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minant action, and most obvious cause ofdeath, I shall adopt as so many heads, underwhich I may clearly arrange the remarks Ihave to offer on the supervening’ actions causingdeath after p1’imary amputation.

Fevers.

The classification of the febrile actionsoffers the greatest difficulty. Almost in-

variably after amputation there is con-

stitutional disturbance, and generally moreor less of a febrile character ; yet to re-

solve the symptoms into a special type offever, where there is little beyond the exist-ence of febrile action to seize-or a mixedand complicated set of symptoms to guideus-is not only a difficult task, but one veryliable to error. I wish this classification,therefore, to be taken as rather an approxi-mation to what seemed the most predominat- Iing symptoms and types, than a ftilly-aseer-tained truth. To have classed all the variouscomplications of organic disease, found inconnection with fever, under tlrat genericterm, might have been safer ; but for manyreasons, which will soon be obvious, andmore particularly that one type seemed topredominate over another, it was desirableto attempt somewhat more closely to definethe febrile action.The three forms I have adopted are the

bilio-remittent, the hectic, and irritative ;the latter more epecially indicating a smallkind of fever, assuming no very broadly-marked characters, although evidently wear-ing away the powers of life, and exhaustingthe patient.

Fever is occasionally, if not wanting, atall events so little obvious, and local or otherdiseased actions so evident, that it altogetherescapes remark or observation; even in phle-bitis, one case is recorded in the analysis,where the attention was chiefly directed tothe bad actions of the stump.Whether remittent, hectic, or irritative, be

the types, we see each are complicated bysecondary abscesses of viscera, or distant

parts, each occasionally with phlebitis. Aparticular form of fever has been ascribed bysome writers to each of these effects ; an ex-ample which I shall hereafter produce, ofone case out of each of the three classes,will prove that such assumption is notcorrect.Whoever refers to the various treatises on

fevers, will perceive that in the mass of opi-nions so various and contradictory, it is mostdifficult to establish therefrom any one seriesof symptoms as distinctive of peculiar types,but more especially of remittent and yellowfevers. The yellow fever is, in truth, abilious remitting fever. The most fataland malignant forms of remittent are deve-loped and modified, in great degree, ifnot generated by endemic and epidemicinfluences, to which some constitutionsand states of the system are so peculiarly

obnoxious, that the attack is generally fatalin its results ; while to others it seems innocu.ous. My attention, as I have stated, wasanxiously devoted to this subject from the cir-cumstance, that of a great mortality in theamputations performed during the month ofMarch, many were carried off by a form offever I have termed bilio-remittent, andwhich, with equal propriety, perhaps, mighthave been called the yellow fever.

In the Spanish hospitals, crowded by thewounded from the same series of actions

fought in that month, I believe the only casesaved out of a large number of amputationswas one of the arm, performed by myself.This patient I removed subsequently into oneof the British hospitals, where a large andairy ward was preserved especially for ope-rations.To the consideration of these cases, and

the influences under which they took theirfatal course, I have already devoted two lec-tures. In the next, I shall proceed to lay be-fore you some views upon the nature of thisbilio-remittent form of fever supervening onoperations, and frequently attended by sup-purative disease in some important organ, ordistant part, and the chief agents in the pro-duction of this type and its complications.

A CASE OF

ACUTE HYDROCEPHALUS,EXPOSED TO GREAT DANGER FROM DELAY IN

THE TREATMENT, IN CONSEQUENCE OF BEINGMISUNDERSTOOD IN THE FIRST INSTANCE.

By Professor DAVIS.

Miss F-, five years of age, a delicatelittle girl, sustained an accident at school, byfalling from the back of her chair. In con-sequence of this accident she complainedloudly of acute pain of the occipital region ofthe head, the part which came in contactwith the floor behind. Being of a cheerfuldisposition, she presently ceased to cry, andadmitted of being soon comforted by herschoolfellows. When, however, she wenthome at noon, she forgot not to mention heraccident to her mother, nor the severity ofthe pain she suffered at the time, and in con-sequence of it. She, nevertheless, eat herdinner as usual, and was cheerful and chattyduring the whole of the remainder of the day.She went to school again the next day, with-out experiencing any observable indisposi-tion, and without making any complaint.When, however, on this, the second day afterthe accident, she came home at noon, shecomplained of being poorly, and refused totake her dinner. She was harassed withsickness and vomiting during the whole ofthe remainder of the day, and rather fre-quently during the following or third dayafter the accident. On the third day, which

