dangerous. I must earnestly caution you against its use. In the stage of collapse, if it is retained, it is, it must be, useless. But when reaction sets in, the opium, previously inert, begins to act, and is at once a serious hindrance to the restoration of the secretions, and, if the quantity given has been large, often hastening on cerebral symptoms ending in coma. These are its dangers, without, so far as I know or could ever discover, a single compensating advantage.

9. What of astringents? No class of remedies have been more used in cholera. The great anxiety has ever been "to restrain the evacuations. Yet I am persuaded that the mere purging rarely kills; and, as I have already said, in the most fatal form of cholera there is no purging, or very little. Graves recommended acetate of lead with opium, and this combination has been more used than perhaps any other remedy in cholera. Sometimes capsicum is added by way of a stimulant. Here, again, we are met by the old difficulty: what service can we expect from such combinations during the condition of collapse? Very little, I fear. And what is likely to be the action of large quantities of this powerful sedative during the stage of reaction? Will it aid or embarrass the struggling system? Again, supposing the remedy to be retained and to act, how far do we benefit the patient by controlling the purging? I don't believe that cholera is caused by "hyperæmia of the nervous centres from heat." If this hyperemia be present, there is something else also, some materies morbi, some subtle poison-what, I know not,, I do not pretend to know. If it be the case, as so many suppose and as I believe, that this poison is in part at least eliminated in the intestinal canal, how far do we benefit our patient by restraining it? I have ridiculed the attempt to secure this object by mechanical means; will the use of astringent drugs stand the test of argument any better? But then experience has sanctioned them. Alas! I have had much experience, and I am sure that I was more successful, as a rule, when I withheld them. Still, there are cases where some astringent is necessary. Granting that the purging within certain limits is salutary, it may go on to such an extent as to lower the patient hopelessly. In such cases an effort must be made to restrain it. Acetate of lead should then be used, in solution, but without opium. In such cases pernitrate of iron, in full doses, might be tried. My friend Surgeon-Major Mudge, of the Madras Army, made a trial of turpentine in egg emulsion with an aromatic, and in a number of cases found it more than answer his expectations. The sufferers in whom Dr. Mudge tried it were all Asiatics. It does not seem to have caused vomiting or even nausea-the objection to which we might expect to find it open, as turpentine is generally a nauseous medicine. In one epidemic

I found nitrate of silver exceedingly useful as an astringent in excessive purging, particularly, as I noted at the time, in children; some of my, native pupils used it extensively during the same epidemic in the great native city of Hyderabad, and with so much success as to gain for themselves considerable reputation. I used it again in the following year, with disappointing results-another proof of the "varying constitution of epidemics."

10. Calomel has been used to fulfil every indication in turn, according to the peculiar belief of the prescriber. Some give it as a purgative, others as a sedative, not a few "to stimulate the secretions." I have seen it given as a cure for vomiting. Then we have a pretty numerous class who give it for no reason in particular. Calomel is the trump-card in their hands; so, like good whist-players, "when in doubt," as men are apt to be in dealing with cholera, they "play trumps "-they give calomel. I have seen it given in every conceivable way, and for every possible or impossible end: in grain doses every hour or half hour, and by heroic practitioners in scruple doses again and again. But, gentlemen, it is the old story. Calomel is of no use during the stage of collapse; but by-and-by, when the powers of life begin to revive again after the shock is over, the first thing the system has to deal with and to dispose of is twenty or thirty grains of calomel. What results? Very often vomiting of that "green paint-looking matter" of which I spoke appears, and you know how hard it is to stop that; or bilious diarrhoea is excited, which soon brings the case to an end. At the best it disturbs the stomach, and interferes with nutrition. At such a time Nature needs the helping hand of the physician to sustain and assist her in the life and death struggle, instead of being searched and goaded by powerful drugs, prescribed no matter with what intention. Called to see a case of cholera a few months ago, I found calomel in combination with opium being "poured in" every hour. I ventured respectfully to ask the reason why; the patient being in a state of collapse, the medicine was accumulating in the stomach like water behind a barrier. "What, I asked, "do you expect will be the action of all this calomel when the barrier gives way, when the functions begin to be restored? The prescriber was not very sure, thought perhaps it might have "a cholagogue action-stimulate the bile." I might have asked, Is it not conceivable that Nature will do this herself? And why not stimulate the kidneys as well? Why concentrate all your attention on the bile? Is the biliary more in abeyance than any other secretion? and so on. I do not think these are impertinent questions. I recommend you to put them to yourselves when you are tempted in moments of doubt to prescribe as D'Alembert said we sometimes do

using physic as a strong but blind man uses a club in a crowd, hitting friend and foe with equal impartiality.

11. Stimulants, both of a medicinal and alcoholic kind, have been much resorted to in cholera, and very naturally. The prostration of the powers of both circulatory and nervous systems is so extreme that we cannot wonder that strenoous efforts have been made to rouse and to sustain them by the free use of remedies of this class. Yet I think that those who have used them most, if observant and candid men, must admit that they have not answered their expectations; and at least all must allow they require to be given with a cautious hand. They are useful. as I shall presently show, when given at the proper time and in the right way. I do not think they are of any use during the stage of collapse, when at first sight they might appear most appropriate.

