called. No remedies were given with reference to their special influence on the tuberculous cachexy, unless cod-liver oil can be so regarded. Tonics were often ordered, with the intention of influencing the processes of digestion and assimilation; and in this point of view they must be regarded as important agents. Cod-liver oil does not hold a very conspicuous place in these cases. Several of them occurred before it came into vogue; and in other cases it was taken for too short a period, either from the repugnance or the disturbance of the digestive organs it gave rise to. In very few instances was it persisted in. "Had a larger number of these cases occurred within a more recent period, or were I to report the cases during the last few years in which the progress of the tuberculosis appeared to be greatly retarded, although not arrested, this remedy would be found to enter more generally and often largely into the treatment. That it is a valuable remedy, I can scarcely entertain a doubt; but it is to be considered that, since it has become emphatically the remedy employed in this disease, improved pathological views and the lessons of experience have wrought a radical change in the management of the disease as regards other measures -a change consisting in the abandonment, to a great extent, of antiphlogistic and debilitating measures, and a recognition, more and more, of the importance of measures of an opposite character." "A point pertaining to the mental constitution of persons affected with tuberculosis seems to me worthy of notice. As regards the successful management of the disease, much depends on the patient's energy and perseverance. Tuberculous patients, as is well known, usually entertain sanguine expectations of recovery; but in a large proportion of cases they expect recovery to take place without any extraordinary agency on their part to secure that result. The disease, while it engenders hopes which are so often fallacious, seems frequently to impair that determination of purpose without which the means requisite to effect an arrest will not be efficiently pursued. A passive expectancy of recovery, and a calm acquiescence in the prospect of a fatal termination, belong to the natural history of the disease. On referring to the cases which I have reported, I find that, in general, the persons manifested greater resolution than is usually associated with the tuberculous cachexy. This was due in some instances to innate strength of character, and in other instances to the force of circumstances." "In conclusion, the general views which, with our present knowledge, are to govern the management of pulmonary tuberculosis, may be summed up in a few words. The ends to be attained are, the removal of the cachexy on which the progress of the disease depends, the consequent arrest of the disease, and the promotion of the processes of restoration. There is no special medication to be pursued for the attainment of these ends; they are to be attained by measures which, in general terms, develop and strengthen the power of the system. This mode of expression, it is true, in a scientific point of view, must be considered rather vague, but in a practical sense it has a meaning sufficiently definite. The measures are hygienic rather than medicinal; but much importance often belongs to the latter. The hygienic measures which are most important are laborious exercise in the open air, conjoined with agreeable mental occupation, and, as conducive thereto, frequently change of business, the selection of a more eligible climate, and travelling, are desirable, if not necessary; generous diet, and in many, if not in most, instances, the free use of alcoholic stimulants. The medicinal remedies, in addition to those which are simply palliative, are chiefly those of the tonic class, and in this category may be included the analeptic, which has of late years had so much celebrity." ART. 44.-Treatment of Phthisis, &c., by "Special Exercises." (American Medical Monthly, March, 1858.) Dr. Davis appears to agree with Dr. Edward Smith, in thinking that a lessened inspiratory action of the air-cells of the lungs has an important part to play in the production of phthisis, and that this lessened inspiratory action will be more effectually counteracted by certain special exercises of the chest than by the forced inspirations recommended by Dr. Smith. He says: "In all the exercises which I recommend for the purpose of developing the chest and increasing the volume of lung, I make the hands the fixed point, moving the body towards them, or suspending a part or the whole of its weight by them. In this way more or less of the weight of the body is thrown upon the pectoral muscles, and as they arise from the sternum and ribs they act upon them in the same direction that they do in voluntary inspirations, without the fatigue that follows that effort. In this use of these muscles there is no necessity of fixing the parts from which they take their rise, as we do when we use them in direct action upon the arm; consequently the ribs and sternum are left free to be drawn by them, as illustrated by their use in asthma. Another consideration is, that involuntary respiration goes on without being disturbed, even should the patient suspend himself by the hands for fifteen or twenty minutes, and this, too, it will be