all ages of the cases under my own personal charge (a few cases being omitted in summer, when the change of assistants for a time threw the returns into a slight degree of confusion) was as follows:

It thus appears that a total number of 703 cases, representing a very low scale (possibly, indeed, too low a scale) of stimulation, gives a mortality of 11.5 per cent., while the mortality from typhus in the adjacent years, in the same hospital, and during the same epidemic, is from 15.81 to 18.86 per

cent.

But by taking special account of the cases of the young (up to fifteenth and sixteenth year), the following very interesting results are obtained :In the two years of comparatively high stimulation (1861 and 1862), the mortality among the young in typhus in the fever wards of Glasgow Royal Infirmary was 33 per cent.

In the cases treated by me in 1863 and 1864, and corresponding to the four series of 703 cases at all ages, above mentioned, there were in all 210 cases (taking in those recorded in the Glasgow Medical Journal) below the fifteenth or the sixteenth year of age; and among all these cases it is doubtful whether more than one was a death from typhus. It is better not to reduce this result to a per centage, however, as I believe it must be regarded, under any view of the facts, as a piece of surprising good fortune. But when we find that the mortality of children in fever in Dr. Todd's hospital practice was certainly considerable, and out of all comparison bigher than this (making every possible allowance for imperfections of the record), it is difficult to resist the conclusion that to the young, at all events, the administration of alcoholic stimulants in high doses in fever is fraught with a very serious danger from "over-stimulation." For although there are no cases of children in fever recorded with details in Dr. Todd's published works, private information leaves no doubt on my mind that his method of administration, as above described, was extended to the most tender ages, as well as to the most delicate and abstemious individuals of adult age.

I have had most ample evidence before me, in consultations, that much injury-often, I believe, fatal injury-has resulted from the inordinate administration of stimulants in acute diseases, especially to the young; and therefore it has been not from any love of innovation or of paradox, but rather from a deep sense of personal responsibility, and under a most serious conviction of the importance of the subject, that I have been led gradually to the conclusions adopted in this paper.

These conclusions, except as regards typhus fever, cannot even now be stated in any very strict or definite form; but the fair analogies deducible from the facts, and the gradually and insensibly acquired experience gained from watching individual cases of general acute disease, concur in rendering probable most of the following inferences :

1. The importance of proper nourishment and sustenance in febrile cases is very great, and nothing can be worse than the old, and now happily exploded, system of depletion and starvation. But it is not less an error to conceive of alcoholic stimulation as a proper substitute, in such cases, for ordinary food. Milk is the normal food of most persons in acute disease, and there are very few persons, even in severe fevers, who cannot receive it to the full extent of their powers of assimilation; but most of the other simpler elements of an ordinary diet may be employed with advantage in particular cases. Beef-tea (so much favored by Dr. Todd, in conjunction with alcohol) is of very inferior nutritive value, and therefore of altogether secondary importance to milk; and further, beef-tea very often disagrees with the stomach when milk and farinacea can be freely taken. In enteric cases

beef-tea has been found occasionally to increase the diarrhoea, and it is usually to be avoided, or very cautiously given, on that account.

2. The proper mode of administering food in cases of febrile disease is to imitate, as closely as the condition of the patient admits, the usual practice in health; and most patients, even in severe fevers, retain so much of the habits and functions of health as to enable them to digest a good deal of simple food, conveyed into the stomach at proper intervals, and with sufficient intervals of rest to allow of a return of the desire for food in some degree before again giving it. To give brandy and beef-tea every hour or halfhour, and to continue this practice for days and nights together, even wakening up the patient (as is recommended by Dr. Todd) in order to give him his food and stimulant, is the surest of all ways to destroy whatever remains of natural appetite, and to derange altogether the already much weakened function of assimilation. In a few almost desperate cases, where the power of swallowing is nearly lost, it may be advisable to give food at much more frequent intervals during waking hours than in other cases; but rarely, if ever, to disturb the patient when asleep.

3. The proper use of alcoholic stimulants in cases of acute disease is nearly the same as in other cases, or in comparative health-viz., to quicken and develop the appetite for real food, and the power of assimilating it. The proper and normal time, therefore, for giving these stimulants in fevers is along with the food-i.e., at the regular meal times, and not during the intervals; except in cases where the nervous system is much disordered, and where a moderate dose of the stronger stimulants may sometimes be of great use in procuring sleep.

