Case of Chronic Hemiplegia, with extreme constipation and coldness of the paralysed side.-F. J., aged 27, consulted me November 6th, 1863. He had to be carried into my room. Became paralysed seven years previously. The elbow is immovably flexed, the fore-arm is pronated, the fingers and thumb are powerfully flexed into the palm of the hand. Can raise the right leg a little, but cannot flex it at all, the foot is drawn inwards, cannot move the toes in any way. The tongue can be only so far protruded as to get its tip over the teeth, can drink with great difficulty, and only very slowly, can bite, but cannot grind his food. Has wholly lost the power of speech. Breathes stertorously, and is often afflicted with an uncontrollable sardonic laugh.

Temperature of right hand 83° Fahr., of left 87°, of right leg 84°, of left 89°. Bowels habitually costive, open about twice a week, sometimes only once if aperient medicine is not taken; makes water with distressing frequency. The patient came to me from Ireland, whither he returned after visiting me once. I ordered ice to be applied along the whole spine three times a day. Owing to his adverse circumstances the treatment was continued only a short time. May 18th, 1864, he wrote to me as follows:-" When three weeks had elapsed [after the date the treatment began] an obstinate constipation, from which I had suffered for years, seemed cured. The temperature of my paralysed hand rose considerably, and for the first time for six years I hobbled about with a walking cane, and continue to improve."

In answer to an enquiry concerning his condition, which I subsequently addressed to him, this patient wrote to me, May 7th, 1866, that "since the very imperfect trial of the ice treatment" immediately after he first consulted me, he had "failed in procuring ice except for a day or two." when, as he said, "we had frost here;" that, nevertheless, his improvement had continued; that he had begun to "mumble a few words;" that, "under favourable circumstances the palsied side is as warn as the other;" that "the bowels act very regularly;" and that, in respect to the excessive micturation with which he was troubled, "there is a grand improvement; for the last few weeks that failing has all but vanished, though it was nearly nine years old."

I regret extremely that this patient could not continue the treatment I advised; it is evident that it was doing him great good; and, to the extent of the benefit derived from it, the case would have afforded a still more decisive illustration than it is already of the remedial efficacy of the method in question, as well as an answer to an eminent London physician who saw the patient with me, and who then said to me, "Well, you don't expect anything can be done here, do you?"-Medical Press and Circular, May 29, 1867, p. 502.

DISEASES OF THE ORGANS OF CIRCULATION.

30.-DIGITALIS IN DISEASE OF THE HEART.

By Dr. J. MILNer Fothergill, Morland, Westmoreland.

Both the experiments of Handfield Jones and Fuller show conclusively that in digitalis-poisoning the heart is found in a state of tonic contraction. Clinical observations, which of course, are much more numerous than physiological experiments, show also that under digitalis, in many cases an irregular pulse becomes much steadier, the beats becoming more equal and regular; clinical observation will show, too, yet another fact, not by any means so well known, that where a heart, with or without valvular disease, is beating so feebly that its apex-beat cannot be felt, that its sounds are inaudible almost, certainly undistinguishable, and the pulse almost imperceptible, under digitalis it becomes so altered that its apex-beat becomes perceptible; not only can the natural sounds, but, where present, the abnormal sounds can be clearly distinguished, whose presence before could only be suspected, and the pulse can be distinctly counted.

To illustrate its action, let me bring forward one or two cases. An old and

easy gentleman-with feeble irregularly-beating heart, with mitral regurgitation. who can scarcely walk round his garden, and is frequently brought in almost pulseless from cardiac syncope, requiring strong stimulants to keep the heart beating at all-in a few weeks after the administration of digitalis can walk two or three miles without discomfort; which state continues, and he has not had an attack of cardiac syncope for months-in fact since the treatment commenced. The dropsical patient-swollen, distended, breathing with the greatest difficulty, and often gasping in agony, his passively congested kidneys secreting only a few ounces of urine daily-under digitalis often leaves his bed relieved, his breathing easier, the oedema diminishing, and his kidneys, which before were unable to relieve the system, however goaded by diuretics, now secreting freely. And this not by its lowering the circulation, and thus relieving the renal congestion, as the old expla nation ran, for in fact the heart beats inore vigorously, the pulse is firmer; but because the blood now circulates more rapidly, is more readily brought in contact with the different depurating organs, and thus its watery portion more quickly excreted. Water is being constantly generated within the body, as one product of hydro-carbonaceous oxidation, and in the removal of it the kidneys have a great share; but unless the different portions of the blood are properly and quickly enongh brought in contact with the depurating organs, elimination cannot be efficiently carried on. "It seldom succeeds in men of great natural strength, of tense fibre, of warm skin, of florid complexion, or in those of a tight and cordy pulse. On the contrary, if the pulse be feeble or intermitting, the countenance pale, the lips livid, the skin cold, the swollen belly soft and fluctuating, or the anasarcous limbs readily pitting under the pressure of the finger, we may expect the diuretic effects to follow in a kindly manner."-(Withering, quoted by Pereira.)