recollected, when the chest is expanded by so much of the weight as rests upon the pectoral muscles. "It is immaterial what this exercise is, provided the hands are made the fixed point. I have used a bar, confined to the ceiling at each end by ropes; from this bar the patient suspends himself by the hands, or, if sufficiently strong, he draws himself up until his chin reaches the bar; then bringing his arms into an extended position, he may repeat it as many times as his strength will permit; or he may throw his weight first upon one hand and then upon the other, alternately; but this requires much practice and muscular power. Another mode is to use ropes with knots every six or eight inches; these he uses to hold upon as he climbs up, or he may suspend his weight, holding by his hands, and swing back and forth; metallic rings may be substituted in the place of knots, answering the same purpose. If quite feeble, he can lean upon some object with his hands at armslength, the object being of such a height that the body will be inclined at an angle of thirty-five or forty degrees; in this position the pectoral muscles will support a portion of the weight, and thus enlarge the chest. To secure the full advantage to be derived from this mode of exercise, it should be prosecuted faithfully. My advice has been to repeat it every half hour, and continue it until a considerable degree of fatigue was produced." ART. 45.-The "Specific Treatment" of Consumption. By RICHARD PAYNE COTTON, M. D., F. R. C. P., Physician to the Hospital for Consumption, &c., Brompton. (Medical Times and Gazette, Feb. 13, 1858.) In a "Memoir" lately published in Paris,* and presented to the Imperial Academy of Medicine, Dr. J. F. Churchill has introduced to the profession, as a "specific" remedy for phthisis, phosphorus in certain combinations. A few months previously he had proposed its employment at the Hospital for Consumption at Brompton; but having then declined to make known its composition, the offer, like many others under similar circumstances, was necessarily rejected by the medical board. The new remedy, however, being now no longer a secret, and its efficacy, as stated in Dr. Churchill's work, being so "immediate" and unprecedented, Dr. Cotton has thought it a duty to give it a fair trial at the Hospital for Consumption, and to publish the results. Dr. Churchill is of opinion that the direct cause of tuberculosis is the decrease in the system of the normal proportion of phosphorus in an oxygenizable state, and that the natural remedy should be sought in some compound of phosphorus at the lowest possible degree of oxydation. The hypophosphites appeared to him to offer the nearest approach to such a quality; and of these he selected the hypophosphites of soda and of lime, as being the most soluble and assimilable. "They produce," he observes (p. 15), "a manifest increase of nervous power, sometimes even from the first day of their administration, together with an unusual feeling of comfort and strength. At the same time, the nervous symptoms, if there have been any, disappear, as well as the func * Sur la Cause immédiate, et le Traitement spécifique de la Tuberculose. Paris, 1858. tional derangement, such as weight, &c., of the intestinal mucous surface. The appetite increases, often in an extraordinary manner. The evacuations become regular, and more abundant; the perspirations, if they have existed, cease; sleep becomes calm and profound." He administered it to thirty-five consumptive patients, all of whom were either in the second or third stage of phthisis. Of these, "nine were completely cured, eleven experienced great melioration, fourteen died," and one was still under treatment. Dr. Cotton's experience of this remedy is based upon carefully made observations upon twenty of his own in-patients at the Hospital for Consumption. Copious notes were taken by Dr. Walker and Mr. Ford, the resident clinical assistant, and are open to the inspection of those who may be desirous of obtaining further information. Dr. Churchill's rules for administering it were carefully attended to; five grains dissolved in water, with the addition of a small quantity of syrup, being given three times a day. The cases consisted of nine males and eleven females, all of whom were adults. Three were in the first stage of consumption, five in the second, and twelve in the third. All were affected with the disease in its simple form, there being no other than the ordinary complications. The remedy was administered for a fortnight, notes being regularly taken; if, at the expiration of this period, no improvement was observable, it was discontinued; but if the patients expressed themselves relieved, other medicines were prescribed with the view of testing whether such relief was fairly attributable to "specific" agency, or to other circumstances, such as improved diet, rest, &c., which should always be taken into account in estimating the effect of medicinal agents upon hospital patients. Of the three patients in the first stage of the disease, two were not perceptibly influenced by the hypophosphites, but afterwards improved considerably under tonic treatment and cod-liver oil; the other considered himself much stronger, but before admission to the hospital he had been almost starved, so that good diet, &c., may reasonably claim a fair share