exhalation to produce perfect pneumonic crepitation.

The commencement of this inflammation, either in the pulmonary tissue itself, or in the bronchial tubes, is the ordinary commencement of tuberculo-pneumonic phthisis; and hence it is that most of the symptoms and physical signs of phthisis may manifest themselves, without evidence of a primary change in the tubercles themselves, being discoverable after death. When the pulmonic inflammation is more considerable than usual, the characteristic heat of skin often remains uninterruptedly for days together, whether accompanied by diminished, increased, or varying perspiration.

The physical signs which become apparent as the disease advances, viz. feebleness or absence of respiratory murmur, bronchophony, tubular respiration, and dullness of sound on percussion, are more the results of this inflammation than of the extension of tubercles; and may occur from a similar cause, in pneumonic

phthisis, without a tubercle ever having existed in the lung at all. These is often a well-marked relation to be observed between the degree and permanency of the characteristic pneumonic heat of skin when present, and the rapidity and extent of these local changes, as ascertained by auscultation and percussion.

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Although the red hepatization occurring in tuberculo-pneumonic phthisis very often passes quickly into softening, and the consequent formation of a cavity, nevertheless, when actual albuminous matter is thrown out, it, like that resulting from pneumonic inflammation without tubercle, usually manifests some attempts at repair; as indicated by more or less hardening and contraction of the deposit itself, and of the pulmonary tissue into which it is effused. These results of inflammation, have been very commonly, but erroneously, regarded as mere varieties of tubercular infiltration. It is the contraction of these deposits that chiefly occasions the diminished size of the lung and flattening of the ribs. Pleurisy, doubtless, very often contributes to the same result; but mere excavation of a portion of a lung has no such effect as diminishing its size. In the worst and most excavating forms of emphysema there is no shrinking of the lung.

"The attempts at repair, or induration, of the pneumonic deposits occurring in tuberculo-pneumonic phthisis are commonly very imperfect, and not durable; so that the deposits for the most part, sooner or later, undergo a second change, by which they soften down and produce excavation. This softening, however, may take place days, weeks, months, or, I believe, even years, after the original deposition. When the disease has proceeded to excavation, the natural cure of the ulcer thus produced consists in the formation of a more or less permanent lining membrane-the true cicatrix of such ulcers. Although this membrane may perhaps, now and then, remain passive and harmless for years, it most commonly happens that the cicatrization is imperfect and incomplete; the efforts at repair fail, the albuminous material, which ought to form the membrane, softens down, and with it successive portions of the pulmonary tissue furnishing it; and thus the ulceration proceeds, till, exhausted by unceasing irritation and imperfect nutrition, the patient dies."

In treating this form of phthisis, our main object should be to prevent the deposition of tubercles, by improving the general health; and when they are found to oppose the progress of inflammatory action, by moderate general and local bleeding, active and continued counter-irritation, &c., and sometimes by the use of mercury.

Tubercular phthisis is characterized by a preponderance of compound asthenic tubercles; and, in Dr. Addison's opinion, is incurable. His remarks upon it are most judicious; but as this is the form of phthisis with which our readers are most familiar, we shall be contented with simply directing their attention to the paper itself.

Dr. Addison's papers claim the best attention of the pathologist and practical physician.

II. Cases in medical jurisprudence, with remarks; by A. S. Taylor. This communication is occupied with the subject of poisoning by prussic acid, and is full of interest. The author has, we think, conclusively shown that the shriek, concerning which so much has been written and said of late, is no necessary accompaniment of poisoning by this drug; that the same is true of convulsions; that, after even a large dose has been taken, there may be sufficient time and consciousness for the individual to cork and put away the bottle, and arrange the bedclothes; that the absence of odour is no proof of the absence of the poison; and that, on the other hand, the odour may often be detected when chemical analysis gives only negative results.