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be found to a certain extent in persons in advanced life,and that, in many cases, it is the result of the aging ofthe cell, so to speak; just as atheroma and ossificationof the arteries are changes incident to advanced life. Thisview, however, does not invalidate the importance of thefact, that in cases of insanity accompanied by violent cere-bral action of considerable duration, a very decided changetakes place in the condition of the ganglionic cells-a changeaccompanied by an alteration of the vessels of the greysubstance, and succeeded by the usual evidences of braindecay-shrinking of the grey and white matter, cedema ofthe brain, excess of fluid in the sac of the arachnoid and inthe lateral ventricles, thickening of the membranes, anddementia.

It is perhaps too much to expect that the microscope willenable us to discover the alterations in the brain which pro-duce mental derangement; but that it reveals to us changesin the nerve-substance, as a consequence of that condition,changes incompatible with healthy mental action, I thinkcertain. There is in this department of histology a vastfield untrodden, and one which will not fail to repay theearnest worker.In conclusion, I would urge observers not to depend on

prepared sections. The brain should always be examined,in the first instance, as fresh as possible. Some of the moredelicate alterations of structure disappear after a prolongedsoaking in spirits, whilst the slightest decomposition rendersthe appearances extremely fallacious. Again, observationsshould not be made too exclusively on the brains of para-lytics and other intaesting cases. If possible, the brainshould be examined microscopically in every case where apost-mortem is made in an asylum. It is only in this way,and by the labour of many workers, that we can expect toascertain the frequency and true value of pathological ap-pearances such as I have referred to.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

ST. GEORGE’S HOSPITAL.A CASE OF ENTERIC FEVER, WITH BLOOD PASSED FROM

THE KIDNEY. A CASE OF COMA OF OBSCURE

ORIGIN.

(Under the care of Dr. OGLE.)

Nullaautem est alia pro certo noscenùi via, nisi quampli-irimlsetmorborumet dissectionum historias, turn aliorum, tnm proprias collectas habere, etinter se compumre.—jMon&AGN’i De Sed. et Calls. IorTi., lib. iv. Proaemium.

THEBE has been a good deal of enteric fever of late in themetropolitan hospitals, and various phases of the diseasehave presented themselves. We recorded one peculiar formlast week in a case of Dr. Duffin’s at King’s College Hos-pital. The following is a brief record of one which also de-serves notice from its rarity.Enteric fever; blood passed f1’om the kidney.-Agnes B-

a servant, aged eighteen, was admitted with fever, and atthe same time with symptoms of an hysterical character,much general restlessness, turning herself about, and greatpain in middle of the back on the left side. After a verydelirious night, the urine was found to be very dark,thick, and opaque, owing to the presence of a large quantityof broken-down fibrinous material, mixed with cells of epi-thelium and a few granular casts of uriniferous tubes, highlyalbuminous, and containing but comparatively few entireblood-globules. Under the use of salines, wine, and nourish-ment, with morphia at bed-time occasionally, the patiententirely recovered ; the deposits in the urine graduallyclearing off, and the hysterical and excited manner sub-siding. She left the hospital quite well, the urine beingclear and in all respects healthy.The following is a case of obscure cerebral disorder :-

Comatose state; cause obsc’1i"e; peculiar sloit-ness of pulse.-Robert B-, aged twenty-tlree, had been subject to severeheadaches and pains in the face. One day he was found bya fellow-servant in a fainting fit, and on the following daywas brought into hospital in a condition like that of sleepin many respects. He was unconscious of circumstancesaround him; but could be ronsed so as partly to put out histongue, and was evidently annoyed when disturbed. The

pupils were very contracted, but equal, and acting some-what to light. There was no rigidity or apparent paralysisof the muscles. The pulse was remarkable, as being only44 per minute, and quite regular. He could swallow well,and took food; but otherwise remained for several days inthe same state. About four days after admission, he an-swered questions sometimes aright, but not always ; his

speech was indistinct, and the pulse was 60. The urinewas free from albumen; and no disease of any of theorgans of the body was ascertained. A week after ad-mission he said he had much pain in the head. Later on, itwas noticed he used wrong words in speaking. He gradu-ally recovered so as to attend to all his wants, and to bemuch more sensible, the pulse being 64 per minute. At notime was any convulsive movement noticed. The treat-ment consisted of free purging, nourishing diet, turpentineenemata, and subsequently a blister to the nape of the neck,which was dressed with mercurial ointment. About twoweeks after admission he was removed into the country byfriends. It was ascertained by letter a fortnight after thisthat he had greatly improved, and was out walking, andthinking of returning to work.