4. The proper dose of alcoholic stimulant, and also the proper kind of stimulant to give in each case, is subject to considerations derived much more from the age, sex, and previous habits of the patient than from the severity or character of the fever. It is an error to suppose that patients affected with very severe symptoms of acute disease are capable of tolerating indefinitely greater amounts of alcoholic liquors than can be given in milder cases, or to the same persons in health. It is even probable that in some cases the susceptibility to over-stimulation is greater in fevers than it is in health. At all events, it is usually a practical error to carry stimulation much beyond the line above generally indicated.

5. In most cases of young persons, and in very many of adults not accustomed to the daily or frequent use of alcoholic liquors, these ought not to be given in quantity, or even at all, without the most clear evidence of their being really required. The effect of each dose should be carefully watched, and it is almost always safer to withdraw the stimulant entirely for a period of hours than to run the risk of over-stimulation. It is almost certain, from facts already observed, that in young persons the mortality of fevers is greatly increased by the continuous administration of alcoholic stimulants, even when the more striking or obvious symptoms of over-stimulation do not become apparent.

6. The effect of stimulants moderately and judiciously used in certain critical states of acute disease is to restore and refresh the patient, to favour natural sleep, to lower the rate of the pulse, to quicken the appetite, and increase the power of assimilating food. The effect of stimulants continuously or immoderately given is to destroy the appetite for food, to produce torpor, to give rise to more or less profuse sweating, to dry the tongue, to prolong the febrile debility, and to protract the crisis. There is reason to think that in typhus fever the normal crisis may be delayed for several days by the constant administration of brandy, after the manner recommended by Dr. Todd.

7. In the self-limited fevers, in which the phenomena of the crisis are well known, and the course of the disease may be easily defined and anticipated, it is usually requisite to be very sparing of stimulants in what may be termed normal cases, because in these the disease is to be recognised as running a definite course; while any considerable excess has a tendency to convert the case into an abnormal one, and to postpone the crisis. It has already been

sufficiently indicated that, in the opinion of the author of this communication, alcoholic stimulants rank with drugs and medicines rather than with food. The same minute knowledge of the course of fevers which induces a well-educated modern practitioner to abstain from constantly drugging his patient will also, in most cases, lead him to abstain from stimulation. And, on the whole, it may be confidently anticipated, as a result of improved consideration given to the subject, that the profuse and continuous administration of alcoholic stimulants, with a view to alimentation in acute disease, will ere long be abandoned as inconsistent with an enlightened physiology and a sound practice. While stimulants will continue to be prescribed to the sick, on the same principles, and for the same ends as causes them frequently to be taken with refreshing and beneficial results in comparative health, their function in acute disease will more and more come to be recognised as a strictly limited one; so that continuous administration of them, or administration carried up to such doses as 24, 36, and 48 ozs. in the twenty-four hours, will be abandoned as involving an error in principle, and a serious danger to life in actual practice.

8. A subordinate, though still very important consideration, bearing upon such profuse and continuous stimulation as is above referred to, is that such liberal doses of wine and spirits given habitually under medical advice, tend to give a wrong bias to public opinion, and (even apart from the grave moral consequences arising from the abuses of alcoholic liquors) to involve the whole medical practice of the country in a system of unnecessary, and therefore wasteful expenditure. It is as nearly as possible a demonstrated fact, that much of what is spent in wines and spirits for the sick in hospitals (and therefore probably also in private practice) is unnecessarily, if not injuriously, spent. Typhus fever, as it occurs in Glasgow, almost always among the poor, and often among the most ill-nourished, debilitated and, dissipated classes, is the very type of a disease which would appear to require the highest doses, and the most frequent and liberal administration, of alcoholic stimulants. Yet it has been clearly shown that typhus fever in Glasgow may be so treated as to have a diminished mortality, with the aid simply of milk diet and careful nursing; alcoholic stimulation being deliberately maintained upon a scale so low as to make it quite an exceptional, and therefore purely therapeutic, agent. In the City of Glasgow Fever Hospital, the careful and most scrupulously watched experiments of Dr. J. B. Russell have led almost insensibly, and without any fixed plan, but without an increased success as regards results, to lower from year and year the scale of stimulation on the whole, until last year the calculated amount of absolute alcohol administered in the form of wines and spirits to each patient, on an average, during each day of the treatment, was less than one-sixth of an ounce (0·1630 oz.), and the expense of this quantity was little more than three farthings; while the entire bill for wines and spirits consumed, during a year in which 969 cases of febrile disease (mostly typhus) were under treatment, was £34 5s. 6d. The mortality of typhus (including all the cases admitted moribund) during the same period was in this hospital only 9:05 per cent.; being the lowest ratio of mortality, I suspect, that has ever been attained in the treatment of so large a number as nearly a thousand cases, accurately distinguished as genuine typhus.-Glasgow Med. Journal, Nov. 1868, p. 15.

