C466c 1871 I Gases The Spinal Ice-Bag and the Spinal Water-Bag, the use of which is exemplified in the Cases reported in this pamphlet, are figured below. The Spinal Ice-Bags vary in breadth from two to four inches and a quarter, the shortest bag being the narrowest, and the longest the broadest. Their lengths are as follows 1n 1 (^ suitable for chil 12 " J dren - -, R " ! suitable for youth , Q " ( of both sexes. 18 » ) 20 ? ) suitable for wo-22 „ J men. „ fi " > suitable for men. Lumbar Ice-bag, 10 inches long. The Spinal Water-Bags are in respect to size as follows : — „ . , ( suitable for youth 6 inch 1 r. , .¦, J \ of both sexes. 8 " 1 10 „ \ suitable for adults 12 „ ( of both sexes. 14 „ ) spinal water- bag. SPINAL ICE-BAG. 12 14 The Spinal Ice-Bag is divided into cells, generally three. By this arrangement the ice, being prevented from falling from the upper parts to the bottom of the bag, can be kept in apposition with the whole or any special part of the spine, even though the patient should be upright, or should walk about. The mouths of all the cells are so effectively closed by means of a clamp that no water can escape even though the whole of the ice be melted. The Bags are sold by the following Agents : — London : C. MACINTOSH & CO., the Manufacturers, 83, Cannon Street, E.C. S. MAW, SON, & THOMPSON, 11, Aldersgate Street, E.C. JOHN G. GOULD, 198, Oxford Street, W. Glasgow : THOMAS CHAPMAN, 56, Buchanan Street. Pakis : THOMAS STUBBS, 25, Eve Royale. Brussels: PERRY & CO., Maison Follett. Philadelphia : J. MARDON WILSON, Jun. Calcutta : WYMAN & COMPANY, 1, Hare Street. AND MAT BE HAD BT ORDER OP ALL DRUGGISTS. A pamphlet containing directions how to select a suitable bag in each case, and how to fill and apply it, as well as other information concerning its use, is supplied, gratis, by the agents. CASES OF DIARRHŒA AND CHOLERA TREATED SUCCESSFULLY THROUGH THE AGENCY OF THE NERVOUS SYSTEM CHIEFLY BY MEANS OF THE SPINAL ICE-BAG. BY JOHN CHAPMAN, M.D. M.R.0.P., M.R.C.S. PHYSICIAN TO THE FABEINGDOIf DISPENBIBT. 'd+t LONDON: BAILLIERE, TINDALL, AND COX, 20, KING WILLIAM STREET, STRAND. MDCCCLXXI. LONDON : SAVILL, EDWARDS AND CO., PRINTERS, CHANDOS STREET, COVENT GARDEN. AnWEX WC X6>^* CWt \m PREFACE. The renewal of professional and public interest respecting diarrhoea and cholera, recently induced by the appearance of cholera in various parts of the European Continent, has tempted me to publish the followin 1 cases. The reports of many of them are extracted from my work on " Diarrhoea and Cholera/ which, owing to its size, is not likely to be consulted, except by that small class of readers who especially concern themselves in investigating the nature and causes of cholera. The method of treating both diarrhoea and cholera exemplified by these cases is but little known, and as its efficacy is, in my opinion, far greater than that of any other, it seems to me expedient that I should publish a brief description of it, with practical illustrations of its mode of action, which may be easily understood by all who are disposed to give a very small amount of time and attention to the subject. Though the fear of the development of cholera in England this year has died away, the reports of its prevalence abroad have not only directed attention to that scourge, but also, and in an especial manner, to its far more fatal congener, diarrhoea — a disease the great destructiveness of which has until lately attracted surprisingly little attention from either the public or the profession. Recently, however, I have been gladdened by observing that the medical journals have discussed the subject in a manner befitting its immense importance ; and inasmuch as, in a subdued form at all events, we have diarrhoea always with us, I earnestly hope that the following records of cases will induce some, at least, of the medical readers of them to test the value of the therapeutical method they exemplify. If during the coming winter this could be done by a sufficiently large number of medical experimenters to make their verdict trustworthy, both the profession and the public would, I venture to PREFACE. say, be assured of the existence of a remedy within reach of everyone, and easy of application, by which diarrhoea, whether attacking infants or adults, will be disarmed of its destructive power. If my estimate of the value of the method in question be even approximatively correct, it is evident that the sooner its value be definitively ascertained and proclaimed, the better : this can only be done by the publication of the cases which are treated conformably to the directions briefly given in this pamphlet, and more fully in my volume already mentioned ; and lam therefore induced to express a hope that reports of cases so treated will be sent, from time to time, to the medical journals for publication. If, however, anyone who has experience of this method of treating either diarrhoea or cholera, but who is himself indisposed to publish an account of that experience, will kindly entrust the report to me, I shall be very glad to be allowed to add it to the store of evidence already accumulated, and still accumulating from various sources, that both diarrhoea and cholera are essentially diseases of the nervous system, and that they can be at once most scientifically and successfully treated through the agency of that system. JOHN CHAPMAN. London : 25, Somerset Street, Portman Square, October IZth, 1871. 