physiology than from a rough crucial experiment of treating a continuous series of patients without alcohol altogether, and then comparing them with a corresponding series treated in the usual fashion. Nevertheless, such a trial is not without considerable value, and we look therefore with satisfaction upon a report made by Dr. Edmunds of sixty-five cases treated at the London "Temperance" Hospital. This establishment was opened in 1873 for the very purpose of putting the question to the test of clinical experience, and alcohol in any form is denied to the patients; even tinctures being superseded by glycerine solutions. And it may be remarked that the medical officers are not ex officio total abstainers in their own persons, but are simply so far convinced of the needlessness of the large quantity of fermented and spirituous drink consumed in general hospitals that they are willing to superintend the experiment, the opportunity for which is given by the benevolence of some wealthy enthusiasts; and we presume that when they saw the experiment failing, they would transfer the patient elsewhere, or else break the rules of the institution. So that no serious risk of danger to human life is incurred. Of course it is not pretended that these few selected cases prove anything; many thousands must be carefully analysed before a guess at a result can be hazarded; but they are at all events a first step. Of the sixtyfive more than two-thirds appear to be abstainers on principle, and of the remaining twenty it is very doubtful if more than half a dozen would have had alcohol prescribed for them at any hospital-indeed to the majority it would have been expressly denied so that no comparison can be instituted, and probably it will be many years before it is attempted. The earliest contributions from this laboratory to the therapeutic art will probably be the invention of some substitutes for alcohol under various circumstances, which should contain its virtues without its vices, in the fulfilment of the indications usually held to demand its use. This would be an aim similar to that of Dr. Parkes, who was not content merely to find fault with alcohol as a stimulant to exertion, but endeavoured to supply its place with something better in the shape of meat extract and coffee. We would call attention to efforts in this direction made by the physicians to "Temperance" Hospital.* One is the employment of digitalis as an arterial tonic in typhoid fever, instead of the wine which delirium is held to justify. Again in a case of a dipsomaniac, sedatives and other "remedies which overcame the constant craving she had for intoxicating liquors,"

1 We have taken "Temperance" for a proper name, as one might say "Guy's" or "Evelina; " otherwise it would seem to imply that other hospitals are intemperate, a pharisaism unworthy of the founders.

were given. Ammonia was administered to a total abstainer to help him to bear up against hæmorrhage during an operation. Hop tea is also suggested by Dr. Edmunds for the use of generally weak persons who often find the benefit of a glass of bitter beer at meals. Sal volatile and aromatics appear to be employed, and chloroform and chloral are not absent from the dispensary, but no statement is made in the little volume under review as to whether they are used to take the place of the more agreeable "aliment d'épargne."

While we look with interest at attempts to find among drugs improved substitutes for alcohol in sickness, we would protest against the careless introduction of these into the daily dietary. As Dr. Edmunds says, "those who in place of alcoholics substitute medical bitters, chlorodyne, chloral, laudanum, morphia, &c., merely fall into habits more injurious and more dangerWe believe him to be quite right, and that the physiological action of alcohol is the wholesomest among all the agents of its class.

ous."

Though the subject of the present review of the question is the 66 use of alcohol," we are tempted to say a few words concerning its abuse. From the abstracts of the literature of alcoholism made by Dr. Magnan and Dr. Lancereaux it would seem that those who have to pay the penalties of excess may be roughly divided into two classes-first, those who employ alcohol as a stimulant to immediate work, and second, those to whom the physiological action is a temptation to try to increase it by an additional dose. The first class (whom one may call the "nippers") runs the greater risk of physical degeneration, though on moral grounds they incur the least blame. Their excess is a gross error of judgment, but not a delusion; and it may often be combatted in reasonable argument, either by pen, by voice, or by example. Let the results of such an experiment as that of Dr. Parkes be made clear to them, and they are led to repeat it on themselves, to substitute nutriment or temporary rest for alcohol, and to convince their minds in the only method in which minds ever are convinced-personal experience. But to talk to them as if they were drunkards, who must give up alcohol entirely when they want to be well, is revolting to their

reason.

The other class is a very troublesome one to society, and is a proof of how much of the brute remains in human nature. It is subdivided by M. Trélat into "drunkards" and "dipsomaniacs," the first being defined such as get drunk whenever

they have the chance, the last such as get drunk when their mania comes upon them.

For "drunkards" there is no doubt that each additional glass diminishes the self-control and self-respect which naturally arrest over-indulgence in reasonable creatures. All the lower animals such as bees, rats, monkeys, bears-when they take alcoholic liquids at all, will go on imbibing it till they get helplessly intoxicated. But it is not so with man. Many a one,

with even a considerable "survival" of the brute in his constitution, has yet such a foresight strong enough to stop when he has had enough, in spite of a secret hankering to go on. And the foresight will be strengthened by use. It is obvious, however, that he is more or less in the peril which so alarms Dr. Richardson, and the question of the more or less he himself alone can determine. If, after trial, he finds his craving irremediably that of a drunkard, if the influences of religion, of regard for others, and self-respect, are not sufficient to hold him back, total abstinence is his path of safety. But that this bestial craving for too much is the rule, and a bodily contentment with enough the exception, even among self-educated persons, we deny; and we deprecate strongly the burdening of the consciences of the majority with a restriction necessary only to a minority. Whether the drunkard's craving be "a disease" is a question of words; it is, at all events, a degradation of the typical perfection of human nature; he is a lower sort of man than the temperate, and must become rarer as the race improves under the inevitable advance of time.