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happened to be Thursday, the medical friend emetic had as yet been administered, al.of the family was sent for, for the first time; though the stomach had been repeatedlybut that gentleman not being at home, nor in emptied by spontaneous vomiting. Upon theLondon, another gentleman attended in his whole, 1 should say that the little patientstead, who had been appointed to see his had become the subject of an ardent pyrexia,patients in his absence. and was considerably advanced in the first,

It unfortunately happened that this gen- or formative, stage of hydrocephalic conges-tleman had had much less experience in his tion.profession than his friend; and that he Such was briefly the state of the case whentreated the case as one simply of gastric irri- I first saw it, and was requested to prescribetation, although he acknowledged that it for it. Upon this occasion my friend, Mr.was accompanied by symptoms of slight Langley, having become himself engaged infever. Medicines to relieve the case as thus the course of the day, failed to give me thereported, were accordingly sent and duly meeting. The other gentleman had not seenadministered by the family, but certainly the patient since he had taken his leave onwithout producing any obvious relief of the the previous day. I considered that theresymptoms. This practitioner saw the patient was no time to be lost, and accordingly Ifrom day to day; daily reported the case as ordered cupping from behind the ears to bean improving one ; and, on the succeeding had recourse to without delay. Before the

Sunday, took his leave as from a case which, operation was completed Mr. Langley ar.

in his conviction, was doing well, and, there- rived, and he stated to me next morning thatfore, not requiring any further attendance our little patient had borne the abstraction offrom him. The little patient, however, eleven ounces of blood before she fainted.thought otherwise, as also did her mother, On recovery from the fainting she had myand other members of the family. On the usual dose of an emetic administered to her,following day, Monday, the mother feeling and on the subsequent morning an active plir-convinced not only that her child was not gative, consisting of calomel and jalap. In

improving, but that the malady was becom- addition to this treatment, directions wereing more and more aggravated, sent for my given to the family to procure one of Mack-friend and neighbour, Mr. Langley, of Tot- intosh’s cold-water cushions, which, in thetenham-street. That gentleman, who had course of the day, was placed under the

frequently seen cases of acute hydrocepha- occiput, to the no small relief and gratifica.lus in consultation with myself, instantly re- tion of the patient. Spirituous lotions werecognised and reported the case now de- in the mean time, and in the usual way, ap-scribed, as one unquestionably of water in plied to the superior and anterior parts of thethe head. - head.

At this time the disorder was rapidly ad- Evening visit of Tuesday. The medicine,vancing, and the heat of the head had become both of last night and this morning, haveso developed as to place the nature of the operated well. Our patient, however, is stillmalady beyond a doubt. He, therefore, sug- inflexibly grave, although the active treat.

gested that it might be proper to take my ment adopted, both last night and to-day,opinion upon the subject, as he wished for have had the effect of considerably reducingmy assistance in its further practical manage- the pyrexial symptoms. I was requested toment; adding, that it had already arrived at pay a second visit in the evening, in ordera period of its progress of considerable dan- that the family might then, peradventure, ob-ger, if not of doubtful result. It unfortu- tain my opinion as to the probable result ofnately happened on the day in question that the case. The usual train of fatal symptomsmy attendance could not be obtained until a not having yet manifested themselves, I feltlate hour in the evening. When I saw the it my duty to give a cautious but encourag-patient for the first time, symptoms of acute ing opinion. The abstraction of blood, al-hydrocephalus were unequivocally esta- though it must have diminished the conges-blished. The gastric symptoms already re- tion, had not removed all the pain of theferred to, had probably been those of sym- head. There was yet, strongly marked, thepathy with the head; inasmuch as when I peculiar expression of countenance of a severefirst saw the patient there was no pain, upon case of acute hydrocephalus.pressure, of any part of the abdomen, nor of There was already a good basis laid forany viscus within its cavity. Added to this further useful and efficient treatment. But

fact, there were obvious symptoms of con- the treatment in question had become neces-gestion of the head, attended by an increase sary, as the formidable malady we had toof its heat, and an intense aching, affecting contend with,although unquestionably greatlyespecially the forehead. The expression of mitigated, was not adequately subdued. Hadthe countenance was that of great distress, the cephalic congestion been sufficiently re-which was attended with obstinate gravity. lieved in the first instance by ample bleeding,The eye looked languid and sickly; the the treatment now to be mentioned might,tongue was white and smooth, but not parti- probably, not have been required. Undercularly furred, nor yellow. The patient had existing circumstances, however, it could notbeen purged by alvine aperients; but no be safely omitted. Accordingly, our next

