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statements, from five to nine years, the man was bitten by a Idog, which at the time was supp3sed to be mad. The markof an injury existed on the inner side of the knee.He was in his usual good health until two days before ad-

mission, when he complained of most acute pain in his head ;the next day he was thoroughly ill, and the same evening hewas convulsed at the attempt to drink some porter.

Throughout the day on which he entered the hospital hebecame gradually worse ; the mention of fluid caused distress-ing spasmodic difhculty of breathing, and the muscular systemgenerally was irregularly excited. He constantly rejected fluidfrom the stomach, and spat frothy fluid without ceasing. Hisintellect, and general and special sensibility was most acute ;and this state of things was aggravated when admitted. The

patient’s manner was then maniacal, but his mind was littledisturbed. In spite of Indian hemp and chloroform, the debi-lity consequent upon the excitement increased, until havingbecome gradually pulseless, he died exhausted.A post-mortem examination has taken place.

THE CHOLERA.

LETTER FROM DR. AYRE, OF HULL, TO THEPRESIDENT AND FELLOWS OF THE ROYALCOLLEGE OF PHYSICIANS.

GENTLEMEN,-The inquiry which you appointed to be under-taken for the purpose of ascertaining the appropriate treatmentof epidemic cholera has just been closed, with a report drawnup by Dr. Gull, in which he states it as his belief, as the resultof that inquiry, that no remedy has hitherto been found forthat disease; but whether this most important conclusion,published to the world under the sanction of your name, andwith the fiat of your imprimatur, be a correct one, and basedon facts duly collected and considered, are questions whichmerit the most searching inquiry, and I trust no apology willbe needed from me for my now engaging in it.

In the list of medicines which have claimed to be accountedremedial in cholera, the foremost place is given to calomel, andsome notice has been bestowed upon my name as the authorand advocate of its use, when administered in doses small andfrequently repeated. To prove, however, that calomel is in-efficient, in whatever dose and in whatever manner it is em-

ployed, Dr. Gull has presented us with reports sent into himby different medical gentlemen, in which it is stated that mytreatment was pursued by them, and on the faith of suchhaving been the fact, he has given the result of their unsuc-cessful trials of it as an appropriate test of its inefficiency. Butin his summing up he has wholly overlooked the importantduty of sifting the evidence, and of thus ascertaining beyondthe reach of all contradiction that the treatment designated asmine was really and truly mine, or whether it was not whatI shall presently prove it to have been, essentially differentfrom that treatment in every particular that can constituteresemblance. The task, therefore, which I shall now assignto myself, will be to show that calomel is indeed not remedialin cholera when given in large doses, or in small ones at wideintervals, but that when administered in small doses accordingto prescribed conditions, and without any other adjuvant thancold water, it exhibits a remedial power well nigh approach-ing to that of a specific, so that, in very truth, the caseswhich Dr. Gull has brought forward in support of his viewstell so strongly against the conclusion which he desires to es-tablish, that I have only to avail myself of them as argumentsto prove the truth of the position, that calomel, when rightlygiven, is the alone remedy in this disease.

Before proceeding further, I shall here briefly repeat, for thesake of obviating all misconception on the subject, the leadingparticulars of what is denominated my plan of treatment, andwhich consists in the stage of collapse of giving one or twograins of calomel every five or ten minutes, with one or twodrops of laudanum with the first few doses of the drug, and inperseveringly continuing the same dose at the same intervalsof time, until the symptoms of collapse become materially sub-dued. This plan I have uninterruptedly pursued fiom thefirst to the last patient I ever attended in the disease, amountingto a very large number; and my reason for giving the smalldose of the calomel was, that large ones were rejected from thestomach, and I repeated it frequently because it was small,

. and that thus the action of the medicine on the stomach mightbe constantly kept up in a disease whose duration is to be

counted by minutes. I gave the minute dose of the opiate to

enable the stomach to retain the calomel, and prevent its tooearly descent into the bowels, and not as a sedative. I ab-stained from the use of all auxiliary treatment in my earlycases, that I might not compromise the conclusion at which Idesired to arrive-as to the remedial power of calomel; and Ihave uniformly avoided them since, because I found thatcalomel in doses small and frequently repeated was the aloneremedy. I have never given stimulants in any form, because Ifound them not to be necessary, and believed they would provepernicious when, from the long duration of the collapse, andthe delay in commencing the treatment, consecutive fevermight be feared; and lastly, I fixed no limit to the quantityof calomel which I gave than that which the duration of thecollapse prescribed, having become early assured that pendingits continuance no absorption of the calomel into the systemtakes place, and that whilst it is so given, no salivation orother inconvenience is induced by it, and that no extremity towhich a patient may be reduced can justify our withholding orabandoning the use of it.