We have thus examined the therapeutic value of the remedies that have been most used in cholera. The result is not encouraging. I may say I have tried most of them, and the above is the result of my experience. You will perhaps say-Do you then advise no treatment in cholera at all? Well, I can only say that in the collapsed stage I know no drug worthy of the smallest confidence. Must we, then, abandon our patients to nature, and do nothing? Must we suffer them to die without an effort to save them? My answer is, that efforts of the kind described above are futile; your remedies are either vomited, or if,retained, are inert,and if given, as they often are, in excessive quantities, they become a serious source of embarrassment, interfering above all with nutrition. If opium, the preparations of lead, or calomel, have been abstained from, Nature, in the stage of reaction, starts, so to speak, fair, which I am sure is not the case when weighted with one or other, or, as I have often seen, with all the above. Because I objected to bleeding intemperate old soldiers of twenty years' service in tropical and malarial climates, taking blood away to the extent of upwards of a hundred ounces when suffering from peri-hepatitis, I was called the other day "the Micawber of medicine," the gentleman "who waits to see what will turn up." Well, I don't object to the name in the least; I had rather be the " Micawber" than the " Sangrado" of modern medicine. The more I have "waited" upon Nature, the less I have attempted to force her, the more I have found that "something" is pretty sure to "turn up" to the advantage of my patients. Very notably has this been the case in cholera. Some-unfortunately a great many-patients in severe epidemics will die, but such cannot be saved by pouring drugs into them in the collapse of this terrible disease.

Suffer me to recapitulate. Secure the best hygienic conditions possible for your patients; avoid crowding them; give abundance of water to

drink and ice to suck; correct cramps and inordinate vomiting by the internal and external use of chloroform; apply external warmth and extra bedclothes if these are grateful to the patient, but if they make him restless do not press them. If the cuticular discharge is excessive, wipe the patient dry from time to time, disturbing him as little as possible. If vomiting be not excessive, and if the remedy does not excite it, ten drops of the mixture I have recommended in the premonitory diarrhoea may be given from time to time, chloroform being substituted if vomiting be urgent. As soon as vomiting ceases, you must support the patient by proper nutriment. At first I begin usually with thin arrow-root, well boiled, and flavoured with a little aromatic. I give this, commencing

with a teaspoonful at a time, giving every now and then a teaspoonful of brandy in it, never over-distending the stomach. Instead of water, I now quench thirst with milk containing a little lime-water, and flavoured, if it be at hand, with a few drops of curaçoa. This may be often given to the patient with a little soda-water. As reaction procceeds, I substitute strong beef-tea, or, better still, essence of meat, using it in the same cautious way-spoonful by spoonful at proper intervals; later still, eggs beat up with little brandy, and flavoured as before with curaçoa, is often relished. The greatest caution is required not to disgust the patient, not to re-excite vomiting, not to over-stimulate, and so to bring on cerebral symptoms during the febrile reaction. When patients are thus carefully nursed, it is seldom that reaction is excessive. Nothing but mischief may be expected from over-anxiety to hasten forward convalescence by too freely pressing food and stimulants on the patient. It re. quires a great deal of drilling and care to get orderlies and half-instructed nurses to understand this; and many cases go wrong from their overanxiety to press both on those under their care. In a word, the treatment of cholera may be summed up in two words-good nursing. The difficulty is to obtain this when an epidemic rages. The man who in such scenes maintains his presence of mind, preserves order, regularity, and good hospital discipline, and so arranges as to secure to each patient a fair amount of this good nursing, will save a larger proportion of cases than by any other method with which I am acquainted. What I recommend to others I followed in my own case. When struck down by this disease, I took no drugs. I experienced the burning thirst I have described; but instead of tormenting myself by abstaining from fluids, I drank freely of iced soda-water, to my infinite comfort and refreshment. When I vomited, which I did often, I drank again. A faithful servant, my only doctor sat by me, and, when too feeble to do more than express my wants by a gesture, replenished my cup

again and yet again. I vividly remember the resolution then formed, and never since departed from—to do unto others as had been done unto me; never to withhold a cup of cold water from a cholera patient. With daylight came a kind and judicious medical friend, who, instead of goading me with physic, sustained me with food, much in the manner I have advised in this lecture. With the result I had and have every reason to be satisfied and thankful. Dangerous reaction-i. e., high fever, with cerebral symptoms and coma, I have seen; but only when Art, coming not to aid but to thwart Nature, has interfered with her eliminatory processes by the too free use of opium, astringents, and such like remedies. In such cases we must have recourse to free purgation by calomel, apply ice to the head, and restore the action of the skin by the wet-sheet, cold sponging, and the like. When the secretion of urine is long delayed, I have seen good results from the free use of chlorate of potash,, and the application of turpentine stupes over the region of the kidneys.

Note. Since the above leeture was delivered, I have seen and read with pleasure and profit Dr. George Johnson's "Notes on Cholera." This able physician has been led to much the same conclusions as to the action of most drugs in cholera as are expressed above. Dr. Johnson puts more faith in the action of purgatives than I can do; for, like every known class of drugs, they have been freely used in India. I sincerely trust that Dr. Johnson may never see so many cases of cholera as I have done; but I cannot help thinking, should it be otherwise, that he will see cause to believe with me that, in a vast majority of cases, there is quite enough purging without artificial aid. Still, for my own part, if again smitten by cholera, let me rather fall into the hands of a purging than an astringing physician-one who thinks he does you service by retaining what Nature is so solicitous to expel from the system.-London Lancet.

NOTES ON CHOLERA BY DR. JOHNSON.*

The appearance of Dr. G. Johnson's unassuming little volume will, we trust, be the means of calling the serious attention of the profession to the terrible subject of the Cholera. For a time this destroyer has ceased its ravages in Europe, and our shores have so far escaped its visitation. But who will assure us that this present year will pass away and leave us still unmolested? The history of former epidemics justify us only too well in anticipating that, before many months are passed, medicine may be again trying conclusions with the enemy here within our very doors.

• Notes on cholera ; its Nature and Treatment. By George Johnson, F.R.C.P., etc. London: 1866.