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that have undergone degeneration, of which are the granularbodies that consist mainly of fat, and are met with in soften-ing as in other degenerating parts, and partly the degeneratenew formations. The differences between red softening, yellowsoftening, and white softening seem the result of the varyingproportions of degenerate new formation to the degeneratenatural elements ; while abscess is the extreme issue ofthem all.One consideration remains. How was it that the mind was

unaffected till near the end ? Because the ganglionic nerve-cells of the hemispheres, which minister to intelligence, werenot directly affected by the morbid action, but continued theirfunction, as they well might, in spite of it. It is usual to de-scribe the sudden comatose attacks in such case as secondaryresults from congestion; for congestion, like charity, covers amultitude of sins. Certainly no man could have looked lesslike a person suffering from congestion than this patient didas he lay in his attacks : pallid, cold, almost pulseless, hecould not have been made to look more like what he did hadhe been bled to death. There is no need to invoke congestionwhen it is perfectly conceivable that a morbid centre in thebrain may, like a morbid centre elsewhere, act by a process oforganic sympathy, or induction, or reflex action-call it as wemay--on a re-acting nervous centre that is not directly impli-cated, and thereby produce secondary disorder of its function.The character of the delirium in such case seems to witness tothat kind of action. It is not the systematized mania of ordi-nary insanity, but the mental disturbance is exhibited in amost incoherent delirium or in dementia; the patient mutterslike an imbecile, and there is a blank forgetfulness of the past,not otherwise than as if there was an irregular and quiveringactivity of the nerve-cells, which might, according to variationof the cause, pass into complete abolition of function, or intotemporary complete restoration thereof. Why this reflex

organic effect should ensue at one time and not another wecannot tell, as we cannot tell why an eccentric irritation shouldat one time produce tetanus and not at another.Queen Anne-street, Cavendish-square, Jan. 1865.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

GUY’S HOSPITAL.

TWELVE CASES OF TYPHUS AND TYPHOID FEVER TREATED

WITHOUT STIMULANTS; CLINICAL REMARKS.

(Under the care of Dr. WILKS.)

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborumet dissectionum historias, tum aliorum, tum proprias collectas habere, et interse comparare.—MORGAGNI De Sed. et Caus. Morb., lib. iv. Proœmium.

THE length of the following report of cases of fever, withthe important observations of Dr. Wilks, preclude us from say-ing more on the present occasion than that the use of stimu-lants in disease is not now so much in vogue in many of theLondon hospitals as was formerly the case, and we hope toadduce evidence of this fact from time to time as opportunitymay permit."With respect to the treatment of fever," observed Dr.

Wilks, " I adhere to the old practice of the hospital-thatwhich was laid down by Drs. Bright, Addison, and Barlow, intheir lectures, and which they adopted for so many yearswith success. The teaching of these professors was to theeffect that a large number of cases ran their course withoutany other treatment than careful watching and feeding; thatthey required no other medicine than a simple saline; but thatsome needed a stimulant during the progress of the disease,and others required it from the commencement. The question,therefore, with regard to the administration of stimulus, was

ivlten to give it, and in what quantity. At the present timethere are advocates for a universal method in favour of alcoholin all cases of fever, just as there are those who indiscrimi-nately administer ammonia in scarlet fever, and who, whenfailing to prove its value in all cases, fall back upon the ex-planation that if alcohol or ammonia be of real service in a badcase of fever or scarlatina, and if these remedies do no harmin the milder forms, it is a good rule to administer themuniversally. Such a method is not only unscientific, but Ibelieve positively injurious; for in many cases of typhus feverin young people, where the brain has been involved, I have avery strong opinion that the brandy which I have seen givenin such cases has been positively hurtful. In my intercoursewith medical men I judge that very many are scarcely aliveto the fact that typhus fever is very rarely fatal in youngpersons-the prognosis, indeed, only becoming serious as yearsare added to the age of the patient,-and therefore that theyare too apt to attribute recovery to their remedies. Youngpersons always do well if left alone. Of this fact I could nowquote a large number of cases in proof, and, on the contrary,the few instances which I have seen end fatally have beenthose in which a large amount of stimulus was given from thecommencement of the disease; and, what perhaps is even moreto the point, the withdrawal of stimulus in some cases where,it was adopted as the method of treatment, has been attendedwith the most decided advantage.

