of the modern Broussais, whose important services to medicine entitle him to the highest praise. From the foregoing observations, it is almost unnecessary to remark, that our treatment of fever in this hospital is not conducted on one invariable rule. In a great proportion of cases, emetics, bleeding, purgatives, diaphoretics, and stimulants, are used in the order now stated; but, in some cases, to adjust these remedies to the disease, and to balance contrary indications, is no easy task. As success is, generally speaking, a criterion of good management, I do not hesitate to challenge a comparison of our hospital practice with that of any other Institution whatever. The proportion of recoveries to deaths would be infinitely greater, were we to exclude from the latter those which occur during the first two or three days after admission. This allowance might fairly be made, as it is obvious to medical men, that in general no human aid could, in fevers, have warded off the fatal blow two or three days only before death. For my part, without descending to an idle boast, I confidently refer to my hospital journal, (and I make no doubt my colleagues can do the same,) to prove, that in cases of simple fever, not one in fifty cases proves fatal, of such as come under my care before the fifth day. The great majority of those who die in this hospital, are such as are admitted in the last week of fever, or who labour under chronic disease of the heart, lungs, or bowels, the sequela of former attacks." IV. DR. H. M'CORMAC ON CHOLERA. THE public in this country was a good deal surprised at the comparatively small mortality of the epidemic in Belfast. The pamphlet published by Dr. M'Cormac, who treated 934 cases, will shew the methodus medendi pursued in the above-mentioned town. "It is of the utmost importance to arrest the purging and vomiting with the least delay; for the fluid discharges are the serum of the blood, and cause weakness and death, as if the blood itself were drawn away. I have often seen a patient pass, in a very short time, a gallon or more of this fluid, which, not long before, was circulating as part of the living blood. This discharge will not cease of itself; it continues till it brings the patient to the verge of death. It is almost the same as if so much blood streamed from open wounds. I never knew a case in which an individual attacked with Cholera Morbus, grew spontaneously well—the diarrhoea always appears to go on to the production of collapse and death, unless medical aid be interposed. The reader will then see the necessity of losing no time, and he will not, therefore, wonder when I tell him, that I do not wait till the discharges and the cramps have made the patient cold and blue, but commence without the loss of a moment, to give the most powerful medicines. These medicines, powerful as they are, cannot be productive of the least injury; but neglected or inefficiently treated Cholera, surely leads to death. The following is the mode of treatment which I follow, specifically laid down: If a person between ten and sixty, whether male or female, not much broken down or previously debilitated, be seized with the disease, whether with purging and vomiting, or purging, vomiting, and cramps. I immediately take away from the arm, if the pulse be not weak and thready, from ten to thirty ounces of blood, the quantity being regulated by the strength of the individual and the effects produced. To a man or strong woman, I give, while the arm is tying up, a scruple of calomel, with two grains of opium, both in powder, and washed down with a mixture of some diluted ardent spirits, as gin, whiskey, or brandy, united with from forty to sixty drops of laudanum. To an ordinary woman or weak man, I administer half this dose; to a child the quarter, and to an infant the eighth part. If the medicine be thrown off, in whole or in part, the whole or a part of the same dose, as it may appear, must be immediately repeated. In two or four hours, or every four hours, the medicine must be repeated, if the symptoms are not subdued. In this case, general directions alone can be given: the whole dose may be given again, the half only, or the fourth part, according to the urgency of the disease; in general, however, I find five grains of calomel, and one grain of opium, sufficient. In this, as in many other particulars, the practitioner,must use his own discretion. If the complaint be early treated, it will generally be checked after the first or second dose very frequently a single dose extinguishes it at once. Time after time, patients have been brought in with almost incessant purging, vomiting, and cramps; yet hardly have they been bled and swallowed their medicine, when all these symptoms have vanished, sleep came on, and the patients have awakened after some hours, weak but well. In most instances, however, the medicines require to be repeated. Sometimes the symptoms will continue in a much diminished form; at