Dr. Ogle has lately had under his care two cases of gene-ral muscular atrophy, both apparently greatly benefited byarsenic. Of these, however, one died with bronchitis, evi-dently from muscular inability to relieve the lungs of theexcessive secretion. In some cases of chorea the Calabarbean has been employed with success; and the nitrite ofpotash has been used apparently with benefit in some casesof acute rheumatism. Dr. Ogle tells us that of late therehas been an unusual number of cases of the slighter formsof rheumatism complicated with gonorrhcea.Under his care now is an interesting case of empyema,

with the heart pushed over, and fixed at 9" point corre-sponding, to the right nipple. Paracentesis by trocar wasresorted to, and much pus evacuated. The wound healed,but since then has spontaneously opened, and much pusnow drains off, the heart remaining displaced as before.

NATIONAL HOSPITAL FOR THE PARALYSEDAND EPILEPTIC.

A CASE WHICH ILLUSTRATES SOME OCCASIONAL

SEQUELÆ OF CEREBRO-SPINAL CONCUSSION.

(Under the care of Dr. BUZZARD.)THERE is a man attending at this hospital just now, whose

case has a certain interest from a medico-legal point of view,as well as from its pathological bearings.A stoker, fortv-five years of age, was employed one day

ten months ago in hauling up some heavy object with arope. The rope broke, and the man fell his length upon thewooden platform on which he had been standing, comingdown upon his back with such violence as to break some ribs.He also struck the back of his head, and was insensible for afew minutes. He kept his bed for eight weeks. His previoushealth had been perfectly good. He describes the follow-ing as the symptoms by which be has since been affected.He has a 11 darting," " throbbing, " or " gathering, whichproceeds from the hollow of his back into the back of thehead. This is constant, but not so bad, he thinks, as it was.Going into the air makes him feel better, but he suffersspecial inconvenience during changes of weather. His

power of hearing on the right side is gradually becomingimpaired. For a long while after the fall, he says, he founddifficulty and delay in passing his urine. On first getting uphe was very helpless with his legs, not being able to stand;there was much tingling in them, which has since disap-

peared, and he is gaining power in his legs, so that he canwalk a mile now : but he has been able to do no work. Hehad little or no sleep until a month ago, and up to that timeas he la, in bed he used to have constant twitching, his wifesays, like a child in convulsions." Ee describes himself as

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being exceedingly "nervous ;" any sudden start makes himgiddy, so that at times he has to hold on for support. Heis greatly depressed in spirits, and his memory is impaired.His pulse is large, soft, and quick. His walk is feeble, andit is said that he has lost much flesh. Tongue brown andfurred. Over the fourth cervical spine there is tendernessto the touch. No retinal changes observed with the oph-thalmoscope.

Dr. Buzzard remarked that the train of symptoms de-tailed by this man was just that which the medical examinerin a case of alleged injury from a railway collision fre-quently hears from the sufferer and his friends. It was

improbable that there was any exaggeration in the presentcase, as the temptation which is often held out by an actionat law against a company was here wanting. He pointedout, however, that, with very slight exception, the man’ssymptoms were subjective. They had to depend upon hisaccount, as there was little to see. But these exceptions,though slight, were very well worth noting: the look ofillness ; the brown, furred tongue; the feeble gait; and,lastly, the quick, weak pulse. Dr. Buzzard called attentionto the fact that there had been no interval of immunity inthis case, such as was sometimes described in cases of rail-way accident. The symptoms of nervous exhaustion had’been constant since the accident, and the man was graduallybut slowly improving. He remarked that he had met witha good many cases in which either paralysis agitans, pro-gressive muscular atrophy, general spinal paralysis, or

locomotor ataxy had followed shock to the cerebro-spinalnervous system ; but it was not, according to his experience,-very common to meet with the peculiar combination ofphysical and moral symptoms such as this man describedin cases of ordinary violence-not due, that is, to railwayaccidents.

GREAT NORTHERN HOSPITAL.CASES OF ULCER ; VARICOSITY; WITH VENOUS

HÆMORRHAGE.

(Under the care of Mr. GAY.)THE successful management of such cases as those which

are here described (from notes taken by Mr. Hopgood) isalways a matter of importance, and often of great difficulty.The details will doubtless be read with interest.

Senile ulcer; varicosity; with venotis hmmorrhage.-W. B-, ,aged seventy-two, thin and emaciated, was admitted inMarch, on account of a superficial stationary ulcer, aboutthe size of a half-crown, on the inner aspect of the leg, twoinches above the malleolus. The long dorsal vein of thefoot ran beneath it; and for the distance of three inches- above the edge of the sore this vein was varicose, nodulated,and very painful on pressure. The veins of the foot werecongested and tortuous, some varicose. The sore had existedfor eight years, and was surrounded by a broad halo ofdusky but not hardened skin. He had suffered much painin it, and also in the varicose segment of vein, on standingor walking ; and latterly he had had repeated attacks ofrather copious haemorrhage. He had old bronchitis, andwas in all respects a decrepid person.Mr. Gay thought this a case of senile ulcer, which had

