works of Wood, Aitken and Bennett. On the other hand, we find several subjects not generally included in works on practice with us, among them we may mention diseases of the uterus, ovaries and vagina, virulent and non-virulent inflammations of the male urethra, with some others.

On taking up this work we turned with especial interest to the chapters upon tubercle and consumption, and we presume most of our readers have read something of the new doctrines of Niemeyer in regard to phthisis, and are interested in his division of the disease into several distinct ones, which are distinguishable always pathologically, and in many instances clinically also. The whole subject of the pathology of tubercle is undergoing a re-examination, a renewed study of it being stimulated by Villemin's discovery, in 1865, of its inoculability, and although much yet remains unknown, although there is far from being harmony among pathologists, this much has certainly been done: the reign of the doctrines of Lænnec has been overthrownmuch has been added to our knowledge-and, to speak after the manner of politicians of the day, a "new departure" has been taken for the final attainment of the whole truth.

It is singular how long the doctrines now current have maintained sway-singular, when it is known that in many points they do not harmonize with the observation of the ancients, nor with the accepted doctrines of any other period of medical history before the present century, nor with the results of modern research. Lænnec was the founder of nearly all the received views as to tubercule, and his renown as the founder of physical diagnosis, aided by the influence of Louis, fixed them upon the profession. Yet there were always dissenters, and during the lifetime of the originator of this school, Broussais opposed them, and so did Andral, and we are surprised to find in this work (vol. i, p. 225) Andral termed an "unqualified adherent of Lænnec's," because Andral recognized the origin of phthisis in inflammation, both bronchial and pulmonary, and also in hæmoptisis, all of which were denied by Lænnec, as now-the diathesis being the sole, at least the chief factor in the origin of the disease.*

The more recent school began with Virchow, and the author is one of its chief teachers. The term tubercle is now strictly limited to miliary tubercle; the diffuse, cheesy, yellow matter called "tubercu

The student who would master the history of the doctrine of tubercle from Hippocrates down to the present time, should read, "Die Tuberculose, die Lungenschwindsuch und Scrofulose. Nach historischen und experimentellen studien bearbeitet von Dr. L. Waldenburg." Ber

lin: 1869.

lous," is a product of inflammation, and not tubercle at all. The miliary tubercle may, and frequently does, undergo "caseous degeneration," and is then, also, yellow and cheesy, but it is circumscribed, either miliary, or in larger nodules formed by the aggregation of miliary. This "caseous degeneration" is not peculiar to tubercle, any pathalogical product may pass through it-Virchow has found it in the middle of malignant growths-but the exudations of pneumonia are especially prone to it, and of these are the diffuse, yellow, cheesy deposits in the lungs, called with us "tubercular deposits," and by the softening and breaking down of which cavities are formed, and thus arise by far the greater proportion of cases of consumption.

These, briefly stated, are the doctrines of the modern German school of pathologists and clinical teachers. Their important bearing upon the doctrines current with us, as to the origin, course, treatment and prophylaxis of consumption is seen at a glance; they effect, if substantiated, nothing more nor less than a complete revolution in medical doctrines.

As we desire to give our readers an opportunity of judging as to the merits of the author and the work, we will quote a few paragraphs in relation to some of these points. Speaking of the fact that "modern physicians and clinical teachers only recognize one form of consumption," the tuberculous, he says:

"I have long contested this doctrine, and, upon various occasions, have declared, in direct contradiction to it, that destruction of the pulmonary tissues, the establishment of cavities and consumption of the lung, are much more frequently a result of chronic inflammation than of tubercular deposit." (Vol. i., p. 206.)

Very different is the consumption dependent upon tubercle. This may be, of course, acute or chronic; the former is so similar in its clinical features to typhus that, we are told, the most experienced often err in diagnosis:

"The development and progress of a tuberculous consumption differ essentially in type from anything hitherto described, and its symptoms are so characteristic that the diagnosis of this form of consumption (which is not common), is, as a rule, easy. In the first place, it has no precursory catarrh. The fever and wasting are not deferred until the sputa become profuse and purulent, the tubercular eruption being accompanied by a marked elevation of the temperature and rapid emaciation of the body from excessive calorification. If we are informed that the patient did not begin to cough and expectorate until several weeks after he had begun to decline in strength, and to grow pale and thin, there is always reason to fear that he has tuberculous consumption." (P. 237.)

What is the connection between these two pathalogical products, the caseous matter of pneumonia and tubercle? The view is held in Germany that the latter is always dependent upon the former, that tubercle is therefore never a primary but always a secondary disease. Niemeyer does not go so far as this, but expresses himself cautiously:

"Although the consolidation and destruction of the pulmonary tissue in consumption is mainly a result of inflammation, yet the frequent co-existence in phthisical lungs of the products of chronic pneumonia and tubercle renders it improbable that the presence of the latter should be purely accidental, and suggests a causative connection between tubercle and the inflammatory lesions. According to the common opinion, this connection is, that tuberculosis is the primary affection to which the pneumonic process is secondary and dependent. It can not be denied that this view is right in certain cases; in a great majority of instances, however, the converse is true; the tuberculosis supervening as a secondary process upon a pre-existing pneumonia. It is, indeed, rare for tubercles to form in a lung which does not contain products of chronic inflammation." (P. 27.)

Now, in regard to the etiology of phthisis there are three points of this creed to be especially noted:

I. The denial of the indispensible necessity of a peculiar diathe sis, and the recognition of its indirect inheritance, i. e., of its being caused in the offspring by the existence even of pure debility alone of the parent:

"I regard the wide-spread doctrine that consumption is solely dependent upon a diathesis, from which it proceeds independently of all so-called "exciting causes," as equally gratuitous and dangerous." (P. 214.)