others, the disease will make efforts to re-appear, after the stimulus has been exhausted. In both cases, the repetition of the medicine will produce the desired results. In some very weak, aged, or broken down persons, the system has rallied for a moment, and then sunk; in this last case, medicine ceases to be of use-nature is exhaustedthe leverage of life is broken. We must never, however, presume this to be the case, beforehand, but continue our efforts, till death itself bid us cease. Some constitutions appear so irritable, that the vomiting will continue for days with intermissions, causing much annoyance to the poor patient. In these cases, I find mustard sinapisms or blisters, applied to the stomach, and occasionally warm-baths, opium in some form, and a little wine negus at intervals, with some soup or tea, having bread sopped in it, sufficient for its suppression. Some patients complain much of a difficulty in making water. These will require, in many cases, the use of the catheter, abdominal frictions, stupes and warm-baths; mild opiates will generally be necessary in addition. With these remedies, this troublesome affection commonly ceases in a few days. Sometimes the mercury will affect the mouth. In this case, port-wine gargles, the warm-bath, careful nourishment, and opiates, will soon cause this symptom to disappear. Every patient has invariably recovered, whose mouth has been affected; and although I never try to produce this result of mercury, as some practitioners recommend, I do not find the recovery in the least retarded by it. Such a trifling and occasional inconvenience in the employment of so admirable a remedy, when the result is the salvation of human life, and a complete victory over a formidable and malignant disease, is not to be regarded for a moment. The patients will sometimes be troubled with griping pains in the stomach and intestines, during their convalescence; but wine and opium, and now and then a warm-bath, quickly disperse them. If the bowels should prove costive, from ten to thirty grains of the compound powder of jalap may be given, or from half an ounce to an ounce of castor oil, with an ounce of peppermint-water and twenty drops of laudanum. Sometimes I make the attendants administer a simple enema or injection of gruel with or without castor oil; for I have more than once seen the use of purgatives bring back the serous purging of the complaint, to the great danger and prejudice of the patient. Indeed, during the prevalence of Cholera, purgatives should be very carefully dealt with, when it is necessary to use them. They are almost always improper, when purging actually exists-as for common salts and other saline purgatives, they should not be touched. In two fatal cases, which occurred in private practice, castor oil in the one case, and castor oil and salts in the other, were most improperly taken by the patients, when they felt the disease coming on them. And I may here be permitted to remark, that very many lives indeed, might be saved, by people calling in instant advice, when affected with unusual purging, whether during the night or day. I shall now, before I detail the diet during convalescence, and the general precautions proper to be put in practice by the community during the, prevalence of Cholera, as well as the steps to be taken by those who are remote from medical aid, proceed to state what I have to say relative to the treatment of collapse. I never found it of any use to bleed the patients in collapse, even so far as it is practicable to do so. The patient in most instances is cold, and requires to be heated with the warm-air bath, a simple contrivance, consisting of a few half hoops, the end ones of iron, stayed together by longitudinal braces. A solid piece of wood is adapted to one end, pierced with a hole, through which a curved tin tube, four inches in diameter, proceeds, and which serves to transmit the heated current of air, impelled upwards by the flame of some spirits of wine, held in a tin cup, supported by a rod on which it slides. By the use of this apparatus, the patient may be well heated in from ten to twenty minutes. The same object, however, is readily effected by bladders or bottles filled with warm waterpillow-cases, containing each a few pounds of hot salt or hot bricks wrapped up in flannel or other cloths. The heat of the bottles may be tempered in the same manner. As soon as the process for heating is put in operation, the patient must receive a scruple of calomel, two grains of opium, and a drachm of laudanum, mixed with spirits and hot water; an injection, composed of half a pint of starch or gruel at blood-heat, and containing a drachm of laudanum, is to be given at the same time." V. INFLUENZA EPIDEMICA. THE history of epidemics presents a curious phenomenon, which has seldom been wanting and still seldomer reversed—namely, their course from east to west. Sometimes this course is slow, as in plague, cholera, &c.; at