forms of the disease, a case with little vomiting or purging is more malignant and more rapidly fatal than one in which these are prominent symptoms." Mr. Fitzgerald says (p. 30)— "In all the collapse cases that proved fatal in the Jounpore jail during the outbreak of 1870, vomiting and purging had invariably ceased, without the pulse being restored; and the sooner, under such circumstances, the vomiting and purging ceased, the more rapidly did the cases proceed to a fatal issue." He adds "At first I had some difficulty in persuading the native doctors and hospital attendants that the vomiting and purging in cholera were not only not dangerous but actually good for the patient, and that the real source of apprehension was from failure of the circulation and suppression of urine. When, however, they saw all those cases turn out badly in which the vomiting and purging ceased without return of the pulse and urine, they grew more reconciled to this doctrine." With reference to this question we extract the following from the very able and interesting paper by Drs. M'Cloy and Robertson, in the fiftieth volume of the Medico-Chirurgical Transactions :' "There is we believe no case on record of a patient having recovered from an attack of cholera without having experienced more or less the peculiar discharges of that disease. Upon looking over our record this will be seen to characterise every case of recovery. Whatever the treatment adopted the result was the same-recovery never occurred without the continuance of the intestinal discharges or their restoration if previously arrested. But if the collapse of cholera be produced by the drain of fluid from the blood consequent upon these discharges, surely recovery ought to be preceded by their arrest, and not by their continuance? Fatal collapse, on the other hand, invariably followed when the discharges could not be restored. May we not then reasonably look upon the discharges as salutary-as the agents by which nature frees the system from a deadly poison? We believe sc, and with this belief we can no longer retain that hypothesis which demands their arrest." Now, it is obvious that, if this be the true interpretation of the intestinal discharges and the collapse of cholera, the cure of the disease cannot be effected by means calculated directly to repress the discharges. "It is plain," says Sir Thomas Watson, "that if elimination' be a condition of recovery the method of elimination is nature's method, which art may help or hinder -help by the cleansing method, hinder by the astringent." We have reason to believe that this principle of treatment is now accepted and acted on by a very large proportion of the 100-L. 25 profession, but it has had to make its way in spite of much opposition and prejudice, and it is manifest that much of the opposition has been based upon a misapprehension. Most writers who have expressed their dissent from the eliminative treatment of cholera erroneously assume that the object of those who advocate this method of treatment is to increase the discharges from the mucous membrane of the alimentary canal, and they proceed to argue that, if this is the correct principle of treatment for cholera, its application to the treatment of other diseases would result in attempts to increase the eruption of small-pox and the other exanthemata. Dr. Bristowe, in his "Croonian Lectures" (Brit. Med. Journal, June 1, 1872) adopts this line of argument, and asks whether "Any one ever attempted to eliminate mumps by promoting saliva or semen, or diphtheria by encouraging the development of its characteristic false membrane? And yet, if the theory of elimination be true, I conceive that this should be the proper indication for treatment." This course of reasoning is based upon an entire misconception of the object proposed by the advocates of the eliminative treatment of cholera, which is not to increase the discharges from the mucous membrane, but simply to prevent their retention and to facilitate their expulsion from the alimentary canal. Upon this point Sir Thomas Watson remarks that "Whatever may have been Dr. Johnson's earlier purpose, he does not now propose to excite discharges from the mucous surface of the digestive canal; but simply to facilitate the removal of matters lodged there;" and Dr. Johnson himself says "The object of a purgative in cholera is not to increase excretion from the blood into the stomach and bowels, but simply to assist in the expulsion of the morbid secretions from the digestive canal." ('Notes on Cholera,' p. 89.) He also expresses his belief that copious draughts of cold water will suffice for the cure of most curable cases of cholera, and he maintains that this cleansing mode of treating cholera is strictly analogous to the treatment of small-pox by free ventilation; the object in both diseases being to facilitate the removal of noxious secretions which have been spontaneously ejected from the circulation. The attempt to excite prejudice against the eliminative treatment of cholera by comparing it with the old heating method of treating small-pox appears to us singularly ill-judged. The treatment of small-pox by excess of clothing, and by closed doors and windows, was the reverse of eliminative; it was a pernicious and fatal practice, not because it increased the cutaneous eruption, but because it compelled the unhappy patient to breathe a close and poisonous atmosphere, and so it was in reality more analogous to the astringent treatment of cholera than to the treatment of that disease by cold water and eva cuants. It is not our intention now to discuss the details of treatment. There is a very general agreement that during the stage of collapse opiates and astringents are injurious, and diminish the probability of recovery. It is also acknowledged by those who are most capable of forming a judgment that, in cases of extreme collapse, none of the ordinary means of treatment have any perceptible influence upon the progress of the malady. If the proximate cause of choleraic collapse be, as we have reason to believe, an arrest of the flow of blood through the lungs, it is obvious that ordinary remedies are powerless to overcome that obstruction, while the immediate and marvellous, though too often temporary relief afforded by hot saline injections into the veins affords additional evidence of the mechanical nature of the obstruction upon which the state of collapse essentially depends. Assuming, as there appears reason for doing, that the morbid blood excites the contraction of the minute pulmonary arteries, it is