of the credit; and he left before other medicines could be tried. Of the five patients in the second stage of the disease, two were not in any way influenced by the hypophosphites, but subsequently expressed themselves as feeling" much better" under tonic treatment with cod-liver oil; two slightly improved, but one of these afterwards advanced at a much more rapid rate under steel and oil, and the other seemed to get on quite as well under steel and quinine; the remaining one became much worse from a gradual advance of the malady. Of the twelve patients in the last stage of the disease, one felt herself better under the hypophosphite than under any other remedy; one improved greatly, but not more than under the subsequent use of other tonics; three improved slightly, but afterwards progressed much more rapidly under steel and codliver oil; two were not at all benefited, but found themselves "much better" under a change of treatment; in two cases no effect was observed, and in spite of all treatment, the disease ran on; one of the patients became worse, but subsequently gained strength under the oil and quinine; the remaining two died. Thus, in only two instances could this remedy be said to act with any marked benefit, and in one of these its good effect was very equivocal, the patient previous to admission having been in an almost starving condition, and leaving the hospital before the comparative trial could be made with other medicines. In all the rest it acted certainly in no way as a "specific;" in most, it seemed to be inert; and the few cases which slightly improved during its administration were evidently instances of the post, and not the propter hoc, since some advanced equally, and many of them more rapidly, under the subsequent use of steel or quinine with cod-liver oil. It is very possible that the compound of phosphorus proposed by Dr. Churchill may in some cases have a tonic and beneficial influence; but to any "specific" action upon tuberculosis it seems to have no claim. In a foot-note to the tabular statement made by the above-named clinical assistants, are the following remarks by Mr. Ford: "As far as we can judge from these cases, it is obvious that the hypophosphites are of no therapeutic value whatever in the treatment of phthisis; indeed, they seem to be simply inert, doing neither good nor harm, except indirectly in the latter sense by interfering with more positively beneficial modes of treatment." This opinion is fully endorsed by Dr. Walker. The employment of phosphorus in the treatment of phthisis is by no means novel. For the last eight or nine years Dr. Cotton has been in the habit of using a mixture consisting of the dilute phosphoric acid with phosphate of iron, and at his suggestion it has been inserted in our Hospital Pharmacopoeia. In many cases much good has attended its administration, but he attributes it to no specific action. Phosphorus is a well known and apparently necessary constituent of all healthy nerve-structure; and in some conditions of low nervous vigor, its medicinal employment may be of very great service. We find that it enters largely into the composition of the most nutritive kinds of grain, and we may be quite sure that it is not placed there without a purpose. ART. 46.-The Action of Cod-Liver Oil in Chest Diseases, and the duty of hospital, dispensary, and parochial medical officers in relation to its administration. By EDWARD SMITH, M.D., LL.B. (British Med. Journal, Nov. 14, 1857.) The object of the paper is to show that, whilst cod-liver oil is a valuable remedy, it acts simply as a fat with certain physical qualities, and may be, and ought to be, supplanted by the ordinary fats used in food. The author points out the numerous and serious evils which arise from public patronage of this remedy by the profession, as regards the relation which exists between the public and the profession, and the great expense imposed upon our charities and poor-law surgeons. He believes that it has tended to lessen the gains of the profession by the indiscriminate employment of it by the public without professional advice, and has tended greatly to lessen the respect for the knowledge of the profession which it is the interest of both the profession and the public to maintain; and, in fact, that it has become, under the especial patronage of medical men, the great quack medicine of the day. He first considers the chemical constitution of the oil, and then the state of #ystem existing in phthisis, and particularly enters into an inquiry which he had instituted upon 500 cases as to the appetite for the various fats in food, and the appetite for, and the effects of, the oil. He finds that there was a diminished appetite for fat in phthisis, but that in no case was the dislike absolute and in all, some kinds of fat could be taken when others were rejected. Thus, fat meat was taken by more than half the patients, and bacon fat by two-thirds; whilst suet, in puddings, butter, and milk were taken by more than nine-tenths of the whole. Afterwards, he states the result of the effect of cod-liver oil upon 150 in-patients, and proved that in nearly half of them the oil was rejected or of no real service. Of 83 who reported themselves benefited, by far the larger portion referred the good effect to improved assimilation; whilst of 67 who were unable to