6 INTRODUCTION : NEUROPHYSIOLOGY AND THERAPEUTICS. He who is intent on rightly understanding the nature and causes of disease must first obtain a correct knowledge of the role of the nervous system in relation to the functions of respiration, circulation, digestion, textural nutrition, and muscular motion (whether voluntary or involuntary) ; and this remark, which applies to disease in general, applies with especial force to diarrhoea and cholera. The introduction to my work on those diseases, as well as the one prefixed to my work on sea-sickness, contains a brief exposition of the most recent doctrines on this important subject. It would of course be impossible within the limits assigned to this pamphlet to reproduce the substance of that exposition here; but the following summary of it may, perhaps, facilitate the apprehension and appreciation of the pathological and therapeutical principles afterwards propounded : — 1. That the chief function of the sympathetic nervous system consists in regulating the diameters of the blood-vessels throughout the body. 2. That when the sympathetic ganglia are in a state of maximum hypersemia the nervous effluence from them to the muscular coats of the arteries to which they are severally related stimulates them so excessively as to induce in them a condition of tonic spasm — a spasm so intense as to result in shutting off the blood altogether from a large proportion of the peripheral arteries. 3. That when the sympathetic ganglia are in a state of maximum anaemia the nervous effluence from them to the muscular coats of the arteries to which they are severally related becomes so extremely feeble that a condition resembling paralysis is induced ; the mus- INTRODUCTION. cular coats of the arteries become consequently extremely relaxed ; and, as the blood flows in the direction of least resistance, the parts supplied by the arteries in question become suffused with blood to an excessive degree. 4. That when the spinal cord is in a state of hypersemia, cramps of the involuntary muscles surrounding the alimentary tube as well as cramps, or even convulsions of the voluntary muscles, which are due to such hypersemia, are likely to ensue. 5. That every gland and glandular follicle in the body is under the control of one motor nerve (which I call the positive motor) emerging from the cerebrospinal system, and distributed to its secreting cells in order to regulate its functional activity; and of another motor nerve (which I call the negative motor) emerging from the sympathetic system, and distributed to its artery or arterial twig, in order to regulate its blood-supply. 6. That in the same manner as glands are supplied with positive, as well as with negative, motor nerves, so, there is reason to believe, every tissue of the body is thus supplied, and is thus placed and sustained in a state of elective affinity for the elements of the blood requisite for its nourishment and functions. 7. That the sympathetic ganglia and the spinal cord can be rendered hypersemic or anaemic, artificially, by means of heat, in the one case, and cold in the other, applied along the spine. 8. That by means of heat applied along the spine the general circulation may be lessened, the activity of the glandular system may be increased, and, in some cases, cramps of both the voluntary and involuntary muscles may be induced. 9. That by means of cold applied along the spine the general circulation may be increased, the activity of the glandular system may be lessened, and cramps of both voluntary and involuntary muscles may be arrested or prevented. 8 CASES OF DIARRHŒA AND CHOLERA. The fundamental principles on which the treatment described and exemplified in the following pages reposes, may be stated summarily as follows : — Negative Principles. 1. That though in exceptional cases diarrhoea as well as cholera may present itself associated with the presence of a blood-poison, neither the one nor the other is as a general rule the product of such a poison j* and that there are very strong and very numerous reasons for believing that the hypothetical so-called " cholera-poison," of the existence of which no proofs have ever been adduced, exists only in the imagination of certain pathologists. 2. That the existence of the so-called " cholera-germs/'f which are alleged to be produced and disseminated in terrific abundance from the gastric and intestinal discharges of cholera patients, has never been shown to be probable by any trustworthy evidence, and that there are numerous and very strong reasons for believing that they are creations as exclusively hypothetical and subjective as is the imaginary " cholera-poison " itself. 