Another case particularly strikes me. A young woman of thirty, suffering from palpitation on the least exertion, was very weak, her pulse merely a tremulous motion,--for no distinct pulse could be ascertained,—the sounds of the heart were undistinguishable, and the impulse imperceptible, to this was added decided azoturia. Tonics of various kinds and variously combined, vegetable, mineral, with and without cod-liver oil, seemed to have no effect at all. At last, beginning to suspect that the state of the heart might be the cause and not the result, digitalis was administered soon the pulse could be distinctly counted, but fast and irregular; the heart's sounds could be made out, and the condition of a simply dilated heart was clearly revealed. Synchronous with the improvement in the centre of the circulation was a decided improvement in the other symptoms; the debility was no longer so extreme; moderate exertion no longer brought on violent attacks of palpitation; the nutrition of the body was improved, and the patient went steadily forward. She had suffered a great deal of mental anxiety and hope deferred." which had probably altered the innervation of the heart.-Edinburgh Medical Journal, April 1869, p. 876.

DISEASES OF THE ORGANS OF RESPIRATION.

31.-ON THE MECHANISM OF THE CREPITANT AND THE SUBCREPITANT RALE.

By Dr. AUSTIN FLINT, Professor of the Principles and Practice of Medicine in the Bellevue Hospital Medical College, New York.

[Laennec attributed the moist crepitant râle to the bubbling of liquid in the air-cells, the bubbles seeming to be extremely small. Dr. Flint in this paper shows that it is really owing to the sudden separation of the coherent surface of the air-vesicles. This he does by producing the râle artificially by means of a new commodity called the "patent india-rubber sponge." In 1842 Dr. Edson Carr communicated a paper to the American Journal of Medical Sciences, showing that in the first stage of pneumonia the air-vesicles contain a certain quantity of thick and tenacious matter.]

.

In the first edition of a work on physical exploration, written by the author of this paper, and published in 1856, Dr. Carr's explanation of the crepitant râle is adopted in the following terms: "The most rational theory, and the one which meets best the objections to that of Laennec, was offered several years ago by Dr. Carr, of Canandaigua, N. Y. Dr. Carr attributes the production of the sound to the abrupt separation of the walls of the cells which had become adherent by means of the viscid exudation incident to the early stage of inflammation. A viscid exudation within the cells and bronchioles belongs among the local phenomena of the disease (pneumonia); and as it is not readily removed by expectoration, but accumulates until the cells are filled, and the lungs solidified, the constancy of the râle for a certain time is intelligible. Its occurrence with inspiration only is fully explained by this theory. The conditions for the production of the sound are only present after the lungs have collapsed with expiration, when the agglutinated walls of the vesicles and bronchioles are separated with the expansion of the lung by the inspiratory act. Adopting Dr. Carr's explanation, it would be expected, as observation shows it to be true, that the sound would be present in the early stage of pneumonitis, the air in this stage still entering the vesicles, and subsequently cease, nearly or entirely, in proportion to the extent of the completeness of the subsequent solidification. The fact that, when solidification has taken place, a certain number of cells are not filled with the morbid exudation, and remain in the condition which characterizes all the sells in the early stage, explains the persistence of the râle in some cases during the second stage of pneumonitis, and its being developed, under some circumstances, by forced inspiration and especially at the ead of the inspiratory act. The theory of Dr. Carr is also equally applicable to cases of œdema and hæmoptysis, in which the crepitant râle is observed. In these affections the vesicles contain a liquid which is glutinous, although in a less degree than in pneumonitis; and we can readily understand that the necessary physical conditions are present sometimes, but not constantly, on account of the greater facility with which the liquid escapes from the cells into the bronchial tubes, thus giving rise to the bubbling râles-the subcrepitant and mucous."