"Although the subject of fever and its treatment may appearexhausted, yet this difference of opinion respecting the use ofalcohol shows that this therapeutic struggle must continue forsome time longer; for whilst we are witnessing the free use ofstimulants in fever, we are reading that it was Dr. Graves’splan to administer antimony in the same disease. When de-liberating on the merits of such contradictory treatment, manyescape the dilemma by believing that different diseases havebeen the subject of treatment, and that fever has changed itstype; they assume, without even a sceptical thought passingthrough their minds, that the favourable issue was due to theremedy, and therefore their conclusion is a logical one. Suchpersons, however, have no right to frame this or any otheropinion as to treatment unless they are conversant with thenatural history of the disease; for, did they quite realize to-themselves the fact that in young persons typhus fever is rarelyfatal, they might with great advantage state the argument inanother form : as, for instance, Will a few doses of antimony,.or a few daily ounces of wine, or the abstraction of a few ouncesof blood, be sufficient to kill a patient suffering from a diseasethe tendency of which is to subside spontaneously in the courseof a few days ? Surely, too, every medical man must haveseen cases, either under his own charge or his neighbour’s,where, from a mistaken diagnosis of the nature of the case, aremedy has been given which above all others he would havediscountenanced had his opinion been otherwise : he must, forinstance, have seen several grains of opium administered dailyon the supposition that the case was one of delirium tremensinstead of fever, and yet the patient has done well. If he sawmany such instances, he might consider that he had goodreason to believe in another change of type. Without, there-fore, denying that fever may annually change in character asto some minor features, yet I believe that the argument of itsgreat alteration founded upon the administration of remediesto be a most fallacious one. It is for this reason that I offer afew cases out of a large number which have recovered withoutthe use of stimulants, also cases where patients were cuppedand bled and yet had a favourable issue. Instances where agood recovery has taken place in patients who have lost muchblood by the nose or bowels must be familiar to every practi-tioner.

" I would not wish to dictate rules of treatment to any ofmy medical brethren; but my own opinion is that expressedin the first few sentences of these observations. I believe that.

support and a moderate amount of wine is the best treatment;but I assert that alcohol is not an antagonist to the fever, whichruns its course in spite of the administration of the stimulant.I would not say that in many cases of typhus in young peoplea little wine may not be useful; but the fact still remains,which cannot be gainsaid, that such cases would do well with-out any stimulant whatever.* When the ground is thus

The subject is not to be argued with those who have never witnessed anybut their own method of treatment, nor with those who refuse to studynature’s laws. The latter class of persons, I am sorry to say, are very numer-ous, and are to be constantly met with amongst eminent men who speak inthis wise. A gentleman, when asked why he did not let blood in injuries tothe head, said he believed it would do harm to his patients, and in the samebreath declared that those were none the worse who lost pints of blood fromthe effects of the injury.

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cleared we shall know better what we are doing. I mightmention that the only two cases which I have seen fatal oflate have been those of two students, to whom a large amountof stimulant was given, and who had the care of the mostassiduous nurses both night and day. In one of these therewere constant convulsive movements during the last five daysof life, with coma vigil, and other symptoms resembling thosein which the late Dr. Graves would have administered anti-mony. In this case there was no albumen in the urine, nor inanother, which recovered, where convulsions were most violent.Albumen has, however, been very frequently present in otherinstances." I will offer one or two instances as examples of several

where the patients have made a good recovery without the useof stimulants. These have been mostly cases of typhus, thisbeing the form of fever principally prevailing; but the sameremarks are applicable to typhoid. With regard to the use ofstimulants, it is important to know how much is needed, evenif it be agreed that the extreme effect is required. It is said

by some that in such a case too much cannot be supplied. Rutof this I have great doubt; for should it be conceded thatalcohol is antidotal to the fever poison, or that it is directlysupporting the patient, it may be still possible that a surplusamount may be harmful. I am under the impression that apatient who requires the alcohol treatment may be kept underthe influence of the stimulant by taking a tablespoonful ofbrandy every hour, which amounts to twelve ounces in thetwenty-four hours. I have grave doubts about more thanthis being of service, although I have of course witnessed re-covery where larger quantities have been taken.

" The other cases of typhoid I give merely to show that lossof blood is not necessarily fatal, nor is sufficient to make usregard those patients in whom it occurs as having a differenttype of fever.

" The case which I should have quoted with the most satis-faction is one of which I cannot give particulars, from thereport-book having been mislaid, but is one which I believesuggests a rule of treatment. It was the case of a young manwho was admitted under my care with typhus fever; he wasvery delirious, wakeful, noisy, and attempted at night to getout of the window. I ordered him, should there be a recur-rence of the symptoms, to be cupped at the back of the neck.On the following night, becoming again very noisy, this ivasdone; he was almost immediately quieted, sank into a sleep,was not again violent, and then passed through the remainderof the disease upon simple treatment, afterwards making arapid recovery.