3. That the pathological changes constituting the phenomena of cholera are not referrible, as suggested by Dr. Gu11, % "to an early and severe depression," or " extreme exhaustion of the great ganglionic nervous centres in the abdomen ;" that " the vital energy of the nerves distributed to the respiratory, the circulatory, and the secreting organs, is either uncommonly depressed or entirely annihilated, is " not " shown by the nature of the characteristic symptoms constituting the malady/ as it is affirmed to be by Dr. Copland ;§ * The doctrine that the blood of cholera patients is poisoned is held by Parkes, Goodeve, Johnson, and a host of other pathologists. f The "cholera-germ" theory was held by Dr. Snow, and has been most zealously advocated by Dr. Budd, of Bristol. % In his admirable " Eeport on the Morbid Anatomy, Pathology, and Treatment of Epidemic Cholera," pp. 117, 119. London : 1854. § "Dictionary of Practical Medicine," vol. in. part i. p. 122. B DIARRHCEA AND CHOLERA: and that a vast array of authentic facts disproves the assertion of Dr. Goodeve that " in the intestines a sort of paralysis of the smaller arteries and capillaries seems to exist, much as occurs in the sections of the sympathetic nerve in the neck in Bernard's experiments."* 4. That cholera does not " travel " from place to place, as, in almost every history of its manifestations, it is said to do ; that it can originate de novo in any place in which certain definable conditions co-exist ; and that it may even be generated afresh, without the aid of " cholera-germs," and without any contact or relation of any kind with cholera patients, by either the stupid conduct or conscious efforts of man himself. 5. That though in the focus of a cholera epidemic the influence generating the disease is often felt by persons who are not actually attacked by it, and though when that influence tends to render all within the sphere of it liable to attack, the emanations of cholera patients, like any other foul or unwholesome emanations, may operate as exciting causes of the disease, nevertheless, cholera is neither infectious nor contagious ; and that the costly and vexatious international regulations, often involving great suffering, by which governments attempt to resist invasions of the disease, are no defence whatever against its attacks, whereas its development and continuance are probably often favoured by the enforcement of the laws of quarantine. Affirmative Principles. 1. That both diarrhoea and cholera, however induced, are essentially and invariably disorders of the nervous system. 2. That the nature of the summer diarrhoea of temperate climates, and that of the diarrhoea which often preludes, and, indeed, constitutes the initial stage of cholera in tropical climates, are essentially identical. 3. That the summer diarrhoea of temperate climates, the socalled cholerine, English or European cholera, and Asiatic cholera, are also essentially or etiologically one and the same disease — these several kinds of it being only the several expressions of the several degrees of intensity with which the force causative of them operates. 4. That the proximate cause of all the phenomena of diarrhoea and of cholera [before the stage of reaction] is hyperaemia, with consequent excessive action, of the spinal cord, and of the ganglionic or sympathetic nervous system. 5. That all these phenomena are naturally divisible into two classes, as follows : — First Class. — Active or Positive Phenomena ¦ — due to Hyperemia of the Spinal Cord. * Article on Epidemic Cholera contributed to the " System of Medicine" edited by Dr. K. Reynolds. Second Edition. Vol. i. p. 712. 2 FUNDAMENTAL PRINCIPLES. Second Class. — Passive or Negative Phenomena — due to Hyperemia oe the Sympathetic Ganglia.. [A complete list of the phenomena comprised in each of these classes is given at page 100 of my volume, entitled " Diarrhoea and Cholera : their Nature, Origin, and Treatment through the Agency of the Nervous System."*] 6. That the different grades of severity with which the symptoms of diarrhoea and cholera present themselves in different cases accurately correspond to and express the different grades of hyperaemia of the spinal cord and sympathetic ganglia which obtain in different cases. 7. That as the comparative strength of the cerebro-spinal and of the sympathetic nervous system in relation to each other differs aboriginally in different constitutions, so in cases of diarrhoea and cholera, each of the two groups of morbid phenomena produced by each of those systems will relatively to each other present different degrees of development in different patients. Hence it is that sometimes the copiousness and frequency of the discharges, and sometimes the algide symptoms, constitute the predominant features of cholera. 8. That any agent capable of producing general hyperaίmia of the spinal cord, and of the sympathetic ganglia, is capable, by doing so, of becoming a cause of both diarrhoea and cholera. 