What shall be done in the mean while? Shall we consider the "poor drunkard" as a patient, and using the power which, according to Aristotle, the strong and wise may justly exercise over the weak and foolish, shall we forcibly put him in a hospital for cure, as we submit a dog or a horse to treatment? There are manifold dangers involved in such a costly experiment, of the same kind as have to be guarded against so rigidly in our management of lunatics, only much more serious, inasmuch as our rights as against the person are more problematical. And again, it is quite certain that if intemperance were thus looked upon as a disease, as a misfortune rather than a fault, the sense of responsibility would be weakened, and a man would in no higher degree feel bound to be sober than he feels bound to be sane or athletic. The religious and moral pressure would be equal in respect of our attainment of all three excellencies, which would be a great misfortune for the world. Circumstances have combined to weaken the hold which, in former ages, Society had over the sense of responsibility in the semilunatic; it is an unavoidable result of the merciful consideration

shown for his temptations, that he makes much less effort than of old to retain his senses, and, therefore, oftener loses them. Let not the same thing happen to the weaker brethren whose case is now under discussion, so that drunkenness should ever cease to be a crime, a sin, and a reproach. Already people bestow too unmixed pity on a madman, whose loss of selfcontrol is really worthy of serious reprobation, beause it was not restrained in an early stage. We hope they will still continue to hold a drunkard entirely responsible.

The same objection lies, but to a less degree, against voluntary "retreats." Properly conducted, such institutions afford an opportunity for the habitual exceeder to regain health and practise self-discipline. Their failures have arisen from too much being expected of them; a perfect cure has been looked for, a conversion of an intemperate man into a temperate, of him whose joy was intoxication into him who feels no pleasure in taking more than enough, and who, therefore, can be trusted with a wholesome allowance of alcohol. This is impossible. The washed sow will not trip daintily through the mire, but must be kept quite dry if she is to be kept long clean. The retreat must be followed up by total abstinence.

"Dipsomania" is indubitably a disease; it begins with premonitory symptoms, both of body and mind, headache, anorexia, gnawing at the epigastrium, depression of spirits, loss of temper, and it runs through a regular succession of stages. It is at first intermittent; the patient will for months or years feel no inclination to exceed, often no inclination to take stimulants at all. Then he breaks out into a fierce fit of uncontrollable debauchery, which, if he be not put under restraint, ends in delirium tremens. The feeling of penitence and self-disgust is terrible, and many times leads to suicide, but is not sufficiently rational to curb the raging impulse. It is itself too wild to antagonise wildness. Argument at such a time is like emptying a teacup on a burning house. When this has passed away, he is as sober and amiable as other people; but each access, if indulged in, shortens the interval, weakens the powers of control, and is more severe than the last. If the patient be kept from drink, that is not the case. The dipsomaniac is unfortunately situated. He feels his fit coming on, and would like to be locked up in an asylum, but he cannot exhibit any delusions which would entitle him to the necessary certificates, so he cannot get the advantage of external restraint till he has qualified for it by falling into the horrors he was anxious to avoid. He is certainly a fit subject for the temporary treatment of a

retreat.

It is uncertain whether the habitual abuse of alcohol does

or does not lead to dipsomania. Systematic writers usually bring this accusation; but the two typical cases detailed by Dr. Magnan do not substantiate such a causation. More generally the malady appears to be a special development of hereditary insanity, and the slight inclination to drink which remains chroni cally between the fits would go to prove that it is distinct from ordinary drunkenness in its pathology, and consequently in some details of its treatment. The unfortunate who is liable to it will do well to remove all alcoholics, not only out of his sight, but out of his house, in order that they may not lie in his way when he is unexpectedly attacked by a paroxysm. And when he feels the premonitory symptoms he should put himself under the charge of a firm and secret friend, who will prevent the latent disease from publicly declaring itself by overt acts.

With these precautions duly observed against the dangers of excess, we hold that it is quite unnecessary to denounce the habitual use of alcohol by temperate persons. And in the cause of temperance we believe such denunciation to be injudicious. from the feeling of injustice which it arouses.

II. Cholera in the United States in 1873.1

IN February, 1873, Cholera appeared at New Orleans, and, in the course of the next five months, extended over a considerable portion of the valley of the Mississippi and its tributaries. As soon as the disposition of the disease to spread became obvious, an effort was made to collect as much evidence regarding it as possible, from the notices in the newspapers of the various localities in which it showed itself, and from these, and some contributions by local practitioners, an account of the outbreak was compiled by Dr. A. B. Judson, of New York, and published, under the auspices of the American Public Health Association, in their volume of Reports for 1873. The same volume contained a paper by Dr. Ely McClellan, of the United States Army Medical Staff, on the epidemic as it appeared in Kentucky.

As these papers were deficient in much that was necessary to settle the questions of origin, and means by which cholera was diffused in 1873, the Senate and House of Representatives by a joint resolution, approved by the President March 25th, 1874, authorized an inquiry into the causes of the disease as it had occurred the previous year. For this purpose the Supervising Surgeon of the Marine Hospital Service, and a medical officer of

1 The Cholera Epidemic of 1873 in the United States. Washington, 1875. 8vo.