others, with short or abridged types, of the same nature, and presenting the same indications.

I see intermittence whenever I see an obvious alternation of symptoms and cessation, however short the intervals may be. But in proportion as the attacks approach each other more nearly, it is obvious that the short intervals which separate them must be more actively employed, and carefully seized. The maxim of the Father of Medicine, Occasio præceps, was never more applicable than here.

66

Moreover, intermittent affections with short periods, are, like ordinary intermittents, more or less distinct, and their intervals more or less complete; so that they may present only the remittent form-a form in which an element of continuity seems combined with one of intermittence; or rather there exists here a local affection, of more or less consequence, to which are added, from time to time, periodic phenomena. Such cases are by no means rare. Here, too, quinine is indicated, and will be often found useful. But here, as in the ordinary intermittent, its success will never be so complete as when we have to do with an uncombined intermittent. The condition of the disease will only be simplified, by removing from its permanent form, all that is intermittent or periodical." 569.

XII. PULMONARY EMPHYSEMA CONSIDERED AS A CAUSE OF DEATH. By Dr. Prus.

Notwithstanding the nature of pulmonary emphysema has received much illustration from recent observers, many questions regarding it yet remain in an undecided state. But the author, in the paper before us, confines his attention to the inquiry to what extent may this affection become the immediate cause of death. Laennec and Louis do not believe that it tends to shorten life, except through the instrumentality of some other disease; but other celebrated men, as Breschet, Magendie, &c., hold different opinions. Cases shewing that pulmonary emphysema has little effect upon the duration of life are numerous; but these, negative facts as they are, must not be allowed to destroy the value of positive facts proving the gravity and danger of the affection. The author quotes two of these, already published, and adds eight others from his own practice. Facts of this description are of importance, not only for the decision of the true pathology, but also in reference to medical jurisprudence.

Prior to relating his cases, he thus delivers his opinion upon the nature of the disease.

"After an attentive and frequently repeated examination of the subject, it is clear to me that pulmonary emphysema is neither more or less than the infiltration of the air into the intervesicular, interlobular, and subpleural cellular tissue -these three designations characterizing three different stages of the same affection.

"I am ignorant of, and I believe it is difficult to ascertain, what degree of distention the pulmonary vesicles may be subjected to without bursting; and the dilatation of the unbroken vesicles is a thing difficult of proof. M. Bouvier states, that all that has been written upon this subject must be subjected to a renewed examination; and, although I am also of this opinion, I believe I have seen some cases of dilated vesicles, recognizable by the manner in which they were grouped towards the termination of the bronchial ramuscule. I may add my opinion, that a dilatation of the vesicles, which cannot pass such very narrow

limits, without inducing a rupture, is a very slight lesion, and is only of importance considered as the commencement of a pulmonary emphysema, i. e. the passage of air into the intervesicular tissue. Reasons derived from anatomy, physiology, and pathology, may assist our solution of the question which now occupies us.

"The small size of the vesicles of a healthy lung renders them hardly perceptible, and it is not to be supposed they can reach ten and more times this size without rupture of their fragile walls. Insufflation of a healthy lung performed with moderation, produces a dilatation of its volume which becomes dissipated by the contractility of its own structure. But if the insufflation has been forcible, the dilatation continues permanent. It is then unequal, the air traversing in various directions, and when the insufflation has ceased, only a partial contraction takes place, leaving projections and inequalities on its surface. In the first case the insufflation has distended without rupturing the cells, and in the second, the vesicles have become ruptured, causing an effusion of air into the intervesicular structure, and which, continuing there, has prevented the lung resuming its primitive volume. It is this fact that leads to the practical rule for the performance of insufflation for asphyxia in the gentlest manner. I have seen a case of asphyxia from hanging, in which the vesicles were ruptured and the air infiltrated. M. Devergie, who has filled the office of Inspector of the Morgue for several years, states that, in all the drowned persons brought there, a rupture of the pulmonary vesicles is found to have been caused by the mere forcing back of the air they contain by the water.

"Pathology confirms these views; for, in comparing the emphysematous with the healthy lung, the permanent distention of the one is contrasted with the subsidence of the other under influence of atmospheric pressure. And this arises from the different localities of the air in the two cases. Moreover, the comparative ease with which the air can be pressed from one part to the other proves it is contained in the freely intercommunicating cellular tissue, and not in the air-cells, which cominunicate only with the bronchial ramifications." 664-6.