Such, then, is the plan of treatment which I pursued andencouraged others to pursue, and to which such frequentreference is made in your report, and it was in the strict fulfilment of the conditions it involves, and which I took no incon-siderable pains to enjoin, that the success of myself and themany who adopted the practice is attributable. That the

, author of the report was well informed on all these points, Icannot entertain a doubt, from the very many communicationsmade by me and others to THE LANCET journal, whose pageshe doubtless consults, and from the information at his requestwhich I afforded him on all that related to my plan of treat-ment, with its results; yet without the consideration due to a,

subject so important, Dr. Gull has given, to use his own words,’’ the results of 365 cases treated by small and frequently-repeated doses of calomel," and has given in alphabetical orderthe names of twenty gentlemen who were engaged in the treat-ment of them. In looking through this list of physicians andgeneral practitioners, and the results of their treatment re-spectively, as announced to be with calomel in doses small andfrequently repeated, I was not a little astonished to find, as Iam sure every one will be who has ever adopted the practice,that out of fifty-one patients whom six of the number arerepresented to have so treated, only six recovered. Thatthe author of the report should have left unquestioned on thesubject those whose failure was so enormous, or that he himselfshould not have distrusted the account rendered by them, aredifficulties which I will not attempt to unravel. That a seriouserror had been committed in attributing such a fearful mortalityto the inefficiency of the treatment became to me apparent,and it was with a view to a correction of such error in thoseand others whose names are given, that I applied to them forinformation, requesting them to favour me by stating whatwas the dose of the calomel and intervals of its exhibition,with the extent to which in each case it was carried, and incombination with what auxiliary treatment, whether medicinalor alcoholic. From a certain proportion of the gentlemen towhom I applied, I have received the information which I

sought, and it is precisely of the nature I anticipated it wouldbe, and I shall now proceed to bring under your notice thesubstance of it. In doing so, and in giving publicity to par-ticulars sent me, I shall only be acting in compliance with therequest which accompanied them, and I rely with confidencethat the same wish was felt by others, and that all hold thequestion at issue too important, and the interests of truth toosacred, to desire for a moment to withhold it. The mystery,which still surrounds the disease, and the varied forms oftreatment invented and employed for it, might well createdistrust, and I can readily excuse those who, from a biastowards other modes of treatment, shall have only partiallycarried out mine, and only failed in saving their patients bydoing so.The cases which I have now to cite, contained in your report,

are of a mixed kind, and deviate more or less from the pre-scribed mode, and with results corresponding; but before givingthem, and as affording a standard by which to judge of what Idesire to be considered the prescribed mode, I shall give thereport sent in by Dr. Shearman, of Rotherham, to your com-mittee, containing an account of his success in the treatmentof two cases, with the details of which he kindly supplied me,and which are as follow:-

" I have had," Dr. Shearman reports, " in my own practice,only two cases of true cholera, both in boys of about the age ofeight. Both the boys resided in the same locality in whichthe cholera broke out so fearfully at its first visitation-poorly

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fed, and badly lodged, and both in the same house.. One

began with diarrhoea, which continued two days before I wasconsulted. I found him in a most complete collapse, with rice-water evacuations, choleraic voice, livid skin, cramps, and

suppression of the kidneys. I gave two grains of calomel everyfive minutes pretty regularly for six hours, and let him drinkfreely of cold water in which a minute quantity of a neutralsalt was contained. At the end of about six hours the sickness

began to abate, he became warm, the cramps moderated, andhe quite recovered in five or six days. The other boy I saw indiarrhœa two days after the first began: on his advancinginto collapse my treatment was exactly the same. This boyshowed symptoms of improvement in four hours, and recovered,but his recovery was slower. I gave about thirty drops of anopiate to each."The gentleman whose practice I shall next quote stands first

in the list of those stated to have followed my plan of treat-ment, and, from a communication with which he has favouredme, I find, what indeed I had anticipated, and even feltassured of, that the reported failures in the trial of the calomelwould be found to arise from the faulty mode of its employ-ment. This gentleman informs your committee " that he hadtried the plan recommended by Dr Ayre in three cases. It didnot appear to do the least good; they all died."Yet this gentleman’s practice, thus assumed to be like mine,

consisted in giving a scruple (TWENTY grains) of calomel everyten minutes, and so continued during Two hours, and then dis-continued, because no benefit was found to arise from it. Thevery extraordinary error here committed, of giving twentygrains of calomel every ten minutes, instead of two grains,requires no comment, except it be to remark that it is