others, it is very rapid, as in influenza. The following brief delineation of the march of a recent influenza, must tend to convince us, that there is something analogous in all epidemics-some one common agent or cause, which gives rise to the westward course of them all. "The INFLUENZA, from which we are at present suffering in this country, (America) prevailed in China during January, 1830, and in Manilla in Sept. of the same year. It preceded the cholera both in Russia and Poland, but we do not know the exact period at which it appeared in those countries; it prevailed in France during May and June last, in England during June and July, and about November began to prevail in this country. Mr. Lawson, surgeon of H. C. ship Inglis, states that in China the symptoms of the disease were, 'pain in the head, more especially over the frontal sinus, cough, discharge from the nose, sense of rawness in the throat and chest, rather than severe pain, great prostration of strength; in some of the cases there was pain in the epigastrium as well as across the loins; with severe aching pains in the limbs, pulse frequent, but generally soft. The febrile symptoms, in most cases, had entirely subsided on the third or fourth day, and the cough, in the majority of instances, in about the space of a week from the commencement. There were, however, some exceptions, where a troublesome cough remained for two or three weeks.** Mr. George Bennet gives the following description of the disease as it occurred at Manilla. The commencement of an attack from this disease was with a general lassitude, followed by pains referable to the lumbar region, and in some cases with muscular pains over the whole body; an increased secretion of mucus in the nose, as also in the fauces and bronchiæ; intense headach, principally referable to the frontal sinuses; tongue white; eyes suffused with tears; skin hot; much thirst; a rawness of the throat; cough, particularly troublesome at night; in some cases a restriction across the chest was much felt; appetite impaired; bowels generally costive; quick pulse; and in those of very plethoric constitutions, (in whom the attacks are severer,) a very * Medical Gazette, Vol. VIII. p. 595. thick fail pulse; flushed countenance. The symptoms varied in intensity in different persons; some having the fever and concomitants so high, with a flushed countenance, and a pulse so full, strong, and quick, as to have almost induced me to resort to venesection; other cases again assumed a very mild character, but in a very slight degree incapacitating the patient from pursuing his occupations. The patients were worse during the night than during the day, the accession of the fever and cough being much greater at that period. After the patients had in some degree reoovered, a troublesome cough, attended in most cases with much expectoration, remained, and in delicate constitutions may be apt to lay the foundation of pulmonary disease. In Paris the disease is described as commencing with coryza, head-ach, lachrymation and sneezing; dryness, pain and tickling of the throat; difficulty of swallowing and cough, sometimes dry and at others accompanied with expectoration of clear, or thick mucus. To this first series of symptoms a more or less marked derangement of the stomach and bowels was added. There was loss of appetite, and sometimes nausea and vomiting, but when vomiting occurred it was generally after violent fits of coughing. There was also lassitude and feeling of soreness in the limbs and more or less depression of spirits. There was often no fever; when it did exist, it was commonly continued, moderately intense, and terminated with abundant sweats. In some plethoric persons the cerebral symptoms and those of pulmonary congestion were very intense. In one case delirium continued for four days, and in another the headach was extremely violent, and yielded only to the repeated application of ice. In a few cases there were abundant and obstinate hæmoptysis. Previously to the appearance of this epidemic in Paris catarrhs had become frequent; as the hot weather came on, the catarrhal state of the respiratory apparatus almost entirely disappeared, but vomiting and diarrhoea, which had been observed in a few of the patients who were affected with the influenza, became more frequent and violent; in many persons there was no vomiting, but only dysenteric symptoms, in others a simple bilious flux. Finally, during the month of August, spasms of the limbs and body were joined in some patients to the symptoms just described, constituting sporadic cholera.