9. That some agents increase the circulation in, and therefore the energy of the whole nervous system simultaneously, and, consequently, engender diarrhoea and cholera without the operation of any apparent exciting cause. [Such agents are solar heatf and atmospheric electricity. Hence it is that while diarrhoea and cholera are only epidemic in temperate climates, and, exceptions apart, are only epidemic in such climates during the summer months, they are more or less endemic in tropical climates throughout the year.] 10. That though great and continuous solar heat is pre-eminently powerful as a cause of diarrhoea and cholera, even the great potency of solar heat as a cause of these diseases is immensely augmented if while the days are hot the nights are cold. [Wide ranges of temperature, when the average temperature remains high, cause tho amount of blood in the surface of the body to vary extremely within each twenty-four hours, and thus by means of the ebb and flow of the blood-currents, as well as by means of the nervous ramifications * Second Edition, enlarged, Bvo, pp. 268. London: Trubner and Co. f "It has been remarked," says the Registrar-General, in his Report for the week ending Saturday, July 15th, 1871, "that whenever the mean temperature of the water of the Thames touches 60° Eahr., an increased fatality from diarrhoea is soon observed." The mean temperature during the week ending August 26th, 1871, exceeded the average on each day of the week; and during that week 515 persons were destroyed in London by diarrhoea or cholera. 3 2 3 DIARRHCEA AND CHOLERA : throughout the surface of the body, exert an oscillating influence on the circulation within the nervous centres themselves, which, rendered permanently hyperaemic by the high average temperature, become still more so in the night, owing partly to the influence of sleep, and partly to the fall of the external temperature which causes the body to become cool, and the surface arteries therefore to become contracted. Careful and exact observations, both in India and in England, have demonstrated that when in connexion with a high temperature there is a great range between the degrees of greatest heat and greatest cold within each twenty-four hours, diarrhoea and cholera are likely to prevail most extensively ; and hence it is that in England as a general rule September, which is especially notable for its hot days and cold nights, is the month in which those diseases are most prevalent and most fatal.] 11. That when a high temperature, with or without great alternations, produces excessive hyperaemia of the nervous centres, the extent of such hyperaemia, and therefore proclivity to diarrhoea or cholera, differs in different persons at the same time, and in the same person at different times, because the constitutional variability of the circulation in the nervous system differs in different persons, and in the same person at different times. 12. That when the spinal cord and sympathetic ganglia have become hyperaemic by the influence of great solar heat, but not sufficiently so to enable them to become self- originative of diarrhoea or cholera, various agents, which without the co-operation of such hyperaemia of solar origin would be powerless to produce either of those disorders, are capable, with that co-operation, of becoming exciting causes of both of them. [The following are some of the most notable of such causative agents : — (a) In India, prolonged marches of so\diers,pilgrimages, and ordinary travelling on foot, by bringing into continuous and energetic action the lower segments of the already hyperaemic spinal cord, are notoriously prolific exciting causes of cholera. (b) Noxious effluvia coming in contact with the great expanse of sensory nerve filaments spread over the nasal and pulmonary mucous membranes, excite the already hyperaesthetic brain and spinal cord of persons exposed to great solar heat, to an extent which would not be possible at other times, and thus become exciting causes of both diarrhoea and cholera. "In spite of exceptions," says Dr. Goodeve, " the places in which the air is most vitiated from privies, cesspools, drains, decaying animal and vegetable refuse, or overcrowding and concentration of human evacuations, are those in which cholera has generally been most fatal and most widely spread." (c) Impure water, which in England may be drunk during winter with comparatively little danger from bowel complaints, quickly induces diarrhoea, and even cholera, in summer, when, by the action of solar heat, the nervous system is already predisposed to those diseases. Moreover, impure water taken from the same source all the year 4 THEIR EXCITING CAUSES. round is more impure in summer than in winter, because, whereas water at 32° Fahr. dissolves scarcely any organic matter, water at temperatures ranging from 60° to 90° Fahr. dissolves it freely. (d) Dad food, and eating to excess are very common exciting causes of cholera in India, where the temperature is always high; generally in temperate climates their morbid influence extends only to the production of diarrhoea ; but when, in England, for example, a predisposition to cholera is already established by great heat, they very often become the agents of its development. (c) Alcoholic fluids are, notoriously, stimulants of the nervous system, and assuming the truth of the doctrines above propounded, my readers will expect that persons who drink these fluids freely in a region where cholera is epidemic, will incur special risks of losing their lives by doing so ; and such is the fact. It was found by Dr. Farr* that "on Saturday, Monday, Tuesday, and Wednesday the deaths from cholera were above, and on Thursday, Friday, and Sunday below the average. In the whole country Tuesday was the most, Friday the least fatal day of the week." The remarkable increase of deaths on Tuesday is an instructive consequence of the fact that Monday (Saint Monday, as it is called by the working classes) is the day especially