probable that the beneficial influence of the saline injections may be explained partly by the fluid diluting the blood in the right side of the heart and in the pulmonary artery, and so rendering it less stimulating to the tissues with which it is brought into contact, partly by the relaxing effect of the warm liquid upon the arterial spasm. It has been conclusively proved that merely tepid injections are followed by much less striking results than the injection of fluids of higher temperature. The late Dr. Mackintosh injected no fewer than 156 patients during the epidemic of 1832. The temperature of the fluid injected by him varied from 106° to 120°, and he states that "the good effects of the injection were rapid in proportion to the heat of the solution." (Mackintosh's Practice of Physic,' vol. i, p. 365.) Mr. Little, during the last epidemic, injected at the London Hospital twenty patients who were considered to be in hopeless collapse, yet six of these patients recovered. The temperature of the saline fluid injected was 110°, and Mr. Little states that "a temperature below 100° is decidedly injurious." (Medical Times and Gazette,' April 6th, 1867.) On the other hand Dr. Parkes obtained much less striking results from injections of lower temperature-98° in one case, and in another said to be "tepid," but the actual temperature not mentioned (p. 219). The effect of a warm bath in relieving the muscular cramps is very striking, and the radial pulse not unfrequently increases in volume and power while the patient is immersed in the bath. These facts are confirmatory of the proposition that a high temperature tends to relax spasm, both of voluntary and involuntary muscular fibre. While the immediate and most striking results of saline injections into the veins are probably due to the relaxation of the arterial spasm; it is not denied that the injection may indirectly assist recovery by increasing the liquid medium for conveying the poisonous products out of the vessels, just as a copious imbibition of water helps to wash out and cleanse the bowel. In the diarrhoea stage of cholera, as in cases of ordinary diarrhoea, that plan of treatment is obviously the best which most speedily and completely arrests the disease without subsequent ill effects. We believe that in the majority of cases no active remedies are needed either of an evacuant or an astringent nature, and that simple diluents, by favouring the natural tendency to recovery, will usually suffice for the cure. An indiscriminate opiate and astringent treatment of diarrhoea is now adopted by comparatively few practitioners, while, on the other hand, the practice of commencing the treatment by a laxative dose is very general. In the words of Sir Thomas Watson: "No doubt the true indication of treatment is to stop the flux as soon as possible; but this may sometimes best be effected by (as also in crapulous diarrhoea, and in the summer cholera of Sydenham) by carrying off the offending matter." The true use of evacuants in this class of cases is to facilitate and quicken the expulsion of undigested food and morbid secretions, and to prevent painful distension of the bowels; while, on the other hand, the true use of opiates and astringents is to soothe the bowel, and to prevent excessive secretion after the expulsion of their morbid and irritating contents. Tact and experience alone can teach the practical use of these remedies in each case. In the treatment of cholera, in all its stages, we strongly deprecate the employment of needlessly active and dangerous remedies. We have repeatedly referred to Mr. Fitzgerald's able pamphlet which contains much interesting matter relating to the etiology and the pathology of cholera, but we are surprised to find that he considers strychnia to have an almost specific curative influence upon the disease, and he advises the employment of that powerful drug in, what we consider, dangerous doses. He gave one-twelfth of a grain every twenty minutes until half a grain was taken, then an equal dose at longer intervals. Some patients had as much as a grain and a half in the four and twenty hours. It is probable, as he says, that "much of it may have passed away with the dejecta without being absorbed, and that this alone prevented the toxic effects of the drug." He proposes in future to administer strychnia hypodermically, and he considers that an eighth of a grain may thus be given as a first dose. Now, considering the probability that in consequence of the drain of water through the alimentary canal there would be an active absorption of liquid from the subcutaneous tissue, we consider this a dangerous dose of strychnia to be thus administered; and, so far as we can learn, there is no evidence that this poisonous drug has a curative influence in any stage of cholera. The same objection applies, although in a less degree, to the large doses of calomel recommended by the late Dr. Marsden. We find that Dr. Alex. Marsden, in the preface to the new edition of his father's little book, expresses his opinion that since the first publication of that work no advance has been made in the scientific treatment of cholera. In this statement we think that he scarcely does justice to his contemporaries. In the original work it is stated that "infectious diseases never attack a human being a second time," and cholera is classed, as a disease which is neither infectious nor contagious, with plague and typhus fever. As this statement is allowed to remain without editorial comment it may be taken as the expression of Dr. Alex. Marsden's opinion upon contagion in general, and upon the contagiousness of plague, cholera, and typhus in particular. We scarcely need add that this doctrine is not in accordance with the conclusions of modern medical science. VII.-State and Progress of Therapeutics. THE science and art of therapeutics now assume a leading place in medical thought and study. It is, indeed, only natural that the most prominent function of medical men-that which they have to do day by day, and which is involved in the most limited exercise of their craft, should occupy a prominent position in their thought and training; yet it is only just now that therapeutics have acquired such a position. Our relation in regard to the subject is this:-we do know a great deal, but we are continually obliged to act as if we knew much more. We cannot stop our art, even if we would, until the science thereof becomes perfect. What concerns us is to show that therapeutical science rests upon a firm and impregnable basis. How we cure, we often |