are incident, according to my observations, to those only whose habits and mode of living have been calculated to do an abiding injury to the nervous system, and who have been long actually suffering from such an injury. Every class of society has furnished me with instances of this form of fever, and every instance has confirmed the truth of the remark.

"Among the higher and educated classes, there is in this age and country a wonderful striving for all the objects of wealth, and honour, and power. We need only think upon the strife of politics, the hazards of mercantile gambling, and the wear and tear of hard professional toil, to see how many there must be who, from the common business of life, have denied both to their minds and bodies new feelings and impulses, and new susceptibilities to disease. These susceptibilities chiefly belong to the brain and nervous system, and they are apt to come forth in frightful activity, when such men become the subject of fever. The trouble of the brain gets the mastery, as it were, of the disorder of every other part.

"The poor and mean among mankind have the mind overwrought, and the nervous system exhausted by real calamities just as the high and educated by their more refined; and thus they often claim an unenviable approximation to them in the character of their disease.

"To these moral causes," says Dr. Latham, "I will add one physical cause, which is of most extensive influence-the habitual indulgence in spirituous liquors. Individuals who have done a permanent harm to the nervous system by the abuse of spirits, do never, when they become the subject of fever, suffer delirium of the ordinary kind, in which the brain is excited nearly in the same proportion as the blood vessels, and which by remedies addressed to the blood vessels is uniformly controlled; but they suffer a delirium in which the brain is actuated disproportionately to, and, perhaps, independently of, the blood vessels, and, if curable, to be cured by opium. This I venture to state almost absolutely, and without any exception."

My experience in those cases of fever under my own observation in Dublin, accords with the preceding eloquent and philosophical remarks. I have invariably observed, that in all cases where the patient had been exposed to the depressing effects which high intellectual or moral excitement, or the abuse of spirituous liquors produces on the nervous system, there will be, during the progress of fever, more or less cerebral disorder. In such cases, if delirium exists independently of vascular action, opium is the best remedy. A good deal of caution is required in regulating the quantity to be administered; and we should carefully feel our way by commencing with small doses, and when we find that these do good, we should increase them. It would not be safe in most cases to exhibit such large doses as we do in delirium tremens. We would begin with small doses, watch their effects, and repeat or discontinue the medicine, according to circumstances.-Lond. Med. and Surg. Journal. (To be continued.)

REVIEWS.

Admonere voluimus, non mordere.

Sunt bona; sunt quædam mediocria, sunt mala plura.

The Croonian Lectures, delivered at the Royal College of Physicians, in 1983, on Cholera. By GEORGE LEITH ROUPELL, M.D. of London.

If the untiring zeal-the patient and persevering research which have characterized, in an eminent degree, the investigations of the medical profession in relation to the nature of cholera, had been attended by a corresponding degree of success, we should have arrived, long since, at a perfect understanding of its mysterious character. But, unfortunately, shrouded in an apparently impenetrable obscurity, it has defied, as yet, the scrutiny of the most learned and talented of our profession. The most eminent physicians, with a self-devotion above all commendation, have thrown themselves, in vain, amidst the wretched victims of the disease, encountering every risk, and in innumerable instances, incurring almost the certainty of death themselves in order to study and unfold its nature.

Bursting upon us with the suddenness and violence of a tornado, it swept across our continent with almost unexampled rapidity-carrying death and consternation in its track. Having passed, however, it was fondly hoped by many that it would not again appear; but that, like some fierce monster, whom inordinate hunger has compelled to trespass far beyond his usual haunts, it would retire to its proper home-India, and no longer molest us. This expectation has, unfortunately, proved delusive, the disease has reappeared in many places, and recently among ourselves, selecting too its victims from among the temperate and most respectable classes. Compelled then to anticipate its reappearance among us, as often as there shall arise that concurrence of circumstances-whatever they are-which conspire to produce it, we are impelled by the most cogent considerations, to seek and disseminate all the information within our reach in relation to it.

Among those whose talents and opportunities afforded the means of accurate and extensive observation, Dr. Roupell must be numbered; having held the appointment of Physician in charge of the cholera patients at St. Bartholomew's Hospital-and of Physician to the floating Hospital for seamen, the Dreadnought, besides being a member of the city of London Board of Health. Actuated by a desire "to communicate to the profession any facts that may appear interesting or important," he selected cholera as the subject of the Croonian lectures which he had

been appointed to deliver at the Royal College of Physicians, and which he has subsequently published, "trusting," he says, "that what I have found serviceable in my practice, will prove equally so in the practice of others, and claiming only the merit of stating with impartiality and good faith, the result of my observation and experience."

After glancing at the origin of the most important epidemics-the plague, sweating sickness, measles, &c. &c. Dr. R. enters upon the consideration of the progress of cholera in England. The term spasmodic, he rejects, preferring that of malignant, because, "first, of its fatal tendency-next, because English cholera is spasmodic, and thirdly, because the more severe form of the disease is not attended by spasms." The objection is certainly valid, and might indeed have been extended to the appellation, "cholera," so far as it is used to convey an idea of the symptoms or nature of the malady. Precision is certainly desirable in affixing names to diseases; but it is now too late to substitute a new one for the disease in question, and the designation, almost universally applied, of "cholera," seems quite sufficient, without prefixing any epithet what

ever.

The generally received opinion that the disease originated in 1817, at Jessore, Dr. R. does not concur in, but believes that a disorder described by Mr. Curtis in the Madrass reports, which prevailed in the year 1782, in the squadron of Sir Edward Hughes, then stationed in the East, and which arose from communication with an infected port of Ceylon, was identical with the disease now known as cholera. That the conclusion is correct there can be no doubt we think, after reading the passages quoted, describing the disease.