devoted to idleness and drinking. (/) Dental Irritation. — Of all exciting causes of cholera or, if the phrase be preferred, of fatal diarrhoea, in temperate climates at least, the process of teething is at once the most extensively operative, the most insidious, and the most deadly. Comparatively few English children are destroyed during each winter by diarrhoea, but the number which it kills every summer is deplorably great, while in those summers which are remarkable for their great heat the number is enormous ;f and I often marvel how little professional inquiry and reflection are excited by this great infant mortality. How does it come to pass ? The answer seems to me easily given : in ordinary English summers solar heat acting alone or even in combination with any of the exciting causes previously mentioned, does not suffice to induce cholera or fatal diarrhoea ; and in English winters the nervous irritation incident to the process of teething rarely induces diarrhoea, and when it does so the disease is rarely fatal ; but when the two exciting forces — solar heat and the nervous irritation caused by teething — are combined, their conjoint force produces that excessive hyperaemia of the already extremely vascular nervous centres of children, which originates the great majority of the very numerous cases called in England " infantile diarrhoea," and in America, where the solar heat is greater, and where consequently the symptoms of the disease are more pronounced, " cholera infantum." * " Report on the Mortality of Cholera in England," 1848-9. f During the week ending August 26th, there were in London 487 deaths from diarrhoea : of these 450 were of infants under two years of age. 5 DIARRHCEA AND CHOLERA : (g) Purgative Medicines. — Besides the several agents already mentioned which easily become transformed into exciting causes of diarrhoea and cholera when heat has already rendered the nervous centres hyperaemic, there are many others which ought to be referred to, but all of which except purgative medicines I must, for the sake of brevity, pass over in silence. That purgative medicines are capable of inducing cholera when the disease is epidemic is proved by an amount of evidence, from the most impartial and authoritative observers, placing the fact wholly beyond question. Testimony to this effect is given by Sir Ranald Martin, Dr. Macpherson, Dr. Laycock, Dr. Mackintosh, Dr. Goodeve, Dr. Twining, Dr. Morehead, and, in short, we find, as Dr. Macpherson says, "the great majority of writers in all countries pronouncing their opinion that when cholera is prevalent it is not safe to take aperients." The results of the several plans of treatment tabulated by the Treatment Committee of the Medical Council of the Royal College of Physicians, so as to show the percentage of deaths following each plan, proved that the percentage following the use of eliminants was greatest of all — viz., 71' 7, and that the percentage of deaths following the treatment by castor-oil was even greater than that which followed the use of eliminants in general : it was 77*6 per cent.] The principles stated above are sustained by an extensive array of facts and arguments in my volume on " Diarrhoea and Cholera;" and to that work I must refer those of my readers who are disposed to learn what those facts and arguments are. But in order to assure those readers who are not so disposed that the principles in question are fairly established, and are therefore worthy of at least provisional acceptance, I am induced to cite an authoritative judgment published in the form of a review of that work in the Medical Times and Gazette, November 3rd, 1866, and written, as I am enabled to state, by one of the most eminent of English pathologists, whose practical experience of cholera has been peculiarly great, and whose very valuable contributions to the science of medicine, conjoined with his high personal character, insure him the general respect of the profession. Of my hypothesis, concerning the nature and causes of diarrhoea and cholera, he says that " it is in harmony with the results of the most recent physiological investigations ;" that " it is only by a close examination of the detailed application of the hypothesis as a means of rendering intelligible the proximate cause of every special symptom that a comprehensive conception of the hypothesis becomes possible ;" that each special symptom " receives a consistent and intelligible explanation," and that " the strength of the theory lies in its comprehensive and simple explanation of seemingly contradictory phenomena, by the application of a recognised general truth." Knowing that to no other hypothesis yet propounded concerning diarrhoea and cholera could these words be 6 THERAPEUTICAL DESIDERATUM. correctly applied, and that many thousands of lives now sacrificed every year might be saved if only we could divine the mystery which has hitherto veiled the real nature of those diseases, I feel constrained to avail myself of the authoritative testimony which these words contain in order to enforce attention to a doctrine which, though revolutionary of prevailing opinions and practices, will, I believe, when once generally recognised, confer a power of preventing and curing those diseases, in the great