corroded the coats of the vein on which it had trespassed.He placed four ligatures on the diseased vein above thesore, after emptying it of its blood by elevating the foot,so as to prevent the formation of clot within the vein as aconsequence of its deligation. This was done to preventfuture haemorrhage, and not as a curative measure so far as-the ulcer was concerned. The ligatures remained until thefourth day, when a smart attack of inflammation began,which ran along the cellular envelope of the vein from abovethe highest ligature to the middle of the thigh, at a pointwhere the vein entered the saphena. The ligatures wereremoved; but abscesses followed, not on the site of theneedles employed, but on the thigh-one just above theknee-joint, and another at the termination of the vein-branch. The cellular tissues sloughed for a considerablespace at each spot, and left large sores, with overlappingedges, across which the vein, bared of its outer tunic, waEobserved to pass. A sharp attack of fever, accompaniedwith symptoms of broncho-pneumonia, a brown, furred, anddry tongue, hot skin, quick feeble pulse, nocturnal delirium,and sordes, attended the formation of these sores. The

patient was treated with purgatives of calomel, rhubarb,jalap, and ginger j and fluid nourishment and moderatestimulus in the way of wine and brandy were given. At

the end of a week the patient began to show signs of re-covery from his previous apparently hopeless condition;the ulcers, both primary and secondary, healed; and at theend of five weeks he was discharged.I The man was a bad subject for operation. The irritation

of the ligatures set up irritation in the coats of the vein at adistance from the part of the vein on which they were ap-plied ; and these were at points at which the vein is knownto communicate with the deep veins. The narrow slits inthe fascia through which these intercommunicating branchespass appear to have arrested the advance of the inflamma-

tory action towards the sub-aponeurotic system of veins;but why at these particular points it should have increasedin intensity it is difficult to say. Pyamia (as it is called)followed, but there was no reason for believing that the pusaround the vein had penetrated its coats, or in any otherway obtained access within. A considerable clot, however,formed in the vein along the inflamed tract, and Mr. Gay ismore inclined to believe that, at least in this case, the symp-toms were due to the admixture with the circulating cur-rent of impure liquoy sanguinis, expressed and etfi’ete blood-

globules, and, perhaps, also, portions of the clot itself, than todirect pus-poisoning.In order to prevent the occurrence of cellulo-phlebitis

from deligation, Mr. Gay has, in more recent operations onthe veins, removed the ligatures within twenty-four hoursof their application; in one instance after twelve hours, andwith perfect success, so far as the obliteration of the veinis concerned.Mr. Gay, in reference to the practice adopted in this case,

protests against the administration of large quantities ofsometimes puye brandy and other stimuli, in persons sufferingfrom pneumonic complications, with a typhoid condition ofthe system, after local injury. The dry brown or black tongueis sure to be retained by such excess of stimulus, and oftenof aliment too. Presently timely diarrhoea sets up to coun-teract the resultant mischief, and this, too, is treated byastringents, as though it were an aggravation of the diseaserather than a relief to the overtasked system. Lives are toooften jeopardised under these circumstances by the diffi-culties under which an enfeebled stomach and system gene-rally are thus, with the best intentions, placed.

Ulcer (venous), with varicosity.—M, T-, aged forty-eight, a healthy-looking person from the country, a cook.

. Has been accustomed to stand about from early life. Shehas an ulcer on the inner aspect of the leg, above themalleolus, surrounded by a broad patch of deep bluish anddense skin, the colotir being of a deeper shade around themargin of the ulcer than elsewhere. The long dorsal veinis severely varicose and nodulated from the edge of theulcer to within a few inches of the knee-joint; there is alsoa varicose vein which passes from it to the external saphenabelow its fascial foramen. The veins at the inner edge ofthe foot are numerous, large, and convoluted. She attri-

’

butes the varicosity, as well as the ulcer, to standing-an. act which has for years been very painful to her, as well as

attended with cramps in the calf and back part of the thigh ;these have now become so severe that she is obliged to giveup her situation. The skin around the ulcer is very hardand tense, the ulcer unhealthy and stationary, and the vari-cose portion of vein hopelessly diseased. The veins had

. been varicose for more than thirty years. The ulcer had

. existed for sixteen months; but the induration of the skinhad, it is probable, anticipated it by many years.

: Mr. Gay made a curved incision on each side, andabout half an inch from the edge, of the ulcer, through the

! fascia and varicose vein, having previously placed three. ligatures on the vein, in the manner described in the account! of the former case. The needles were taken out the follow-! ing day, and the vein gently compressed by a pledget of’ lint and bandage. The wounds gaped, but healed in the

course of three weeks. The ulcer began to heal at the same’ time, and is now nearly closed ; whilst the vein is obliterated,’ and that without the occurrence of any inflammatory action! on the sites occupied by the needles.

It has been objected to the incisions around ulcers that,. being made in diseased tissues, they do not always heal.. Mr. Gay has made these incisions repeatedly into every’ kind of tissue that can be met with around ulcers-and so