It would be affectation not to admit that I derive a certain degree of personal gratification in the demonstration of the correctness of Dr. Carr's explanation, from the fact that no other work on auscultation, within my knowledge, has adopted this explanation. Of prominent contemporaries I may name Barth and Roger, Fuller, Gerhard, Bowditch, Hughes, Blakiston, Latham, Gairdner, and Skoda (London edition, 1853), as adhering to the bubbling theory. Gerhard, in his treatise on the chest, edition of 1846, attributes the râle in part to bubbles, and in part, to "the dilatation of the thickened and stiffened vesicles." My friend Dr. Loomis, of this city, in his recent publication, entitled "Lessons on Physical Diagnosis," after stating that there are two views as to the mechanism, viz., one attributing it to bubbling, and the other to the separation of the walls of the air-cells glued together by a viscid secretion, expresses the opinion that "it may probably be produced in both these ways." He introduces, however, a diagram from the work on diagnosis, by Da Costa, in which bubbles are figured within the air cells. In the late work on Internal Pathology and Therapeutics, by Niemeyer, I find the following sentence: " Perhaps it (the crepitant râle) originates in the following manner: the alveolar walls are glued together by a viscid exudation during expiration, while they are forcibly separated by the entrance of air during inspiration."

The opinions which have been noticed relate to the mechanism of the crepitant râle. As regards the subcrepitant râle there have not been differences of opinion. That this is a bubbling râle no one can doubt. The character of the sounds, their occurrence in both inspiration and expiration, the inequality of the sounds which enter into the râle, and the comparative slowness of their evolution, constitute adequate evidence of bubbles.

For my knowledge of the artificial production of the crepitant râle in the way I am about to describe, I am indebted to my friend and associate, Dr.

Henry F. Walker. Dr. Walker happened to purchase an articled labelled "Patent India-rubber Sponge," which is designed to take the place of the ordinary sponge for the toilet. This article consists of a block of india-rubber which has been made to assume a cellular arrangement, evidently by the introduction of air or gas while the substance is in a liquid state and during its congelation. On examining the article, it will be seen to be made up of cells of unequal size, the appearance being very like that of a portion of emphysematous lung. The elasticity of the india-rubber causes the article to expand after it has been compressed, the well-known cohesiveness of this substance offering a certain amount of resistance to the expansion. Now, after having examined the structure, if each one present will compress with the finger the article which I shall ask you presently to pass around, holding it close to the ear, and then allow it to expand, it will be at once perceived that a crepitant râle is beautifully represented. The fineness and the dryness of this râle are perfectly exemplified. It will be observed that the compression of the article causes no sound. This act of compression is to be considered as taking the place of expiration. The expansion is analogous to the movement of the lung in inspiration. The compression brings the walls of the cells into contact, and, from the adhesiveness of the substance, they cohere with a certain amount of force. There being no liquid present, the râle must be produced by the separation of the cell-walls by the elasticity of the substance. The intensity of the crepitation will be found to be proportionate to the force of the compression, the cell-walls being brought more completely into contact and the cohesion being greater according to the amount of compressing force.

Purchasing the article for another purpose, Dr. Walker was led to notice this unexpected application, and being associated with me in giving practical lessons in auscultation, he called my attention to its usefulness, as affording an exact representation of the crepitant râle preparatory to the demonstration of this sign in cases of pneumonia. It is indeed highly useful for this purpose. But, in addition, it serves to demonstrate that the crepitant râle in cases of disease is produced, not by bubbling, but by the separation of the coherent walls of the cells and bronchioles. The representation of this sign is so complete by means of this article, that I do not see how any one can doubt that the mechanism is the same. I assume, therefore, that the explanation of the crepitant râle, published more than twenty-five years ago, by our countryman Carr, is proved to be the true explanation; and I claim in be half of his memory the credit of the explanation which, by the author of the article on Auscultation, in the new French Dictionary of Medicine and Surgery, is accorded to others. As a friend of the late Dr. Carr, I cannot but have a feeling of regret that he did not live to see the correctness of his explanation established. As it is, justice to his memory, in respect of the originality and priority of the explanation, will be gratifying to numerous friends who held him in high esteem for his professional attainments and private worth.