The different theories in relation to the cause and propagation of the disease are briefly adverted to, but the Doctor declines entering upon the discussion of its contagion, though he intimates in no very equivocal terms, his own conviction of the affirmative of the question. Many interesting statistical details are given, according to which it appears that the proportion of deaths in Great Britain has been about in the ratio of 1 to every 800 of its population. The rate at which the disease traveled in England was a little over 100 miles in three months,—a progress but slow compared with that in this country. That the disease may be expected to return, Dr. R. seems to entertain no doubt, as it has recurred repeatedly within the fifty years that it has been known in India: between the years 1817 and 1830 it has broken out no less than 650 times in different parts of India, and with very variable degrees of malignancy.

After alluding to the various, and often very contradictory, plans of treatment that have been adopted; whether addressed to the cutaneous structure, such as heat, acupuncture, moxa, &c.—to the respiratory organs, such as the inhalation of different vapors, and of oxygen, chlorine,

&c.-the abstraction or transfusion of blood, &c. and to the almost endless variety of internal remedies, the Doctor takes up the consideration of those means which he thinks experience has most extensively sanctioned, viz: bleeding, emetics, salines, stimulants, purgatives, and sedatives. To venesection he attaches more value than to any other remedy, in the more severe forms of the disease, when resorted to either during the premonitory diarrhea, or even after it has more clearly developed itself, provided the system be not exhausted by copious discharges. The advantages derived from blood-letting do not depend, however, in Dr. R's opinion, upon the relief afforded to the congested venous system, as generally supposed, but to the check it furnishes to diarrhea; and various cases are given to sustain this position; his observations on this point have led him to the following inferences:-"1st. That venesection. will stop a diarrhoea, when calomel and opium, and an emetic have failed. 2d. That venesection will stop the purging in cholera, before collapse has taken place. 3d. That in collapse, bleeding is of doubtful benefit, if not positively hurtful." To emetics, no great degree of usefulness is allowed, though their occasional exhibition has been beneficial in his hands. Practitioners have been induced, he thinks, to give them undue importance, in consequence of observing sometimes after their administration, a rise in the pulse, and even the disappearance of the lividity of the skin, but this flattering change in the condition of the patient is usually but transient. Salines afford but little benefit generally, though he has witnessed good effects from their use in a few cases. The employment of stimulants, such as brandy, ether, &c. can only be resorted to with propriety, Dr. R. contends, in the early stage of the disease, when they will often arrest it, and should never be continued, as they often perniciously are, too long. With the view of simply removing the irritating contents of the intestinal canal, purgatives are of essential value,—but should chiefly be given in the commencement of the disease. As to narcotics, "although no remedies are of more consequence when properly directed, none have been more seriously abused," the proper period for their administration is at the commencement of the disease, and then in full doses. Calomel, which, in various doses, has been more extensively used, perhaps, than any other article, receives but little notice from Dr. R.—as a purgative, it has his approbation, but he dissents from those who "chiefly rely on it, in almost unlimited doses." Nor does he consider the constitutional action of mercury an antidote to the disease, even when its influence is produced before collapse occurs-though its appearance must be regarded as an evidence of a favorable condition of the system.

In his third lecture, Dr. Roupell considers the nature of cholera, and after alluding to the unsatisfactory efforts of others to elucidate it, with becoming diffidence, gives his own peculiar views. Considering the

theories of inflammation, and of congestion of the gastro-intestinal mucous membrane and of an alteration of the secretions, &c. &c. as insufficient to account for the phenomena presented, he expresses his own belief to be, "that the primary cause of the effects witnessed arises from an affection of the nervous system; that the immediate result of this is an irritability of the lymphatic portion of the vascular system, occasioning increased fluid discharges, which exhaust the system, and prove eventually fatal. The depression of the sanguiferous system is not the first step in the disease, for although the pulse is in general depressed, yet it by no means is invariably so, for cases are occasionally met in which copious and characteristic dejections are found while the pulse continues good." That the nervous system is first affected, Dr. R. thinks is proved by the cramps of the calves of the legs, arms, hands, &c. which so often occur in medical and other attendants when they first approach the sick. The fluids effused in cholera, Dr. R. affirms, are not simple serum, and differ essentially from that secretion which is produced by active irritation of minute vessels. "It contains a coagulating part; fibrine is suspended in it; its appearance is milky;-circumstances which distinguish it from simple serous effusion; but in each point in which it differs from serum, it approaches to the usual contents of the lymphatic vessels." Dr. R. denies that the copious discharges poured out by the bowels could be supplied by the blood vessels, as that would imply an excitement of the sanguiferous system, which, on the contrary, is usually paralyzed, in its superficial branches, though cholera proceeds in its course for hours after the suspension of the pulse.

"It is not probable that the profuse discharges poured out in cholera should be furnished from the vessels of a depressed system, to whose contents the discharges, in substance, bear no resemblance; but it is highly probable that these discharges should proceed from the action of the lymphatic system, which derives its energies from the depression of the sanguiferous system, more especially when the discharges are in their nature, as nearly as can be judged, identically the same as the ordinary contents of the lymphatic vessels."

The arguments which the Doctor adduces, to prove that nearly all the phenomena of the disease are explicable upon his views of its nature, our limits do not permit us to notice in detail, nor is it necessary, as their scope may be gathered from what has already been said.

The adaptation of the mode of treatment recommended, to the idea entertained of its nature, form the conclusion of the volume.

"In the premonitory stage, calomel, opium, brandy and other stimulants may be exhibited, when only the nervous extremities are affected, or determination be only slightly occasioned; this may blunt the impressions, and thus render the nerves insensible to the cholera stimulus, or by general excitement of the sanguiferous system the disease may be