only one amongst the many that have found a place in yourreport, and where the discrepancy between this treatment andmine is scarcely less remarkable. I shall pass on now, there-fore, to cases reported, in which deviations from the rightmode, but in an opposite direction, are found. In illustrationof this fact, and, also, as showing with what success the rightmethod of treatment is attended, and with what failure thewrong one, I shall here give twelve cases found in the

report, with the details of which I have been favoured, fromthe Western Dispensary, Lisson-grove. Five of these patientsdied, and seven recovered. Of the five fatal cases-The first : Calomel every quarter of an hour; was under

treatment imperfectly for six hours, and was then removed tothe Infirmary.The second: One dose of cajeput oil; calomel, two grains

. - every half-hour ; carbonate of soda and camphor julep, sixteengrains of calomel; had been taken between three and nine inthe evening ; at nine the following morning had only takenthirty grains in eighteen hours.The third: Calomel, two grains every quarter of an hour;

carbonate of ammonia, chloride of soda; in nine hours onlyforty-eight grains were taken.The fourth: Calomel every quarter of an hour; ammonia.

and other stimulants.The fifth: calomel and opium, the dose not named; chloro-

form internally.Here follow the seven cases in which recovery took place :-The first : Two grains of calomel every quarter of an hour;

took it to the extent of ninety grains; improved rapidly underthe use of the calomel, and recovered without consecutivefever.The second: Two grains every quarter of an hour were taken

to the extent of 120 grains, with early and marked benefit;the patient recovered without consecutive fever.The third: Calomel every quarter of an hour to the extent

of ninety grains; was considered convalescent, when, on thethird day after his first attack, he had a relapse, equally severeas the first, from eating stewed eels. The same treatment wasrenewed; the calomel was pushed to 120 grains, when thepatient recovered, with a sore mouth, but with no consecutivefever.The fourth: Calomel, two grains, every quarter of an hour;

recovered without consecutive fever. No quantity named ofthe calomel.The fifth: Calomel, two grains every quarter of an hour, the

quantity taken not named; recovered.The sixth: Calomel, four grains, followed by two every

quarter of an hour, and continued to 120 grains; on the eighthday was discharged quite well.The seventh: Calomel, two grains every quarter of an hour;

no quantity named; recovered; no consecutive fever. ,

Li the foregoing twelve cases it will be seen that the treat-ment pursued in the first five differed essentially from that

employed in the seven which follow, and whilst in the fatalcases the calomel was given at wide intervals, so that onlythirty grains were taken in eighteen hours, and in anotherinstance only forty-eight grains were taken in nine hours, so inthe seven cases where the treatment was in conformity withmine the patients all recovered.

It is not my purpose to call off your attention from thepoint I especially desire to prove-namely, that Dr. Gull, inhis report, has greatly erred in giving the above fatal cases asaffording an appropriate test of the treatment advocated byme, but I cannot forbear pressing upon your attention a factwhich I may hereafter revert to, which is, that usually onpatients being treated in the mode recommended, no consecu-tive fever ensues, and that patients come out of the stage ofcollapse into a condition of comparative health, so that afterhaving been livid, cold, and even pulseless on the first day ofthe week, they will sometimes be found before half of it isover in a condition to leave their sick room, and often evento pursue their accustomed avocations. I shall next give aseries of eight cases (being two more than are in the report)which were treated in the Westminster Hospital, the particu-lars of which have been afforded me. There are four deathsand four recoveries recorded. In the fatal cases the prescribedtreatment was not attempted, and, in those that recovered, soimperfectly as to admit of consecutive fever to succeed thecollapse, and thus to render the recovery more tedious.

1st.—Collapse in an aggravated form. Ten grains of calomelevery hour, with opiate; after six hours, discontinued. Fatalthe same day.2nd.-Usual symptoms of cholera. Five grains of calomel

every hour; took eight doses. The following day moreevident; consecutive fever followed. Death on the fourth

day.3rd.-Admitted almost in the stage of collapse; had been in

the disease six hours before his admission. Calomel, threegrains every half hour; after twelve doses, calomel discon-tinued and salines substituted; consecutive fever followed.Death on the fourth day.4th.-Had the usual symptoms of cholera. Five grains of

calomel every hour. Took eight doses; purging continuedwithout abatement. Died on the fourth day.First.-Admitted in diarrhoea, followed by symptoms of