Dr. Prus, having detailed the cases and their post-mortem examinations, considers that he may fairly declare death to have been caused by asphyxia, occasioned by the pulmonary emphysema, seeing that there was no other means of accounting for its production. The patient, a prey to habitual dyspnoea, which occasionally becomes almost suffocative, and manifesting a greater or less degree of cyanosis, at last dies; and, on examination marked pulmonary emphysema is found, the heart and great vessels are in a normal condition, (except in some instances of slight hypertrophy with dilatation of the right ventricle, which has been proved by Laennec and Louis to be consecutive upon pulmonary emphysema,) no oedema present; the blood in the cavities of the heart black and oilylooking. The vessels of the brain and its membranes gorged with black non-coagulable blood. It is impossible not to seize the connection of the facts of the patient presenting all the signs of defective changes in the blood, and the presence of a disease which in a greater or less degree presented an obstacle to the due hæmatosis. In seven out of the ten cases, the patient was between 56 and 79 years of age, when the cells would have become irregular, dry, and fragile-thus offering every facility for the production of the disease. Frequent opportunities of examining the condition of the parts in broken-winded horses confirm the above conclusions.

Another series of confirmatory observations may be adduced from the

fact, that several diseases, which would not otherwise have caused the patient's death, become at once mortal when complicated with this

one.

"Thus a Winter does not occur wherein we do not observe in our infirmaries for the aged a great number of patients seized with pneumonia of so very limited an extent, that frequently it only becomes mortal, because a more or less considerable portion of the lung, being affected with emphysema, is unable to effect the requisite changes in the blood. How frequently too have affections of the heart, which could not be said to menace life, except at some distant epoch, become suddenly mortal, owing to this complication." 711.

Upon the connexion of Pulmonary Emphysema with Asthma, we have the following observations :

"To seek, as some do, to explain all the phenomena of asthma by pulmonary emphysema, is to commit a serious error. Those who refuse to be led away by prevailing theories, will recognize in asthmatics three circumstances, which are often united, but may exist separately, viz. the nervous affection, pulmonary emphysema, and bronchitis.

"The neurosis, which is the sole essential condition of asthma, may exist a long time without emphysema or bronchitis. Every physician has seen patients who, after violent paroxysms of asthma, entirely recover perfect freedom of breathing, of motion, and of exercise of all their powers. It is for this neurosis, whether simple or complicated with emphysema or bronchitis, that opium has been prescribed with such constant success by Floyer, Laennec, Louis, and others.

"Pulmonary emphysema, which might be expected to be, and frequently is, the consequence of the deep and violent inspirations of asthmatics, may arise also from other causes, as violent muscular efforts, &c., and need not be accompanied by any of the signs of asthma. M. Louis cites three cases of undoubted pulmonary emphysema, in which the patients suffered from no difficulty of breathing.

"Bronchitis, which, in a great number of cases of asthma, is the sole determining cause of the paroxysm, and in almost all adds singularly to the frequency and intensity of the paroxysm, is not necessarily a companion of either nervous asthma or pulmonary emphysema.' 700.

The following are the author's conclusions:

"1. The seat of pulmonary emphysema is the intervesicular, interlobular, and subpleural cellular tissue. 2. M. Louis is correct in his statement, that when pulmonary emphysema is once produced it always remains. 3. It is generally the case also that the extent and degree of pulmonary emphysema are in direct proportion to its duration. 4. This affection may, by gradually diminishing the hæmatosis, produce a slow death, long foreseen, and constituting the aerian phthisis of Storck. 5. Under other circumstances, it may produce sudden or almost sudden death-these being the cases to which medical legists should especially direct their attention. 6. When, in the absence of any other organic lesion sufficient to account for death, we find, in cases of sudden death, a well developed pulmonary emphysema, a careful examination of the blood should be made. If this is found blackish, fluid, and oily, there is strong reason to believe that death has arisen from asphyxia, produced by the pulmonary emphy

sema.

721.

No. LXXVIII.

X

XIII. ON THE POISONOUS PROPERTIES OF SULPHATE OF QUININE. By Dr. Mélier.

The timidity with which this medicine was administered at its first introduction, has, according to Dr. Mélier, been succeeded in France by an undue degree of rashness. He especially alludes to the enormous doses (about 100 grains per diem) given by M. Briquet in acute articular rheumatism. Soon after these were recommended, the author and Magendie administered large quantities to several dogs. Most of these animals died, and their lungs were found congested and infiltrated with blood, while their substance in many parts was converted into a spleen-like substance. The blood was in a great measure deprived of its coagulability, the clot softened, diffluent, separating easily from the serum, which remained discolored and thick, holding the colouring matter in solution. It is important, in a therapeutic point of view, to observe that the quinine acted far more energetically on the animals, when given fasting, and when dissolved in sulphuric acid, than when given upon a full stomach, or in its partly soluble condition.

