that is, in diseases resulting from some defect of primary assimilation, its effects have not been very accurately studied, chiefly perhaps from the difficulty of finding pure and uncomplicated cases of this affection. It appears to be most useful in the atonic varieties, and in those cases of inflammatory gastro-duodenal dyspepsia, in which, after reduction of the more prominent symptoms, the digestive powers of the stomach and duodenum recover themselves with difficulty. But in any cases in which the dyspeptic symptoms are dependent on more serious lesions, on ulceration of the stomach, or on incipient organic disease of the walls, &c. the cod-liver oil appears to be unsuited, and even if retained on the stomach, to be inefficacious, or perhaps hurtful. It is chiefly in affections proceeding, as far as we at present know, from secondary malassimilation (to use the term of Dr. Prout), that the oil appears most useful. Such appears to be the case in chronic rheumatism, in rickets, in the various affections which are the local manifestations of the scrofulous diathesis, scrofulous caries, ophthalmia, tabes mesenterica, tubercular peritonitis, &c.; in phthisis pulmonalis, especially in the early stages; and in various chronic eruptions of the skin, as eczema, herpes, and some forms of impetigo. It appears to be more useful in these diseases of the skin, according as they can be traced back to some disorder of nutrition, and more especially if this borders on the condition which occurs in the scrofulous diathesis.

In addition, the oil has been used in a vast number of other affections, with an amount of benefit less marked and determinate. In true gout, psoriasis, porrigo, osteomalacia, in atonic amenorrhoea, in worms, and in the various sequelae of smallpox, measles, and typhus, the opinions of its utility are very contradictory. It has appeared to be possessed of little power in Bright's disease, diabetes mellitus, and some other deep-seated and obscure affections. Cod-liver oil has also been found useful in cases in which tonics are indicated; as in convalescence after influenza, bronchitis, pneumonia, pleurisy, and other cases in which the disease having been partially or entirely removed, the constitution requires to have cautiously supplied to it both materials from which its impaired tissue may derive new force, and tone by which those materials may be effectively assimilated.

An opinion has been advanced, on very insufficient grounds however, that chronic rheumatism and tubercular consumption are in some degree antagonistic to each other. But independently of other arguments against such a view, we might be led to question its correctness by observing that the two diseases, or series of diseases, over which cod-liver oil appears to exert a considerable action, are chronic rheumatism and scrofulous affections. While in most other cases the benefit resulting from the use of the oil appears to be simply owing to its common tonic powers, in the abovenamed diseases there almost appears to be something specific about its action. In the work before us, as in other treatises on the same subject, we find very strong statements respecting the utility of the oil in phthisis. Some of these are derived from previous writings, others are made by several eminent Dutch physicians, whose opinions on this point Dr. de Jongh ascertained. Suermann, Schroeder Van der Kolk, Loncq, Pruys, Van der Hoeven, Sebastiani, and Suringar, all agree in attributing very great benefit to its employment. They almost all, however, consider that its good effects are chiefly limited to the early stages, before softening has

commenced. At this time, undoubted cures have been effected; the further deposition of tubercle appears to have been arrested, and the tubercles already formed have retrograded in one of the usual ways, most commonly by cretaceous deposit. When softening has occurred, the virtues of the oil are more questionable; for while occasionally it appears to be of immense benefit, at other times it has exerted no effect whatever. In phthisical diarrhoea it has seemed decidedly hurtful.

In an able paper by Dr. Williams, which has lately appeared,* the utility of the oil in phthisis, particularly in the latter stages, is rated even higher than in the above paragraph. Dr. Williams's conclusions are based on the experience of about 400 cases. Of these, 234 are recorded in his note-books, and are therefore susceptible of numerical classification and analysis. Among these 234, there were 9 cases in which the oil disagreed, 19 in which it appeared to do no good, and 206 in which its use was followed by marked and unequivocal improvement. Of the 206 patients, 62 had cavities; all of these improved materially under the use of the oil; in 34 the improvement has continued; in 11 the improvement was only temporary; in 17 the patients were lost sight of. In 100 patients the tubercles had commenced to soften, but actual cavities had not formed, and both physical and general symptoms materially and rapidly changed for the better. The process of softening seemed arrested, as the moist rhonchi in the supra- or infra-clavicular or the supra-spinous regions gradually ceased, the dullness more or less disappeared, and at last, vesicular breath-sound returned, and no physical signs whatever remained, except a little prolonged and, perhaps, tubular expiration. Coincidently with these changes, the constitutional symptoms disappeared. In the remaining 44 patients, the disease was in the early stage, and the results were not less satisfactory. Eleven of the advanced cases are related as illustrations of the degree of improvement.