continue its use, or who were not benefited, the ill effect was referred to sickness and other circumstances connected with the first acts of digestion. After thus showing the degree of good and harm resulting from the oil, and the degree of appetite for, and dislike of, fat of various kinds in food, he proves that in the large majority of cases there was an appetite for fats when the oil did good, and the contrary when it did harm, but this was not universal; and he also proved that in the very cases in which the oil was rejected there was always appetite for some kind of fat food, and in some cases even for the fat of meat. Hence he proves that there was no ground for the assertion that the oil was more easily digested and assimilated than some of the natural fats in food. The inquiry and medical testimony now prove that cod-oil acts beneficially as a nutrient; and he affirms, from special experience, that the oil has no advantage over the fats in food, provided an increased quantity be taken of such of the nutrient fats as the patient can eat. Hence he urges the profession to distinguish properly between food and physic; and, if the oil is administered as a nutrient, to inform the patient that it is given as food, or, as he preferred, to direct them to increase the nutrient fats in proper quantities and of a suitable kind, and to administer other articles as medicine. The following are the author's conclusions: That neither cod-oil nor fat of any kind removes phthisis. That the cases of arrest of the disease are very few. That commonly the disease progresses, and is as fatal now as it was before the oil came into general use. That in about half of the cases the rate of progress is retarded. That the patient may be both stronger and stouter, and yet the disease quietly progress. That when the oil disagrees, it is chiefly from its influence upon the digestive organs. That when it agrees, it is chiefly by improving nutrition; but that in many cases it is believed by the patient to have a local influence. That this local influence is most important in the pharynx and other parts of the mucous tract. That it acts almost entirely as a fat, and supplies a defect in the system. That it has no advantage over fats used in food, and may, like some of them, be taken and rejected. That there is a large class in whom it is not beneficial, and it should be used with discrimination. That it is our duty and our interest to dissociate food and physic. Lastly, that it leaves the essence of the disease untouched; but that the great good which it often does temporarily proves the importance of fat in the animal economy. Dr. Smith shows how much more frequently there is appetite for fat in bronchitis than in phthisis and mere debility, and particularly in liver diseases; but he defers the discussion of the question, and of the use of fats in general to another occasion. He urges upon the profession the impropriety of poorlaw surgeons being compelled to supply the oil, when the guardians ought to give fat in food; and of the medical officers of hospitals and dispensaries taxing the over-burdened funds to supply so extensive a food. ART. 47.-The Effect of Local Influences on Spasmodic Asthma. By Dr. HYDE SALTER, Assistant-Physician to Charing-cross Hospital. (Lancet, Dec. 26, 1857.) The purport of this paper is to show that, in a very large proportion of cases of asthma in which it has been fairly tried, change of locality effects an instantaneous cure, which is permanent as long as the asthmatic continues his residence in the place that has cured him. The author remarks that, although the subject of his paper is a single method of cure of a single disease, yet that the efficacy and completeness of the cure, and the painfulness and intractability of the complaint, vindicated it from unimportance; and, indeed, that in so distressing and unmanageable a disease, any remedy that offered even a small percentage of cures might be considered the greatest possible boon. The paper is illustrated by nearly thirty original cases, and the points that the author considered to be established are as follows:: 1. That residence in one locality will radically and permanently cure asthma resisting all treatment in another locality. 2. That the localities which are the most beneficial to the largest number of cases are large, populous, and smoky cities. 3. That this effect of locality depends, probably, on the air. 4. That the air that would be imagined to be the worst for the general health is, as a rule, the best for asthma; thus the worst parts of cities are the best, and conversely. 5. That this is not always the case, the very reverse being sometimes so-a city air not being tolerated, and an open, pure air effecting a cure. 6. That there is no end of the apparent caprice of asthma in this respect, the most varying and opposite airs unaccountably curing. 7. That, consequently, it is impossible to predict what will be the effect of any given air, but that probably the most opposite to that in which the asthma seems worst will cure. 8. That some of these differences, determining the presence or cure of asthma, appear to be of the slightest possible kind, arbitrary, and inscrutable. 9. That the mere conditions of locality appear to be adequate to the production of asthma in a person whose disposition to it was never before sus |