" The cases of supposed perforation of intestine I give as amatter of great interest, although unconnected with the presentsubject of treatment. The sudden accession of abdominal

symptoms would lead one to suppose that a perforation hadoccurred, and yet the recovery would almost preclude such asupposition, especially in the absence of evidence of generalperitonitis. I cannot but think, however, that it does some-times occur to a slight amount, sufficient, perhaps, to allowonly the escape of gas ; for even in fatal cases we occasionallymeet with perforations which are of a pinhole size. The lastcase, where a peritoneal abscess was found, pointed to perfora- I,tion in fever, although this, of course, could not be absolutelyproved."CASE 1. Typhus feoeo trcccted without stimulants.—Francis

S—, aged fifteen, residing in the Borough, and employed asa wharf labourer. His sister was in Lydia ward, sufferingfrom typhus fever, and was discharged three days since. Hewas quite well until five days before admission, when he feltlanguid, with pains in his limbs, headache, &c. On the follow-ing day he was worse ; on the third day he had increasedheadache, was giddy, and very feverish. His bowels beingconfined, he took a dose of Epsom salts. On the next day hehad bleeding at the nose, which continued for some time, andamounted to several ounces.On admission, he was seen to be a well-nourished lad; he

presented a drowsy, listless appearance, almost amounting to

stupor, but answered questions rationally when roused. Skinhot, dry, and mottled, there being an indistinct mulberry rashmixed with flea-bites; face flushed, eyes suffused, deafness ;pulse 112, respiration 30 ; tongue covered with a white, moistfrlr; bowels not moved ; urine turbid, no albumen. Orderedbeef-tea and arrowroot, and infusion of anthemis, thrice aday. This was the fifth day of the fever. On the sixth hewas much the same. On the seventh he passed a’very restlessnight, tossing about, and talking incoherently; pulse 116;respiration 36; skin universally mottled, but not presenting

so well-marked a mulberry rash as seen in older people. Onthe eighth, ninth, and tenth days he was much the same ;bowels open; urine free from albumen ; skin the same ; pulse104. On the eleventh day he appeared about the same, butthe pulse had fallen to 84 ; respiration 36. On the thirteenthday he was considerably better, the skin presenting an almostnatural appearance, and with a disposition to be moist ; pulse72 ; respiration 20. He continued to improve, and on the fif-teenth day was ordered bitter infusion with ammonia. Onthe seventeenth day he was convalescent, the pulse being 56 ;tongue clean. To have the ordinary diet.

I CASE 2. Typhoid fever treated without stimulants.—(Reportedby Mr. Bosworth. )-John R aged twenty-nine, admittedSept. 6th, 1864. Had been ailing twelve days. On admissionthere was an eruption of pink-coloured spots scattered over thebody, and which disappeared on pressure; tongue coated ;face flushed; bowels loose, as they had previously been; pulse108; respiration 36; temperature in axilla, 980. Ordered theacetate of ammonia mixture.

This man went on well, with all the usual symptoms oftyphoid, until the 20th, when there was a marked improve-ment. The state of pulse, respiration, and temperature, wasas follows :-

On the 20th the pulse fell to 90, and he was much better;spots had almost disappeared. On the 23rd the spots had allgone, and he was gaining strength; to take quinine mixture.After this he rapidly convalesced.

CASE 3. Typhus fever treated without stimulants.—J. H--,aged seventeen. Previous health good. Taken ill on the 9thwith pain in the back, headache, loss of appetite, and graduallygot worse until admission on the 16th. He was then very ill;covered with a mulberry rash; spots not disappearing on pres-sure ; delirious at times ; pulse 120. To take no stimulants.20th : Very delirious during the night. 22nd : This was thefourteenth day of the fever, and the spots were fast disappear-ing. Rapidly convalesced.CASE 4. Typhus fever treated zvzthoict stii7tztlai2ts.-R. P--,

aged twenty-eight. Admitted Sept. 2nd. Ill nine days. Onadmission there was mulberry rash, not disappearing on pres-sure ; tongue brown, &c. Ordered acetate of ammonia mixture.He continued with all the usual symptoms until the 7th, whenhe was improving; the pulse had gone down to 60. On the 8th hewas much better, and the pulse was 48. Soon left convalescent.CASE 5. Typhoid fever treated without stimulants. (Reportedby Mr. S. EUiston.) - G. W , aged twenty-nine. Ad-mitted Sept. 9th. He had been very ill about six days withordinary symptoms of fever, but had been ailing longer. Tonguefurred with red edges; bowels loose; several rose spots on theabdomen, which were marked with ink. Ordered acetate ofammonia mixture. He continued with the ordinary symptoms.On the 15th the spots, which had been marked, had dis-appeared ; pulse 98. On the 20th he had considerably im-proved, and made so rapid a convalescence that he left thehospital on the 29th.CASE 6. Typhitsfeve2- treated without stimulants.—This was