collapse. Calomel three grains every ten minutes ; but aftertwelve doses the calomel was discontinued, and the salineplan substituted. On the temperature of the body fallingrapidly the wet sheet was employed and large quantities ofbrandy were given which the stomach alone retained. Thepurging continued at intervals, and the calomel was againgiven-three grains every fifteen minutes. After eight dosesthe dejections became bilious. The calomel was then givenevery hour, and, in six hours, febrile reaction commenced; thecalomel was then discontinued. The patient passed through asevere consecutive fever, but ultimately recovered.Second.-Admitted in the early stage. Brandy, ammonia,

saline injections, without any mitigation of symptoms.Twenty-four hours after admission, symptoms of collapse cameon. Three grains of calomel every fifteen minutes, and strongmercurial ointment in the inguinal region and axilla. The

purging continued, but the evacutions showed the presence ofbile. In twenty-six hours the vomiting ceased, the pulsebecame perceptible, reaction was set up, the mercurials werediscontinued, symptoms of improvement progressed, and atthe end of twelve days the patient was convalescent.Third.-Twelve days after admission to the hospital under

continued fever, symptoms of cholera appeared. Three grainsof calomel every fifteen minutes: took ten doses; sinapisms tothe body. Brandy and soda-water were given. Dejectionsbecame coloured with bile. In thirty-six hours the purginghad ceased, and on the third day febrile reaction commenced.A minute quantity of blood was drawn, followed by drycupping. The patient became slowly convalescent.Fourth.-Admitted with the usual symptoms of cholera.

Saline treatment before mentioned. Calomel three grains everyhour : after ten doses the vomiting and purging ceased, thelast motion being of a dark, bilious hue; slight febrile reactionfollowed. During the next two days quickly became con-valescent. At this time the epidemic was becoming milder.Upon the foregoing cases I need scarcely repeat the remark

that the treatment of the four fatal cases is utterly differentfrom that which I pursue, and the four which recovered re-sembled it in calomel having been given, but differed in thematerial point of the calomel not having been persevered incontinuously until the symptoms of collapse were removed,and also in the exhibition of stimulants which, with the limited

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use of the calomel, led on to the consecutive fever. In thesecond case of the recovered patients, mercurial inunction wasemployed, on the assumption that the action of the mercuryon the disease is by its absorption into the system-an opinionthat endures an abiding refutation in the fact, that give what-ever quantity of calomel you may in the stage of collapse, noabsorption of the medicine takes place, as is proved by nosalivation resulting from it so long as its use is confined tothat stage of the disease, for when continued into that of re-action, this particular effect is produced by it.But to proceed. We now come to the details of seventy

patients reported from the Pimlico Dispensary, and who arerepresented to have been treated by calomel in doses small andfrequently repeated, and of whom thirty-one died and thirty-nine recovered. Of the condition of those patients when thetreatment commenced, we are informed that

Besides the above details, we learn from the report that nomention is made of any obvious effect, immediate or remote.Of the thirty-nine recoveries, seventeen had consecutive fever;in fourteen of the worst cases a salt-and-water emetic wasgiven; in eleven, venesection was used; in two, the hot-airbath; some took saline draughts containing chlorate of potash.These seventy form a part of the 365 cases which are especiallybrought forward as having undergone the treatment by calomelin small and frequently-repeated doses; and yet in the reportquoted above it appears that to fourteen of the number twentygrains were given, in a single dose, every half-hour; and tothirty-nine, only five grains in the same time; whilst it willbe seen that only ten of the whole seventy were treated inconformity with the mode declared in the report to have beenfollowed in all.Had the gentleman engaged in the treatment of those

patients responded to the request twice made to him, to affordsome particulars as to the extent to which he had pushed thetreatment by calomel in the several cases respectively, it wouldnot have been left me now to affirm that no conclusion what-ever can be grounded on data so vague and unexplained. Ofthe seventy cases asserted to be of cholera, fourteen were onlyin the premonitory stage, or that of urgent diarrhoea, and forthe treatment of which the five grains every half-hour wassomewhat more than sufficient ; whilst for the same numberstated to have been in slight collapse, the dose of five grainsevery quarter of an hour would also avail In the report,however, nothing is stated regarding the result of the treatmentin which twenty grains were given to the fourteen patientsevery half-hour, or of five grains every two hours, or thirtyevery three hours. There is also an entire absence of all in-formation as to the extent to which the calomel was carried inthe several cases, and by which no knowledge can be gainedwhether or not the exhibition of five grains every fifteenminutes had failed; and if so, whether, as in other cases towhich allusion had been made, the failure had not arisen fromthe medicine having been too early discontinued. The non-continuance of the small dose perseveringly would be as fatalto the hopes of success as the giving of twenty-grain doses atwide intervals would be, and that no limit need or should beset may be seen in the account sent in by Mr. Taylor, ofMaghull, near Liverpool, to your committee, and who, in aletter with which he kindly favoured me, thus writes:-

