slightly tinged with bile. The pulse was now felt for the first time in the brachial artery, and the heart-sounds were louder. She complained of intense thirst all the time, for which she had as much cold water to drink as she liked, quite irrespectively of the vomiting; at times, she had a little soda-water for a change. On a few occasions, the water she drank was slightly acidulated with dilute sulphuric acid. This she liked, at intervals, as she said "it cleared the mouth".-At 10 o'clock, the temperature fell a little, being recorded at 97.8 degs. Fahr.; and, shortly afterwards, six grains more chloral were injected into one gluteal muscle. At midnight, four more grains were injected into the other gluteal muscle; so that, within eight hours, she had thirtytwo grains of chloral injected altogether.

At 4 o'clock a.m., (Oct. 28th), the temperature was marked 98.2 degs. Fahr., and she had some sleep. The liquid motions were now pretty well covered by bile.-At 7 o'clock a. m., the pulse could be felt in the radial artery, 82 per minute; respiration 20. She was drowsy, apparently from the effects of the cholar, but could be easily roused, and answered questions. The voice was still very sepulchral and eyes sunk; tongue and breath not so cold. She was drinking water continually, most of which she retained. The temperature, which was now taken every two hours, varied between 97.4 and 98.2 degs. Fahr.— At 1 o'clock p.m., she passed some urine. Liquid bilious stools were repeatedly passed during the afternoon.-At 6:30 p. m., she said she would like "a good sleep", and one scruple of chloral in three ounces of water, and some syrup, was given by the mouth, which she kept down. She had 2 hours' sound sleep. At 8:30 p.m., the temperature was normal; she had, altogether, a good night. The urine that she passed was tested, and found to contain a quantity of albumen. The heart-sounds had gradu ally became normal.

On the sixth day after the attack, the temperature rose to 100.6 degs. Fahr., but never higher, so that she can hardly be said to have had any secondary fever. Some quinine, however, in five-grain doses was given, but more as a precautionary meaShe was fed with plenty of milk, chicken-broth, and beef

sure.

tea, when reaction was established, but had no stimulant whatever until a few days before she went out of the hospital (on November 13th), when a little brandv and soda-water were allowed. At the places where the injections had been given, there was a little superficial redness and tenderness for a few days; but some mild arnica lotion was applied to the skin, and no further inconvenience resulted. She made a very good recovery; and, more than four months afterwards, is in good health, and has shown no ill effects whatever on the result of the disease.

REMARKS Although the particulars here given are only those of a solitary case, still they may be worth publication in the pages of the British Medical Journal. At all events, they apparently show, that a very considerable quantity of a powerful vascular depressant, like chloral-hydrate, can be introduced into the system during the cold stage of cholera without doing any harm. And this, taken in conjunction with the fact now generally recognised, that alcoholic stimulants do positive injury in that stage, may give some indication as to the correct principle of treatment that is required.

Without going into the different symptoms enumerated above in this paper, the writer desires to invite particular attention to two of them, viz., the resonant sound emitted by the usual area of cardiac dulness, and the almost total absence of the sounds of the heart, and ventures to give the following attempt at an explanation of their causation.

From personal experience of an attack of cholera, the writer feels convinced that at the commencement the contractions of the heart become more forcible, the calibre of the arteries become smaller, and there is generally increased arterial tension, probably caused by excessive stimulation of the vaso-motor centre. As the cold stage becomes intensified, the spasm of the muscular walls of the heart is so strong that there is almost a continuous systole, the diastole not being allowed to take place so as to dilate the cavities as in health. It, therefore, occupies. a smaller space than usual, and the first sound is only faintly heard, the second being indiscernible. Then, the whole of the arterial muscular fibres being also in a state of contraction, it

has occurred to the writer that the heart may be pulled upwards and backwards to a slight extent by the aorta, thus allowing a portion of the lung to occupy its usual position. We are told by minute anatomists, that the small arteries are very contractile, and that the large ones are very elastic, but possesses little contractility. But it may happen, that the intense stimulation to which the aorta is thus supposed to be subjected, may cause it to contract the heart in the manner indicated. The heart, therefore, may be so contracted, and occupy such a much smaller space than normal, that a portion of the lung may get in front of it, and occasion the resonant sound heard on percussion.