In estimating the exact value of this evidence, it would be necessary to strike off from the list a certain per-centage of improvement which seems to occur in phthisis from the employment of any judicious treatment,† such as a regulated temperature, change of air, proper diet, regular habits, and various medicines, according to circumstances. The exact amount which would be thus struck off, cannot, from want of data, be at present determined, but there is no reason to believe that it would be very considerable. A certain amount of benefit would still remain, which must be ascribed to the cod-liver oil alone.

Dr. Williams's estimate of the value of cod-liver oil is certainly higher than that of most writers, and possibly higher than it would have been had the remedial measures which were employed in addition to the oil been taken into the account. But yet the opinion of a physician so eminent, and so skilled in the diagnosis of phthisis, is necessarily of great weight.

Dr. de Jongh has attempted to determine which kind of oil is most useful in scrofula and rheumatism. He made a series of comparative

* London Journal of Medicine, Jan., 1849.

+ Dr. Walshe's excellent Report on Phthisis, in our Fifth Number, indicates that the improvement under various modes of treatment is greater than was anticipated. Cod-liver oil was probably employed in many of Dr. Walshe's cases, so that we cannot tell the exact amount of improvement not referable to the employment of this agent.

trials, using the oil as the only remedy, and choosing for the experiments patients who, as far as regarded the kind and condition of the disease, the external circumstances surrounding them, &c., appeared to be proper subjects of comparison. The general results of the trials were very much in favour of the brown oil, the cures being effected in half the time required by the other oils; the light brown and the paler oils seemed nearly on a par. The cases are, however, so very few in number, six in each class, that we do not feel disposed to attach much importance to these results. The various disturbing and modifying circumstances in such an inquiry are so numerous, that they can only be got over by a much larger number of experiments.

We shall not enlarge on the modus operandi of cod-liver oil in chronic rheumatism and the scrofulous and phthisical diatheses. Various speculations have been advanced to account for its efficacy in the last-named conditions of the habit, but we must confess that they appear to us to be as crude and unsatisfactory as most hypotheses of the kind. It certainly appears probable that the oil does not act simply as a nutritive agent, as has been supposed by some practitioners. If this were the case, it would depend simply upon the fat contained in the oil, but it is not found that other oils and fats can be substituted for the cod-liver oil; and, moreover, the doses in which this last often operates most beneficially are too small to allow us to consider its use to be confined to that of a mere dietetic. The utility of the oil depends then possibly on some principle or principles which it contains; but which of these is the active agent, is quite undetermined. The iodine is in small quantity, but yet evidently passes through the system, and can often be detected in the urine; the phosphorus, butyric acid, and other agents do not produce the beneficial results when administered separately; the Gaduine appears altogether inert. From the fact of the brown oil appearing more useful than the other oils, it has been surmised by De Jongh that the biliary matter, which is in higher proportion in the brown oil, may be the active ingredient; and that there is some foundation for this opinion appears from the fact, that Klencke, without knowing that the oil contained biliary matter, declared that it could become a substitute for bile, and to this in part attributed its utility. Perhaps, as suggested by Dr. de Jongh, the properties may not depend solely on the phosphorus, the iodine, the fat, or the biliary matter, but on the mixture of all these ingredients, the union of the whole producing a compound which acts in a way which cannot be imitated by its disunited components.

As we are at present almost entirely ignorant of the nature of the peculiar malassimilation, if we may venture to use the term, which gives rise to the scrofulous diathesis, or to the tubercular cachexia, if a distinction is to be drawn between them, and as we are just as ignorant of the active principle or principles of the cod-liver oil, it certainly does appear in the highest degree premature to attempt learnedly to account for the method in which the oil so usefully operates in these affections. Let any one review the various hypotheses which have been advanced, and candidly confess what amount of satisfaction he has derived from them: it has been supposed that the oil is converted into albumen; that it forms an essential ingredient in the fat-globules which have become deficient ; that it gives to the albumen the necessary additional element for the

formation of cells, without which the albumen, incapable of organization, would be deposited as scrofulous or tuberculous deposit; that it affords to the chyle a finer "molecular base," from which it is assumed that a better plasma may be formed; or that its beneficial influence is connected rather with the aid or the relief, which the highly carbonaceous and combustible particles of the oil afford to the principles which are ordinarily consumefl in the respiratory process, than with any direct influence on the process of nutrition. It would be most easy to show how scanty is the evidence which can be advanced for any one of these hypotheses; but the assumptions on which they are founded are so transparent, that it would be a waste of time to do so. It is much better, in the present state of our knowledge, to determine from experience alone the utility of our remedies; and if hypotheses are to be formed of their modus operandi, to be careful that such doubtful speculations are not allowed unduly to influence our notions of the morbid processes in the disease which we are treating, or to bias our conclusions of the value of the remedy itself.