" The calomel treatment, which was the one principallyfollowed by myself and colleagues, was most successful. Thedose usually given was two grains every five minutes, until thepatient was decidedly improved. The greatest amount takenwas by a female aged twenty-four, who took 1160 grains, withlittle appearance of salivation. A boy of sixteen took 900grains, without any appearance of salivation whatever. Boththese patients got perfectly well. The remedy was given to

patients of all ages. From five to twenty grains generallyproduced the desired effects. Children under the calomeltreatment would come round in a few hours. Out of 147 cases,I had 126 recoveries, and twenty-one deaths, or about a seventhpart of the whole: this includes all ages and various states,from the slight to the complete collapse."

I shall not quote farther from Mr. Taylor’s report, as I shallhereafter have to refer to it; but I would wish to invite atten-tion to the particularity of detail observed in his account, ascontrasted with that which I have just noticed the want of,and to point out the important fact, that not only no limitneed be placed on the quantity below what is required tosubdue the collapse, but that patients under apparently thesame condition in respect to the disease require a very differentamount of calomel in the gross to subdue it, extending, as inthe cases quoted from Mr. Taylor, to the enormous amount of900 and 1160 grains of calomel, and from which we have tolearn that a perseverance in its use in each case is necessaryuntil the collapse is removed, and that from the neglect of thisrule so many have experienced a failure in the limited andpartial use they have made of it. It is affirmed by your com-mittee that calomel is wholly inert in this disease, and tosupport this opinion an appeal is made to the large amountwhich can be taken in it; but such a notion can only be enter-tained by those whose knowledge of the disease has beenacquired in the closet, or who have had but little experience inthe treatment of it, and who therefore have not had the oppor-tunity of watching the gradual progressing of a patient towardsrecovery, whilst under its steady use, and his backward changeon its temporary suspension, and his onward progress and finalattainment of recovery upon the treatment being resumed.All who have made trial of this treatment, and have steadilypursued it, will, I believe, vouch for the truth of these facts.

Before I conclude this letter, I shall bring under your noticenumerous examples where gentlemen with every indispositionto adopt this practice have realized, in the result, all they hadbeen promised, and have tested its efficacy by a comparisonwith all that they had known before of the inefficacy of everyother. If the patients, as affirmed by Dr. Gull, would haverecovered without the calomel, then are we placed on thehorns of this dilemma, that if the many under its use recoverwithout its aid, then the excess of deaths under other modesof treatment must arise from the nimium diligentiae ’tnedt’ci,for when I come to that part of my subject in which I shall beable to show that more than eighty per cent. are recoveredunder the calomel treatment, and with a conformity of result,among those who rightly conduct it, which no accident what-ever could produce, then it may justly be inquired, whencearises the difference ?

(To be continued.)

ON A CASE OF EMPYEMA.

BY WILLIAM SEDGWICK, ESQ., M.R.C.S., L.S.A.LATE SURGEON TO THE NORTH DISTRICT OF ST. MARYLEBONE.

I

THE following case of empyema, in which paracentesisthoracis was successfully performed, possesses many points ofconsiderable interest. The subsequent death of the patientfrom cholera, after health had been for some time restored, gaveme the opportunity of examining the condition of the chest,which was the more valuable from its being an instance ofalmost complete re-expansion of the side after great retraction.

C. S-, aged seven years, a delicate boy, of fair complexion,with a timid, downcast countenance. He is stated to havebeen a strong, hearty child up to about the age of three years,when he had an attack of measles, and was very ill for twelveor thirteen weeks. He suffered from a troublesome cough, fora long time afterwards, and never appeared to recover fully hisstrength. Subsequently he has been troubled at times withsevere headaches, accompanied by great heat in the head,restlessness, and occasional delirium.

In November, 1851, for one of these attacks, of a more severecharacter than previous, the boy had been subjected to activemedical treatment; his head had been shaved, leeches applied,and mercury freely given for some time, but without affectingthe system. It was during convalesence from this head affection,that he had caught cold, in consequence of having sat up inbed, near an open window, one cold day about a fortnightbefore christmas. I was called in two days after this hadoccurred, and found him suffering from an attack of pleurisy ofthe right side, friction being heard very generally over thatpart. The treatment consisted in the application of a few