so well-marked an example of the mulberry rash that a waxmodel was taken. Geo. L-, aged twenty-one, living at agrocer’s in the Borough. On Jan. 9th he had severe headache.On the 10th and llth he felt very ill, but continued at work.On the 12th he took to his bed. On the 13th (fifth day) he wasadmitted covered all over with a measly rash, as at the onsetof typhus, but scarcely characteristic; ordered saline medicine.On the 17th (ninth day) the eruption had perfectly developeditself into a well-marked mulberry rash. (Model taken.) Onthe 20th (twelfth day) the rash ceased to fade on pressure. On

’ the 21st (thirteenth day), the rash, as a whole, fading ; someof the larger spots darker ; tongue cleaning and fever abating.Ordered six ounces of wine for drink in twenty-four hours. Onthe 22nd fever quickly going. After this he convalesced rapidly,and on the 30th left his bed.

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CASE 7. Typhus fez-e2-, with much hœmorrhage from bozce.ls,treated without stimulants.—A man, about thirty years of age,was at work as engineer on Saturday the 22nd, but felt so ill

Bthat he was obliged to desist. He had felt unwell the whole of Ithe week. On the following day it was evidently a case offever. During the week rose spots appeared on the skin,diarrhoea came on, and there was considerable haemorrhagefrom the bowels. This occurred several times; on one occasionthere was as much as a pint lost. During this time he took nostimulants. Fresh rose spots appeared; the abdomen was notvery tumid, nor very tender; pulse 96, tolerably good. At theend of the third week he began with some ammonia and wine,and he made a good recovery, as rapid as ordinarily.CASE 8. Typhoid f6ver; venesection.—Vm. L-, aged

twenty-six; a labourer at Deptford. Heivas admitted intothe hospital one evening, being very ill, with considerabledyspnoea, cough, and spitting of blood. He was immediatelybled to twelve ounces by the house-surgeon, and some salinewith ipecacuanha wine was ordered. On the following day theparticulars of his case were taken. Then, having been in bedsome hours, he presented a different aspect; his skin was hot,and on it could be discovered a few rose spots; his tongue wasred and glazed ; his abdomen tumid, and bowels loose. He saidhe had been ill a fortnight. On the next and following daythe typhoid condition was well marked; many more rose spotshad appeared; the diarrhoea continued ; also some spitting ofblood. An examination of the lungs showed that no more thana congested condition had existed. He continued with themixture and low diet for eight days, when he began to im-prove. He went on well until a fortnight afterwards, when hehad a relapse. The diarrhoea returned, and fresh rose spotsappeared. In twelve days he began to improve. On thissecond attack of fever he was ordered ammonia and wine.

CASE 9. Typhus fever; cupping.—(Case unfortunately mis-laid.) A young man admitted with well-marked typhus fever,accompanied by great restlessness, and at night noisy delirium,with getting out of bed, &c. Not sleeping at all, Dr. Wilksordered that he should on the following night be cupped if thesame symptoms occurred. This was accordingly done to theamount of a few ounces at the back of the neck, with the resultof the patient falling into a quiet sleep, with no recurrence of thefurious delirium, and afterwards a satisfactory progress of thecase.

CASE 10. Typhoid fever; slight perforation (9) ; recovery.—A young man had reached the height of the fever, and had beenimproving for two days, when he was seized with a pain in theright iliac region. The whole abdomen became distended,febrile symptoms came on, and it was ’considered that therewas a local peritonitis arising from some exudation through theileum. He was kept perfectly quiet and treated with opium,and in three days he was better.CASE 11. Typhoid fever; slight perforation (?); recovery.—

A boy, aged thirteen, was not well whilst at school, but onAug. 20th was observed to be decidedly ill, and a purge wasgiven him. He continued so until the 28th, when he was seento have fever; he was drowsy, feverish, delirious at night, &c.On Sept. 5th his nose bled; he became gradually worse, and onthe 8th almost unconscious; his abdomen was tumid, and hehad fluid ochry stools. The lad was excessively ill, but tookhis nourishment well. On the 10th (twenty-third day) thefever was probably at its height, but there seemed no reasonwhy he should not do well. On the afternoon of this day hebecame suddenly much worse; he was collapsed, insensible, andthe abdomen very distended and tense; pulse could not becounted, appeared to be nearly 200, and was like a thread; themotions were passing away involuntarily. Turpentine fomen-tations and brandy were ordered. Dr. Wilks believed thatperforation of the ileum had taken place, and that the boywould shortly die; indeed the symptoms seemed too desperatefor any other conclusion. He continued in the same precariousstate all night, and in the morning he had somewhat rallied.During the day the tympanitis went down, and he took nourish-ment and then rapidly recovered.CASE 12. Abscess following supposed perforation of bo?4-el.-