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object was to excite a gentle salivation, assoon as that effect could be obtained. It iswell known to the profession, that it is not

always easy in the cases of young children toproduce salivation as speedily as could bewished, by safe and moderate doses of calo-mel. The quantities prescribed upon thisoccasion were six doses daily, consisting ofthree grains each of calomel, with an equalquantity of compound powder of tragacanth,and with a very minute addition to each ofpowdered opium, to check its action upon thebowels. An active purgative, I believe

powdered jalap, was added to the first doseor two of the calomel, in order to obtain suffi-cient freedom of the bowels at the commence-ment of the treatment. The cold Mackintoshcushion was continued, it became a greatfavourite, and was replenished from time totime with fresh and colder water, which wasfrequently ordered to be renewed by thepatient herself. There was no remission asto the use of the spirituous lotions to the fore-head and temples. I have thus transmittedto the pages of THE LANCET a case of acutehydrocephalus of great danger, from want ofdue recognition of the disease and of activepractice in the beginning. If the little

patient’s malady had been duly recognisedas one of probable danger of the accession ofhydrocephalus on the first day of the patient’sindisposition, i.e., on the Thursday, or nextday but one after her accident, and she hadbeen then bled, ad deliquium, and otherwisetreated by an emetic and a purgative ofcalomel and jalap, agreeably to the methodof treatment recommended in my recently-published tract on Acute Hydrocephalus,there is no good reason to suppose that the casemight not at once have yielded to the prac-tice in question. Instead, however, of anearly recognition of the essential symptomsof hydrocephalus, they were totally neglectedduring the entire of Thursday, and the daysconsecutively of Friday, Saturday, Sunday,and a part of Monday, when towards themiddle of that day they were recognised bymy friend, Mr. Langley. This is an un-rar-nished statement of facts. It is not my ob-ject to injure the individual whom this state-ment would inculpate, and therefore I pur-posely withhold his name ; but for the benefitof the profession and of society, I publish thefact as a beacon to young practitioners, towarn them against too much confidence intheir own ability, to decide definitively atonce, and, as it were, extempore, upon thediagnosis of certain insidious and dangerousdiseases. How much better managed was acase of gastric irritation, which occurredabout the same time, in the practice of myfriend, Mr. Bartlet, of Kensington Gore ?The case was seen by me only once. Thequestion with Mr. Bartlet was, how far itwas exclusively a case of gastric irritation,or one of gastric irritation with the super-addition of a state of congestion of the vessels

of the head. I decided on the former viewof the case, although I have to acknowledgethat I came to that opinion with some diffi-culty. The case yielded to the action of anemetic, and the free use of purgatives.

It was once the practice to attribute manyfatal cases of acute hydrocephalus to thesupposed influence of worms in the intestines;and hydrocephalic affections were then notunfrequently called worm-fevers. It wassubsequently the practice of another school,of which the founder was the late Mr. Aber-nethy, to attribute cephalic affections of nolittle importance to disorders of the gastricfunctions, without immediate reference to thepresence of worms in the bowels. Boththose views of pathology had the effect ofmisleading the profession to an erroneous

assumption of the nature of the disease underconsideration, and necessarily, therefore, ofthe proper practice to be adopted for its cure.The universality of the worm-fever theoryhas pretty nearly ceased to exist; whilst thegastric theory of Mr. Abernethy, as a falsely-assumed cause of hydrocephalus, is likewisewaning apace into practical desuetude. Mr.Abernethy had, unquestionably, the merit ofextending the limits of surgery, by giving itthe benefit of a more intimate dependence

upon a correct knowledge of medicine; al-though that gentleman, notwithstanding his

sarcasms in reference to others, was, in manyrespects, far from being himself a consum-mate physician.

It is extremely important, if possible, toavoid the necessity of having recourse to themercurial treatment, found indispensable tothe cure of the case just reported; in as muchas the early and adequate vascular depletion,which I have thought it my duty strongly andrepeatedly to urge, is usually competent toeffect a subduction of the malady, is incom-parably the most certain of all means whichcan be made available for the attainment ofthe results to be hoped for; and is rarely, ifever, objectionable, on the ground of any per-manent damage to be incurred from its useby the constitution.

17, Russell-place, Fitzroy-square,May z1.

CASES OF

LARYNGISMUS STRIDULUS

(THYMIC ASTHMA, &c.).

To the Editor of THE LANCET.

SIR :-I had written the accompanyingremarks some weeks since, but delayedsending them until the present time, whenthe notice taken of thymic asthma, in a

late Number of THE LANCET, led me to inferthey would not prove unacceptable ; shouldthey meet your approbation, their insertion