Is

We have spoken very highly, in the preceding pages, of the cod-liver oil, as a remedy in several most intractable and deep-seated affections. there not some fear lest the utility of this medicine may have been overrated by the zeal of those, who deem they have at last discovered a means of checking the inroads of some of those diseases, which have been the opprobria medicorum? How many specifics, alas! have we not been called upon to receive as almost infallible; how many have maintained their reputation; how many of these ephemeridae have attracted all eyes by the brilliancy of their colours, and the elegance of their forms, and yet while still we gazed, the colours have become dim, and the forms have died away into obscurity! Have we not reason to dread that a reputation, born in a moment, and sanctioned by an experience so limited, cannot have its foundations planted in the immoveable basis of undeniable demonstration? Will our successors be decimated by consumption even as ourselves have been, and will the next generation record the name of our boasted remedy among the phantoms which have been worshipped as realities? We do not indeed think so. We cannot but believe that testimony so strong as that which has been given by most competent and, as far as we know, unprejudiced witnesses, in proof of the real and decided efficacy, in certain diseases, of cod-liver oil, cannot be altogether erroneous. It may perhaps be over-coloured. This is hardly to be avoided, until a greater experience has indicated the true extent of its utility; but we do firmly believe that this wider experience, while it may limit its powers in some respects, will but more certainly establish the undoubted benefit which we shall derive from the judicious employment of this remarkable agent.

ART. XIII.

1. On Healthy and Diseased Structure, and the True Principles of Treatment for the Cure of Disease, especially Consumption and Scrofula; founded on Microscopical Analysis. By WILLIAM ADDISON, M.D., F.R.S., Licentiate of the Royal College of Physicians.-London, 1849. 8vo, pp. 320. With Four Plates.

2. Thoughts on Pulmonary Consumption; with an Appendix on the Climate of Torquay. By WILLIAM HERRIES MADDEN, M.D., Physician to the Torbay Infirmary and Dispensary, &c.-London, 1849. Post 8vo, pp. 220.

3. De l'Analogie et des Différences entre les Tubercules et les Scrofules; Mémoire qui au Concours, fondé par Portal, a mérité de l'Académie de Médecine une mention honorable. Par A. LEGRAND, Docteur en Médecine de la Faculté de Paris, &c. &c.-Paris, 1849. 8vo, pp. 402.

IN our review of the first two of these works in the preceding Number, we intimated our intention of returning to the more particular consideration of the question discussed by M. Legrand, as to the points of conformity and distinction between tubercle and scrofula;-a question which is not yet decided in the minds of many intelligent pathologists and practitioners both in this country and elsewhere, and as to which we believe that great misconception is prevalent among those who have not devoted to it any large amount of special consideration.

In our treatment of this subject, we shall not think it necessary to confine ourselves to the order observed by M. Legrand-an order, by the way, which the reader is not assisted in discovering by any table of contents, or even by any complete subdivision into chapters or sections with appropriate headings. His object, indeed, would appear to have been, -assuming from the marked difference as to fatality between tubercle and scrofula (in their popular acceptation) an essential difference between them-to point out the particulars by which this difference may be recognised, rather than to discover by observation and comparison of the manifested effects of the supposed two principles, whether their assumed diversity is true or not. It seems desirable, in the first place, in this, as in most discussions, to secure, by appropriate definitions, an agreement as to the meaning of the leading terms employed, for there is certainly considerable variation in the use of the word Scrofula; and it is absolutely necessary, when the question of the relations of this state to tubercle is proposed for discussion, that we should have a definite conception of what is intended by the former. M. Legrand does not appear to think this a matter of primary importance; for it is not till past the middle of the work, that we can gather, except by inference, what he intends by the term. We then find him adopting a signification which seems to correspond pretty closely with that attaching to the terms scrofulous cachexia or diathesis; for he defines scrofula to be "the cause of a disease of the lymphatic system, most commonly characterised by swelling and suppuration of the lymphatic ganglia of the neck, and much less frequently of those of other regions of the body; by swelling and even caries of the bones, and by superficial ulcerations of the skin," &c. M. Legrand pro