James W—, aged eleven, was admitted in a state of extremeemaciation, with tumid painful abdomen as seen in chronicperitonitis, and he lived only a week after admission. Thehistory was obscure, but he was said to have been ill somemonths with fever, wasting, and diarrhoea. The case was

believed to be one of tubercular peritonitis.The body was carefully examined, and no tubercles were

found in the lung?:, brain; or other organs. On opening the

abdomen a large abscess was seen at its lower part within theperitoneum ; it was circumscribed by the parietes in front andby the intestines behind, the cavity of the pelvis being in-cluded in the abscess. The pus was of good colour, but hada faecal odour. The lower coils of ileum were firmly unitedtogether, but when unravelled and opened it was seen thatulcers had formerly existed on the mucous surface. Thesewere not tubercular, for they had healed, and merely existedas slate-coloured rough patches in those parts which are

known to be affected by fever, especially towards the ileo-csecal valve. Some of these had evidently been ulcers, andhad now cicatrized, whilst others had not yet healed.

Seeing that there was no tubercle present and that the ab-scess was isolated, it was surmised, with reason, that the latterhad been set up by some disease of the intestine; and sincethe bowel showed traces of disease which exactly correspondedin position and shape with those appearances which are pro-duced by typhoid fever, the inference did not seem unjustthat the abscess had been set up by a slight perforation of theileum during the progress of typhoid fever. The only thing’wanting to prove this was a good history of the case.

Provinical Hospital Reports.GENERAL HOSPITAL, NOTTINGHAM.

CANCER OF THE FEMUR ; AMPUTATION AT THE HIP

JOINT; RECOVERY.

(Under the care of Mr. JOSEPH THOMPSON.)J. W-, aged eighteen, was admitted August 2nd, 1864,.

with a tumour on the lower end of the right femur. His

general health has always been good ; habits temperate ;.family history good; no history of cancer. His present illnesscommenced about seven months ago, and was attributed to a

piece of iron falling on to the lower part of the thigh. Abouta week after this it began to swell, and was accompanied by agood deal of pain, of a sharp darting character ; easiest in bed.He walked lame, but his knee was not at all bent. The swell-

ing increased gradually to a certain size, and then remainedstationary for about a month. The swelling was situated onthe inner side of the thigh ; it was elongated, about five incheslong and three broad, well defined, and projected beyond thesurface probably about two inches. At this time (four monthsafter its commencement) Mr. Thompson recommended ampu--tation, but the patient would not consent to this, and left thehospital, after being in three weeks. About a week after he

was discharged, the tumour at the point of greatest circum-ference measured fourteen inches and three quarters.About three months afterwards he was re-admitted. His

general health was still good ; looked pale ; had no wastedappearance, but said he had lost flesh; the tumour had gra-dually been increasing in size (according to the patient’s state-ment) on an average of half an inch in circumference per week.The knee was bent at an obtuse angle. There was some de-

gree of motion in the joint. Its greatest circumference nowwas nineteen inches and a half, and it was eight inches in lengthon its inner side ; (the corresponding point of the opposite legmeasured eleven inches and a half.) Its upper surface waswell dehned ; its lower surface gradually shaded off and ex-tended below the patella. It stretched completely round theleg at the popliteal space, and round the knee. It was firmand resistant to the touch; no feeling of fluctuation at any

point. It was somewhat tender, and the skin had a shiningappearance. The pain was still present, and extended to thefoot. The temperature of the limb was normal. Several glandsin the groin felt slightly hardened and enlarged. The patientwas ordered to take five grains of opium pill every night, andan ounce of quinine mixture thrice a day, with wine and gooddiet.

August Sth.- A consultation having been called, amputationat the hip-joint was performed, under chloroform. During theoperation there was much haemorrhage ; fifteen ligatures wereapplied, and the lips of the wound brought together with wiresutures and plaster.-Ten P.M.: There was a large amount ofhaemorrhage, the blood issuing in a full stream. In Mr.

Thompson’s absence, llr. Thomas Wright opened the lips ofthe wound and secured with difficulty what appeared to be