"The tendency to consumption is, in many cases, congenital. When the congenital tendency is due to the fact that the parents were consumptive at the time of begetting the offspring, it may properly be spoken of as inherited. But it is not (as is often asserted) the malady which causes the inheritance, but the weakness and vulnerability of constitution which had already laid the foundation of the consumption in the parents, or which had arisen in them in consequence of that disease. The hereditary constitutional feebleness of the offspring may proceed from other diseases of the parent instead of consumption. Parents afflicted with other exhausting maladies, or who are ruined by debauchery, or who are far advanced in years, are quite as liable as consumptive parents to beget children who come into the world with a predisposition to consumption." (P. 213.)

II. A distinct recognition of the occurrence of hæmoptisis in persons with healthy lungs, and the dependence of consumption upon the hemorrhage:

"Many physicians do not hesitate to accept a brisk hæmoptisis as a sure sign of incipient, or even established tuberculosis, although the patient may present

no symptoms, either subjective or objective, of disease of the lungs, and when, soon after the occurrence of hæmoptisis, signs of consumption have arisen, they confidently assume that the bleeding has been caused by the presence of tuber-cles, or by the process of its deposit in the lungs.

"I must earnestly protest against this opinion, as altogether unwarranted, and fraught with danger to the patient.

*

"In the very great majority of cases in which the first attack of hæmoptisis has not been preceded by either cough, dyspnea, or other signs of pulmonary disorder, the lungs are free, and by no means the seat of tubercular deposit, at the commencement of the bleeding." (P. 143.)

Upon this point the author is in harmony with all authorities in medical history down to the beginning of the present century; the doctrine was only departed from under the influence of Lænnec, and is now, by the help of others besides Niemeyer, being re-installed in its ancient sovereignty.

III. The direct origin of phthisis in repeated catarrhs is taught:

"Even a simple, genuine catarrh may extend into the air vesicles in a person of apparently perfect health and vigor. Healthy men should never feel sure that they will not die of an acute or chronic catarrhal pneumonia, proceeding from a cold, and resulting in caseous infiltration and destruction of the pulmonary substance," P. 210.)

* *

"Whenever there is the slightest suspicion of a predisposition to consumption, every catarrh, no matter how slight, is to be treated with the utmost care, which is not to be relaxed until the catarrh is entirely well. * Many patients fall a victim to the deeply rooted prejudice that a neglected catarrh never leads to consumption." (P.241.)

These extracts will suffice to show how our accepted doctrines in regard to tubercle and consumption are assailed, and how sweeping is the revolution proposed.

We must pass on to some other points.

In therapeutics the author will be found more reliable than fertile as to variety of means; more sceptical than over-reliant as to the power of medicines to control morbid processes. The reader will not unfrequently find some of his therapeutic idols overthrown by a rude shock and disposed of with brief ceremony. On the other hand, several remedies not usual with us are frequently prescribed, and we can afford to balance against his scepticism the confidence which we can not fail to feel when such an observer and teacher states a medicine to be efficacious. But whatever doubts he may entertain and express as to the powers of medicines, we speedily become convinced, as we read his pages, that they are neither idle whims nor prejudices, but the direct offspring of clinical experience. In the preface he takes occa

sion to lay down the principles which should guide us in judging of the action of medicines, and they are the only correct ones, too often overlooked, too often forgotten. Years ago he says he "declared it idle to hope for the time when a medical prescription should be the simple resultant of a computation of known quantities;" he laments the tendency to seek aid from physiology, pathology and chemistry, all of which yield now and then "an ingenious suggestion;" believes the study of the effect of medicines upon animals useless, or at least as far inferior to the one and only mode of studying therapeutics, observation at the bedside. "The empirical method of investigation is the only rational and proper one for the study either of therapeutics, or of any other department of natural science." These, as we said before, are correct principles, this is laying a sure basis, and in urging these views he is in harmony with such renowned and unsurpassed clinical teachers a Trousseau and Graves.

We will begin by illustrating his scepticism, and quote from the treatment of the effusion of pleurisy where, we think, generally, with us, the treatment would be pretty active to promote absorption and free the chest of the water-logged patient:

"Remedies for the promoting of re-absorption of the effusion deserve little reliance. It is, indeed, questionable whether it be possible, by any therapeutic means, to bring about the conditions upon which the absorption of pleuritic effusion depends. If, after the inflammatory symptoms have subsided, the effusion remain undiminished, all medication both external and internal, is to be rejected, and the application of blisters is of very doubtful use. The action of the diuretics, of which bi-tartrate of potash, boracic cream of tartar, and the juniper-berry are the best, is very uncertain, so that we can not promise ourselves much from their use, and the pernicious effects of the drastics upon digestion and asssimilation forms a serious objection to their employment. *

An attempt may also be made to excite re-absorption by the outward and inward administration of iodine, which has a well-known reputation as an absorbent. I have seen such remarkably rapid absorption take place under the internal use of syr. ferri iodidi in conjunction with the external application of a weak compound solution of iodine upon the affected side of the chest, that I can not help regarding the beneficial action of this prescription as probable, although I do not regard it as proved." (Pp. 272, 273.)

The "antiphlogistics" are not in much favor with him; he is far from being a "bleeder" in the old sense of the term. Neither in pneumonia nor pleurisy does he believe venesection has power to cut short the progress of the disease. The former, indeed, we are told, is markedly "cyclical" in character, a fact not recognized, "owing to