which only come once to the hospital during the first week of the disease become classed with those which have no ulcer, although many of them no doubt have it developed later; indeed, as a matter of fact, the ulcer does not appear until the paroxysmal stage has existed for some days. The average length of attendance at the hospital of those having the ulcer was 6.5 weeks; but, among those not having it, it was 4.8 weeks.

The following table shows the ulcer at different ages:

Among the 84 cases, 45 were females and 39 males, and the ulcer of the frænum was present in 16 out of the 45 females, and 11 out of the 39 males.

From the foregoing table it would appear, that the third, fourth, and fifth years are the ones during which the ulcer most frequently occurs.

That the cause of ulceration is due entirely to the friction of the soft parts against the teeth I have myself little doubt, and can entirely indorse what Dr. Maccall says on this point. I have never seen the ulcer in a child before the lower incisors were cut, and, in two cases, where the lower incisors had entirely disappeared in children of three or four years respectively, the ulcer never appeared, although repeatedly looked for. The manner in which children cough is a very important point in the production of the ulcer. Some children instinctively protrude their tongues as far as possible—especially is this the case in those of three or four years old, in whom the pharynx is small; but with older children the necesssty for the protrusion of the tongue is not so urgent, and they have also, in one sense, a greater command over it; hence, in these latter, the ulcer is not so frequently formed. The time, also, at which the ulcer usually first appears, viz., during the second and third

weeks, and its coincident disappearance with the spasmodic stage, is exactly what the mechanical theory requires.

Perhaps the inflamed and swollen orifices of Wharton's ducts, opening as they do on each side of the frænum near the central line, have been mistaken for the commencement of follicular ulcer; but this condition, I take it, results also from mechanical irritation. That the symptom is an important diagnostic one I think all are agreed, and its simple explanation does not detract one whit from its value.

Transfusion.-At the meeting of the Société Biologie, Dr. Brown-Sequard gave an interesting account of his experiments on transfusion. He had made use of different sorts of liquid for transfusion, such as normal blood, blood without its fibrine, and milk. In such case he found the results to be the same, but in the case of the milk the quantity that it was necessary to inject was more considerable than in the others. Ninetyfive grammes of blood was drawn from a dog, and were replaced by the same amount of milk. Shortly after the operation (about forty-five minutes) there was no trace of milk globules to be found in the blood, and the dog has continned in excellent health ever since the operation, which took place more than five months ago. M. Malassez found, upon examining the blood after the transfusion, a greater number of white globules than normal. In concluding his remarks. Dr. Brown-Séquard expressed the opinion that the liquid injected should be at least of a temperature of 10° to 12° C. It was preferable, he thought, to chose the arteries rather than the veins, and recommended the operation to be done very slowly, in order to allow the liquid injection to acquire the temperature of the blood. Transfusion also succeeded in animals when the blood made use of comes from a species of animals different from that of the one under experi ment. It appears that Dr. Thomas, of New York, has tried the transfusion of milk on the living subject, and is convinced that it acts as well as blood.-The Lancet.

MEDICAL & SURGICAL JOURNAL

DECEMBER, 1878.

Original Communications.

PHTHISIS AND ITS VARIETIES:

A LECTURE DELIVERED AT MONTREAL,

BY ANDREW CLARK, M.D., F. R. C. P., LOND.,

Physician to the London Hospital, &c., &c.

It was signified by circular, signed by Dr. Geo. W. Campbell, the Dean of the Medical Faculty of McGill University, and addressed to the profession at Montreal, that Dr. Andrew Clark, who had come to this country on the staff of H. R. H. the Princess Louise, would deliver a lecture on the subject of Phthisis. In response to the general invitation extended the Lecture Room of the Natural History Society was filled with medical practitioners of both nationalities, as well as with the students of the three medical schools in this city. A number of coloured drawings illustrative of cases that had come under Dr. Clark's observation, were placed on the table.