The production of the crepitant râle, in the manner now illustrated, demonstrates the error of attributing the fineness of the râle to the small size of the cells. The fineness is not less marked when produced by the india-rubber sponge than when it emanates from the pulmonary vesicles and bronchioles. Dr. Carr's mode of illustration, by pressing together and separating the finger and thumb moistened with thick paste or mucilage, also demonstrates this

error.

In concluding my remarks on the crepitant râle, I will refer to an explanation of the peculiar quality of the inspiratory sound in the normal vesicular murmur, which, so far as I know, is original with me. Quoting from my work on physical exploration (2nd ed., p. 133), I say with reference to this point as follows: " May not the peculiar quality (called the vesicular quality) be owing to the separation of the walls of the cells, or bronchioles, which, to a greater or less extent, are in contact, and owing to the moisture of the tissues Lecome slightly adherent during the partial collapse of the lung at the end of an expiration? We shall see hereafter that this is the most rational explana

tion of an important and highly distinctive physical sign of disease, namely, the crepitant râle. The fact that the air does not circulate freely in the arcells and bronchioles with each inspiratory act, renders probable the explanation suggested by the foregoing inquiry. Other facts supporting this explanation are, the increase of this peculiar quality of sound in the inspiratory act which succeeds a forced expiration in the act of coughing; the diminution of the quality in cases of permanent dilatation of the air-cells, or emphysema, and the limitation of this quality to the inspiratory sound." In view of the demonstration of the mechanism of the crepitant râle, the correctness of the explanation of the vesicular quality in normal respiration, which is offered in the foregoing quotation, seeins to me extremely probable. We have the crepitant râle in pneumonia, because the air-vesicles and bronchioles are glued together at the end of expiration by a viscid morbid product. We have a slight approach to this râle in health, in the vesicular quality of the inspiratory sound, because the air vesicles aud bronchioles are very slightly coherent at the end of expiration. The peculiar quality of the inspiratory sound in the normal vesicular murmur, Laennec compared to a "slight crepitation," but in view of his theory of the crepitant râle he could not, of course, suppose that the mechanisin of this slight crepitation and of the crepitant râle is the same.

A good imitation of the vesicular quality in the inspiration of health is obtained by wetting a fine ordinary sponge, squeezing it as dry as possible, then compressing it, and allowing it to expand close to the ear. The liquid may be so effectually squeezed out of an ordinary sponge that there is not enough left for bubbling; but the moisture occasions a very slight cohesion of the cells when pressure is made, and the expansion gives such an approach to crepitation as constitutes the vesicular quality in the normal vesicular murmur. This mode of representing the vesicular quality goes to prove its mechanism. Concerning the mechanism of the subcrepitant râle, as already stated, there is no difference of opinion. This râle is produced by the bubbling of liquid; it is therefore essentially different from the crepitant râle. The article which, as has just been seen, represents crepitation, may be used to exemplify the subcrepitant râle, and to illustrate certain points relating to the differentiation of the two râles. The application of the "india-rubber sponge" to show the mechanisin of the subcrepitant râle was suggested by Dr. William J. Chandler, one of the house physicians at Bellevue hospital. If a portion of the "sponge be compressed and allowed to expand under water, the cells are filled with liquid; and now, holding it close to the ear and alternately pressing it and relaxing the pressure, fine bubbling sounds are produced. That bubbling is caused by the pressure, is shown when the portion of " sponge," of the cells filled with liquid, is compressed under water; small bubbles, of unequal size, in great abundance, rise to the surface. This artificial subcrepitant râle is produced alike by the pressure of the "sponge," and by the expansion after the pressure; thus, the fact of the occurrence of this râle, as a morbid sign, in both inspiration and expiration is illustrated.

The bubbling, as thus produced, is very fine, and the resemblance of the subcrepitant to the crepitant râle is admirably shown by producing alternately, with two portions of "sponge," one portion dry and the other filled with liquid, the representation of the two râles. This may be practised with advantage in order to exercise the ear in discriminating the differential characters of these two râles.-New York Medical Journal, Feb. 1869, p. 449.

32. ON THE USE OF ETHER AND ETHERISED COD-LIVER OIL IN THE TREATMENT OF PHTHISIS.

By Dr. BALTHAZER W. FOSTER, Physician to the General Hospital, Birmingham.

[It is only of late years that the disorders of digestion associated with pulmonary tubercle, have attracted special attention. The difficulty of assimi