2.-SULPHUROUS ACID IN TYPHOID.

Sulphurous acid in typhoid is highly praised by Dr. R. Hamilton, who has given it in large doses. To children he gave it in drachm doses every four hours, and to adults in three drachm doses. He regards it "as in reality but the internal administration of sulphur!"-Practitioner, Feb. 1869, p. 116.

3. THE PREVENTIVE TREATMENT OF SCARLET FEVER. By Dr. PETER HOOD, London.

In the ordinary run of cases the first symptom usually complained of is headache, next soreness and swelling of the throat, followed by vomiting-and we find that the aforementioned symptoms are relieved by the vomiting taking place. The healthy action of the liver is interfered with, and the bile, instead of taking its natural course, finds its way into the stomach, and is invariably found in the materials ejected. Hence the importance of giving an emetic at the onset of the fever, if vomiting have not occurred. We may to a certainty judge, for our guidance, of the presence of bile in the stomach by the appearance of the tongue; if this member be covered, or only partially so, with a brown fur, bile will be thrown up as soon as the act of vomiting

occurs.

We sometimes meet with a case of continuous vomiting, attended with extreme irritability of stomach; this condition, if judiciously managed, is not fraught with danger, as there is more to be apprehended from the absence of vomiting that when it is an excess. The perverted course of the bile points to a defect existing in the liver, which defect is one of congestion. Here, again, we are called upon to assist nature in relieving this important organ; no medicine operates so beneficially in this case as a dose of calomel and scammony. And if we take the appearance of the tongue as our guide throughout the whole period of the fever, and when it is otherwise than perfectly clean administer gentle alterative medicines to sustain the healthy action of the liver, we shall most effectually prevent dropsy from occurring, and avoid deafness and all the other sequelæ attendant on this disease.

When the stomach has been relieved by vomiting, either by the operation of nature or art, and the liver and bowels also by the administration of an efficient dose of medicine, it is then the proper time to avail ourselves of the antiseptic property of quinine, which drug is, according to my experience, as powerful in destroying the scarlatinal germ as it is potent in the cure of ague. I do not hesitate to say that, if the previous injunctions as to the emetic and purgative are attended to, any medical man who has never before employed this medicine in the treatment of scarlet fever, will never employ any other when he witnesses the gratifying progress of a case only twenty-four hours after using it. He will find the pulse diminished in frequency, the soreness of throat and difficulty of swallowing scarcely complained of, obviating all necessity for the use of gargles, sponging, caustics, etc., the heat of skin most sensibly decreased, and the restlessness, frequently so distressing a symptom, succeeded by a calm composure. In the worst forms of scarlet fever, in which the blood of the patient is in a dyscrastic state, indicated by virulent coryza, discharges from the mouth, eyes, and ears, owing to the disintegration of the mucose surfaces, it is imperative to administer iron with the quinine, and suitable doses of the tincture of sesquichloride of iron, or of the sulphate of iron, should be diligently persevered with; at the same time paying strict attention to procuring a daily alvine evacuation.