* In England the epidemic is stated to have commenced like a common cold, but the constitutional disturbance was much more considerable than the catarrhal sypmtoms 'Running at the Editor of the Lonwith racking pain seemed to account for. nose and eyes,' says the don Medical Gazette, over the brows, are the most frequent local affections; which, however, are often accompanied or succeeded by cough, and sometimes by nausea and an irritable state of the bowels. The feelings of languor, oppression, and discomfort, are always considerable, and sometimes very distressing; being occasionally attended with anxiety at the chest and tendency to faint. Some have severe muscular pains, of a rheumatic character, with tenderness of the integ uments. The attacks generally last from two days to a week, passing off with perspiration, and, in the worst cases, leaving the patients considerably reduced.'t Dr. Burne says that the head is heavy and painful, and is jarred distressingly by the paroxysms of coughing, which gives the sensations as if the head was splitting. In this city the disease has usually come on with catarrhal symptoms, generally attended with intense head-ach and gastric derangement. Delirium has been by no means an uncommon attendant on the disease, and in some cases the prominent affection has been that of the head, and even occasionally it has been a fatal one. Great depression of spirits has been occasionally present. When the catarrhal symptoms have predominated, there has often been much pain in the side, with rheumatism of the intercostal muscles and sometimes of the loins and limbs. The cough has been * Gazette Medicale, June 25th, 1831, and Sept. 10th, 1831. Medical Gazette, July, 1831. usually dry at the commencement, and sometimes occurring in paroxysms; the efforts to cough cause great racking of the brain. We have seen the disease commence with vomiting and purging, like cholera, followed by a catarrhal affection of the respiratory mucous membrane, and rheumatic pains in the chest and limbs. The tongue has been in almost all cases exceedingly loaded, but there has been little or no tenderness of the abdomen on pressure. In the treatment, venesection has been nearly always demanded, and sometimes it has been necessary to repeat it two or three times. After general bleeding, local depletion by cups along the dorsal and lumbar vertebræ, has been exceedingly useful in relieving oppression of the chest, when it was present, or the rheumatic affection of the limbs. Cups to the back of the neck and to the head, relieved the cerebral symptoms. Gum water, rice water, lemonade, and the like, for sole diet, and mild laxatives have, for the most part, completed the cure. Treated upon these general principles, patients have nearly always speedily convalesced, and their recovery has been complete. Where, on the contrary, active depletion has been neglected at the commencement, the case has frequently terminated fatally; or engorgements of some of the viscera, particularly of the lungs, have taken place, and the foundation has been laid for incurable pulmonary disease. Our space does not permit us to enter into any further details respecting this complaint at present, but we shall probably hereafter recur to it."* VI. CLINICAL OBSERVATIONS ON THE EXHIBI- In the second number of our Dublin contemporary there is a paper by Dr. Stokes, on the effects of opium in inflammatory diseases, which deserves notice. Various practitioners in hot climates have demonstrated the utility of opium in conjunction with other remedies, in subduing inflammatory affections, as dysentery, hepatitis, and fever; while Hamilton, Armstrong, and many others have done the same in this country. Dr. Armstrong, indeed, and the late Mr. Hayden, proposed opium alone, in abdominal phlegmasia-and Dr. Stokes appears to follow in the same track. "The first form of disease in which the use of opium appears peculiarly advantageous, may be stated to be that of Peritonitis occurring under circumstances where bloodletting cannot be employed. Now, the following are the circumstances under which I have seen this condition of parts to arise: 1st.-Peritonitis arising from the escape of fecal matters into the peritoneal cavity, through a perforating ulcer of the intestine. 2nd.-Peritonitis arising from the bursting of an abscess into the serous cavity. 3rd.-Peritonitis occurring after the operation of paracentesis in debilitated subjects. In addition to these eases which I have myself witnessed, we may add, that low typhoid peritonitis, occurring after delivery, as described by Drs. Cusack and Gooch; and the peritonitis which results from rupture of the intestine, induced by external violence." There can scarcely be a more appaling accident than perforation of the intestine and escape of its contents, among the bowels, with the rapid and dreadful peritonitis that ensues. As this accident generally supervenes on a wasting disease, as intestinal or typhoid fever, there is nothing to be gained by bleeding, as the disease runs a rapid course, and prostration of strength exists from the very beginning. We have then, two indications (according to our author) to pursue-first, to support the * Philadelphia Journal of Medical Sci- strength of the patient;-secondly, to preences, No. XVIII. vent the further effusion into the peritoneal |