However, whether this may be an approach to the truth or not, the fact may be tested repeatedly, that, in deep cholera collapse, the heart-sounds are not heard. There are, in addition, the cold skin, and no pulse, or very little, felt in the usual localities. Now this state might be brought about if the heart were in a state of diastole when there would be true syncope. But if this were the actual condition in cholera, it may be affirmed that alcohol would do good instead of harm; as it is universally admitted that, where there is real atony of the heart, alcoholic stimulants produce a temporary benefit. But if, as is supposed here, the heart be in a condition of almost continuous systole, not dilating sufficiently to allow much blood to enter its cavities from the gorged veins, and the arteries be so reduced in diameter as not to allow that little blood to flow properly through them, then the administration of alcohol would, it is presumed, do harm, which experience has shown to be the case. Hence, apparently, a state of pulselessness may be produced by two opposite conditions: in one of which, where there is syncope, stimulants do good; in the other, as cholera collapse, they do absolute harm.

Turning now from theory to practice, there are a few points which must be attended to by those who may use chloral subcutaneously in cholera. The strength of the solution employed may be laid down at one in ten; if it be stronger than this, it will probably cause great irritation, ulceration, or even sloughing (as it has done in some cases). Besides, if the

specific gravity of the solution be too high, it will probably not be absorbed as it ought to be.

Then, as to the mode of injecting: it is most strongly recommended that the solution should be put, not merely under the skin, but into the substance of a muscle. In cholera-collapse, where the skin is cold, absorption may be said to be reduced to a minimum, and the drug employed may lie inert, if it be not introduced as deep into a muscle as is consistent with safety Mr. Higginson, lately chief surgeon of Kheri, in Oudh, in his report of cases treated by him, published in the Supplement to the Gazette of India, February, 14th, 1874, of which seventeen out of nineteen recovered, writes, "The injections were made in the arms and thighs, the cannula of the syringe being plunged pretty deeply into the flesh"; and, in a letter to the Indian Medical Gazette, which appeared in the October number for 1873, he writes, "I think it is essentially necessary to plunge the cannula deeply into the flesh; merely inserting its point underneath the skin will not do." It does not appear, even after this advice, that this precaution has been taken by those who have used chloral hypodermically.

recommends the folWhen premonitory

In conclusion, the writer emphatically lowing course of treatment in cholera. diarrhoea is observed, let all alkalies and opium be specially avoided, as well as alcohol. Dilute sulphuric acid, in half a drachm to drachm doses, in a bottle of gingerade or some syrup and water, diluted as much as will only give a strong, but not disagreeably acid flavour, will probably be found the best thing to take, as often as may be required.

If collapse should set it, or the patient be first seen in that stage, inject at once. Let the clinical thermometer determine the amount of chloral to be administered. The lower the readings, the faster the injections. It may be yet proved, in very severe cases, when the temperature is down nearly to 90 degs. Fahr., that as much as one drachm of that drug may be necessary before a decided effect is produced. Take frequent observations with the thermometer, and be guided by it. Give the patient plenty of cold water (no ice) to drink. Never mind if

it should be rejected; it relieves the great thirst. But do not, under any circumstance, give any wine, spirits or opium. We sometimes hear of the sedative action of opium; but, perhaps, this term may tend to mislead as to its real therapeutic effects. Poisonous doses of the true sedatives, as pointed out many years ago by Dr. Headland, produce death by syncope. Opium causes death by coma apnoea It is a stimulating narcotic, according to Dr. John Harley.

Should reaction be established, milk, nourishing soups and broths, and afterwards more solid food, may be constantly given in gradually increasing quantities. Not even then it is recommended that alcohol be prohibited until convalescence is assured.

If secondary fever should manifest itself, then quinine, according to circumstances, by the mouth, or hypodermically, if the stomach will not bear it. The neutral sulphate is now always used in India for injections. Again, let the clinical thermometer be the guide; the higher the body-heat, the more quinine.

The writer earnestly begs those of the readers of this paper who may have opportunities to carry out all the details recommended above, and hopes, in spite of adverse statements, that the treatment advocated may be attended with success. At all events, he trusts that these remarks may be the means of inducing medical men to give the method a complete trial, and that reports that may be published before long may settle definitely the question whether in chloral-hydrate we have, or have not, a remedy of efficacy in malignant cholera.

Ruptured Pericardium; Fractured Pelvis, and Ruptured Urethra.-(Under the care of Dr. PUZEY)—R. M., aged forty-eight, was admitted on Feb. 27th, 1878, having been knocked down and crushed by a bale of cotton striking him on the back. The diagnosis was, fracture of both pubic bones, with rupture of membraneous urethra. There was considerable hæmorrhage from urethra ; extravasation of blood slight. He complained of great pain in the cardiac region; and had an incessant painful cough and a markedly anxious expression.