I must refer to one other subject connected with the treatment of scarlet fever, which I regard almost as important as the use of quinine itself. This is the disinfection of the sick room by the employment of chlorine; and here I must differ from what Dr. Budd's experience has led him to say on this subject. I quote the passage to which I refer :-" Many medical men are in the habit of fumigating the sick room, either constantly or several times a day, with chlorine or sulphurous acid pending the whole course of the fever. There can be no objection to this measure, but I do not myself attach much importance to it. Experience of the largest and most decisive kind has shown that chlorine-and I believe the observation applies equally to the other chemical agent-in the degree of atmospheric impregnation respirable by man, has no appreciable influence in preventing the spread of infectious disorders." Dr. Budd has not told us in what manner he has employed disinfecting agents, chlorine more especially, to enable us to judge whether his method of using them were likely to be efficient or not.

My experience of the beneficial effects of a free use of chlorine is directly opposed to Dr. Budd's views; and I am able to state from my own observation that, if this gas be properly used in the sick room of the patient, the contagion of scarlet fever will be confined to that room. My method of using it is as follows. I direct large coarse towels to be saturated with a solution of chloride of lime, and hung over the backs of chairs, and a sheet to be hung in front of the bed-room door. We may judge of the quantity required for disinfecting the room by smell and taste on going into it. This process should be continued throughout the course of the fever.

I have always found the effect of breathing the chlorine to be most refreshing to the patient and most soothing to the throat; for frequently, when patients have complained of a difficulty in swallowing previously to its being used, directly they have breathed the gas they have exclaimed, "I can breathe much better now."

I could give numerous instances of the power possessed by chlorine in localising the scarlatinal poison. I will confine myself, however, to one as a type of the others; and I select this instance on account of the unusual opportunity I had of watching the progress of the case from the commencement, when it showed signs of being most severe, to its termination. I extract this case from short notes made at the time, giving the treatment employed for the subjugation of the fever.

Two years ago I was on a visit to a family in Scotland, where I stayed three weeks. On the morning after my arrival, the lady of the house came to me in great tribulation and asked me to see her little girl, eight years of age, who, she feared, had scarlet fever. This lady, two years previously, had lost a girl from scarlet fever about the same age, and her second son was very nearly following his sister. The mother told me that the illness of her other children began exactly with the same symptoms as the present little girl had. She had been quite well the day before, but in the evening complained of cold and had a rigor. I learnt that the child had been delirious throughout the night. She complained of intense headache, her throat was very painful, the tonsils were much swollen and of a deep red colour, and she had great difficulty in swallowing. Her eyes were blood-shot, and she had been repeatedly sick. Her skin was burning-hot, and there was a rash all over her body. Pulse 120; tongue very foul, and her breath very foetid; great restlessness and intense thirst. I first saw her on the 9th of Aug., at 10 a.m. I ordered one grain of calomel, and one grain of James' powder, to be made into a powder with some sugar, one to be given every four hours; a tea-spoonful of the effervescing citrate of magnesia to be given one hour after each powder. Small pieces of ice and iced water to quench the thirst. This was very grateful to the child. The air of the room was impregnated with chlorine in the way described. When I saw her at 7 p.m. the child was better. She had taken three powders. The sickness and headache had left her. Her throat was less sore on swallowing; she having felt almost instant relief from this symptom the moment she breathed the chlorine. She had had several most offensive watery evacuations throughout the day. The rash and heat of skin remained the same. The tongue had quite changed its appearance from the brown colour of the morning, to a red, chalky condition. I ordered the powders to be left off, and no other medicine to be given until the morning, when she was to have a dose of the citrate of magnesia. On August 10th, the rash, which yesterday was of a dingy red, this morning was a vivid scarlet. The burning heat of skin and quickness of pulse remained the same. I ordered her one grain and a half doses of quinine, with ten-drop doses of dilute sulphuric acid, with tincture and syrup of orange peel to be given in water every six hours. Her diet was beef-tea and bread. When I saw her at midnight I heard that she had fallen asleep at 7 p.m., and remained so until that time. On the 11th, the child was in all respects better. She had slept until 3 a.m.; awoke, and fell asleep again. The rash still continued. The pulse was less rapid, the heat of skin less, the throat more comfortable. She felt so well that she wanted to get up and be dressed. The tongue was more furred to-day. I ordered her a dose of scammony and