In reference to the effects of too large doses on man, it is to be remarked that many writers had noticed the occasional ill effects of bark, prior to the discovery of quinine, when administered too largely. The author reviews in succession the various cases, giving his authorities, in which quinine has been manifestly hurtful. Death is distinctly traced to its use in four cases of articular rheumatism, presenting no especial marks of danger, and occurring within a short period. Delirium and coma, paralysis, epilepsy, pneumonia, hæmaturia, gastralgia and diarrhoea, are among its ill effects. Deafness, too, is a pre-eminently common effect. Moderate doses of quinine are indeed sometimes followed by temporary deafness, but after excessive doses it may become incurable.

These accidents are reducible to three categories or degrees. 1. When they affect the nervous system, seeming to be a mere exaggeration of the regular mode of action of the medicine. 2. When the influence is extended to the circulation, whence congestion, pneumonia, hæmaturia, and cerebral mischief. 3. Complete prostration of power, coma, and death.

These observations may throw some light upon the mode of action of the remedy. Formerly, when fears of the ill effects of bark or quinine were expressed, these were directed to the possibility of its producing inflammatory affections of the stomach or intestines; but, although these may be produced they are neither of the same extent or probability as supposed. It is remarkable indeed how large a dose of quinine the stomach will support. It is not therefore the local but the general action of this substance that is to be dreaded. Absorbed into the blood, it changes the constitution of this fluid, depriving it of its coagulability, and acting upon it, when in sufficient dose, in the same manner as many other poisonous agents. Its absorption into the blood and elimination from it, seems to take place very rapidly, as it has been detected in the urine in a very short time;-from which fact the precept may be deduced, not to administer it at too long a period prior to the paroxysm it is directed against. Convinced from the above researches of the danger of these

large doses, the author is no less so of their uselessness. Prompt cures have been procured by moderate doses, in the various diseases to which the medicine is applicable, and the having recourse to such extraordinary quantities he attributes to a prevailing rage for excessive doses (perhaps a re-action from former timidity), by which some think everything is to be accomplished.

The author protests against any desire of underrating the utility of quinine, and appeals to a paper of his, which we have already noticed, recommending an extension of its employment to several affections, in which it has not been customary to employ it. He considers it as the most precious of all the agents which have enriched therapeutics. Moreover, in the very affection in question, namely articular rheumatism, he sees reason, from the intermittence which is usually present, to approve of its administration; and adverts to the fact that bark has been recommended by Morton and others for this disease, and the quinine itself employed by others with variable success. He only protests against the scruple and other large doses which tend at once to dishonour the medicine, and to compromise the safety of the patient.

We have left unnoticed the following papers. A Case of Severe Injury to the Brain attended by no serious symptoms, although accompanied by extensive loss of substance. An Essay upon Phthisis in Martinique. A Paper on Hypochondriasis-and one by Dr. Foville upon the Communications between the Cerebrum and Spinal-marrow. The three first present little worthy attention; and the last requires a fuller analysis than our limits now permit. We hope to return to it at a future opportunity.

A TREATISE ON FOOD AND DIET, WITH OBSERVATIONS ON THE DIETETICAL REGIMEN SUITED FOR DISORDERED STATES OF THE DIGESTIVE ORGANS; AND AN ACCOUNT OF THE DIETARIES OF SOME OF THE PRINCIPAL METROPOLITAN AND OTHER ESTABLISHMENTS FOR PAUPERS, &c. &c. &c. By Jonathan Pereira, M.D. F.R.S. & L.S. London. Longman, &c. &c. 1843.

We already possessed in our language several works on the Materia Alimentaria, viz. Cullen's celebrated works on that subject, Dr. Paris's deservedly popular work" on Diet," with many others of various degrees of merit. The present treatise, however, differs from its predecessors in many particulars. In the first place it contains a tolerably full account of the Chemical Elements of the food; 2dly, it is remarkable for the increased space devoted to the consideration of Alimentary Principles, after which the subject of Compound Aliments is considered. This plan of separately considering Alimentary Principles and Compound Aliments the author has adopted from Tiedemann. The work is divided into Two PARTS. In the first part we have the chemical elements of the food, the Alimentary Principles of