Dr. Campbell, in a few words, introduced the lecturer, who said :—

When I desired to have the privilege of laying these drawings of phthisical lungs before you, and of setting forth, in short and simple outline, the views which I have formed concerning the varieties of phthisis, I did not presume to think that in a place so distinguished for its additions to science as this is, and in the presence of persons, many of whom have contributed and are contributing to that distinction, I could say anything which would appear new, still, I desire to lay these drawings before you, and to set forth the views which I have formed, after long study of the subject in order that I might have the benefit of your friendly criticism, and learn how far your own experience corroborated or confirmed my own conclusions. It is not

NO. LXXVII.

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my intention—indeed it would be out of place to enter into any critical or historical sketch of the history of the various theories which have been promulgated respecting phthisis. I shall proceed without further preface, at once, to the heart of my subject, and endeavor in the fewest words and plainest manner to lay before you the conclusions at which I have arrived.

By phthisis I mean that assemblage and progression of symptoms, due to suppurative or ulcerative destruction, of more or less circumscribed non-malignant deposits in the lung. I shall not pretend that this definition is perfect, but I claim for it that it is a good working definition, and has this enormous advantage, that it involves no hypothesis, and whatever our views of phthisis may be, we may retain the name whilst the idea may change. You will observe in this definition that I have set entirely on one side the disease with which we are all familiar, under the name of Acute Tuberculosis.

The chief thing I have to say about that disease, before dismissing it, is this :-I think it has no special relations to phthisis at all. In its methods of approach, in the phenomena which attend its progress, and in the changes which we discover in them after death, in the state of the organs during life, it exhibits all the characteristics of what we call zymotic disease. I look upon acute tuberculosis as a sort of fever; which has for one of its anatomical expressions the little things called tubercles. If I appeal to the experience of any one present who has had the opportunity, not often acquired, of examining a number of cases of acute tuberculosis, I am sure he will agree with me that acute tuberculosis rarely issues in what we call phthisis, or in any disease which would come within the terms of the definition I have made. Acute primitive tuberculosis, beginning often, either in children or adults, in apparently perfect health, producing fever, with a sort of capil lary bronchitis, making rapid progress, marked by irregular fever, usually terminates in death in from three to six weeks.

Now, I might add, that having been occupied at the same time as Villemin in performing experiments upon inoculation, and having also tried other methods of producing tuberculosis

as well as by inoculation, I have come to the conclusion that the disease produced by inoculation is not a true tuberculosis. In all my experiments on animals, I found that with decent care, the so-called tuberculosis produced, invariably disappeared, that the progress of the malady, whatever it was, was unattended except at the beginning by any fever; that in animals inoculated, a disease is produced which does not appear to affect the general health, and which within five or six weeks disappears, leaving the animal as well as before. You will agree with me that this cannot be called acute tuberculosis in the same sense as that other malady, which is sudden in its commencement, rapid in its progress, profound in its constitutional effects and terminates almost invariably in death. When we examine the lungs of the bodies of patients who have died of phthisis, we may, without any undue refinement, classify these lungs under three groups. In the first group, we shall find that the dominant destructive element is tubercle, and its secondary consequences. In the second group we have pneumonia as the dominant anatomical element. In the third group the dominant anatomical element is fibroid tissue. I have purposely used the term "dominant element," to protect myself against any adverse criticism which has no just foundation.

The lung is a complete organ, and several anatomic elements enter into its constitution. When these are irritated by any foreign body, each comports itself after the manner of its kind; so that with one irritating agent, you may have different anatomical results. If tubercle is deposited in the lung and the patient is susceptible of being irritated by it, we know that two secondary consequences prevail,-one, a form of pneumonia, the other, some form of fibroid change, and just as the one or other of these secondary results prevail in the future progress of the case, rapid and febrile if the pneumonic, slow and free from fever if the fibroid prevails. So true is this, it has almost given rise to an axiom with respect to the chronic phthisis, that in tubercles, per se, it never kills; it is the tubercle plus the secondary effects of the tubercle, which is fatal.

a. Now, as each of these three groups has a distinctive history;