majority of cases, as easily and effectually as that disease which in many respects resembles them very closely, and which hitherto has defied the power of medical art — viz., sea-sickness, can now be prevented and cured by means of the Spinal Ice-bag. Assuming the truth of the principles already affirmed, we are led inevitably to the conclusion that any agent which is capable of abolishing that state of hyperaemia of the spinal cord and of the sympathetic ganglia constituting, as alleged, the proximate cause of diarrhoea and cholera, is capable of curing those diseases; and that any agent capable even of lessening that hyperaemia, may so lessen the force of those diseases as, in the battle of life, to enable the vis medicatrix naturce to become victorious. English summer diarrhoea may, in a large proportion of cases, be completely arrested by suitable medicines, but that in a very large number of cases it cannot be thus arrested is, I presume, fairly proven by its great destruction of life, and especially of infant life, during the months of August and September of almost every year ; for I suppose that in the majority of fatal cases, the medical attendants have exhausted their resources in endeavouring to avert death. In England and Wales during the twenty years 1847-66, diarrhoea and cholera destroyed 417,199 persons, and of this vast number about three-fourths, or 311,200, were destroyed by diarrhoea. In London during the twenty-one years, 1847-67, these diseases destroyed 88,247 persons, and of this number nearly two-thirds, or 53,706, were victims of diarrhoea. As is well known, a very large proportion of these victims are children. I should, however, expect, inasmuch as the exciting cause of the summer diarrhoea of infants is in almost every case dental irritation, that the disorder when presenting itself in them would be far less amenable to the curative power of any drug than the summer diarrhoea of adults is actually found to be ; and though, so far as lam aware, no statistics have yet been tabulated by which I can test the accuracy of my opinion on this point, I am persuaded of its truth by considering that whereas the action of any exciting cause of summer diarrhoea in adults is likely to be temporary and easily removable, the action of the most common exciting cause of the malady in children — dental irritation — is prolonged, and though it may be lessened, is generally irremovable. Hence it is, I believe, that astringents which, in cases of summer diarrhoea in adults generally act beneficially, prove useless when prescribed for children suffering from the same malady. 7 DIARRHCEA AND CHOLERA : Acting on this opinion, I am in the habit, when obliged to treat infantile diarrhoea, whether merging into cholera or not, by means of medicines only, of prescribing those which are known to exert a special influence on the nervous system — viz., bromide and iodide of potassium. My experience leads me to believe that these drugs are far more effective than are any astringents, or any eliminants in counteracting the cause of the disorder when a consequence of teething ; and were I compelled to trust to drugs alone in the treatment of cholera, I should, with my present knowledge, place my chief trust, which, however, would not be great, in bromide of potassium. The summer diarrhoea of adults may in many cases be arrested by astringents : chalk and opium very often prove efficient — restraining the discharges, while the proximate cause of the malady subsides ; but knowing that in those cases in which notwithstanding this treatment the disease increases, the opium already given is likely to augment its virulence, I as a general rule avoid that drug, and have recourse to frequent doses of sulphuric acid with or without very small quantities of quinine, according to the peculiarities of the case. And this treatment I find so often successful, and, unlike the treatment involving the use of opium, so free from danger, in cases of simple diarrhoea, that when compelled to trust to drugs only, my main reliance is on sulphuric acid. When, however, decided choleraic symptoms — especially cramps — present themselves, sulphuric acid appears to me for a priori reasons (expressed in my volume on " Diarrhoea and Cholera") the most dangerous of medicines, and a large experience confirms my theoretical conclusion in the most decisive manner. According to the report of the Treatment Committee of the Medical Council of the Royal College of Physicians, when the different plans of treatment were tested in respect to their relative efficacy in cases of choleraic collapse, it was found that the percentage of deaths following the use of sulphuric acid was 78*9, or I*3 greater even than that following the treatment by castor-oil. This conclusion was confirmed by the experience of the cholera epidemic of 1866 : Dr. Andrew Clark informed me that, while he had found at the London Hospital sulphuric acid extremely beneficial in the treatment of diarrhoea, it proved quite the contrary in the treatment of cholera. I may add that the numerous and careful experiments made at that hospital in 1866, in order to determine the efficacy of various drugs said to be curative of cholera, resulted only in confirming the mournful conclusion arrived at during the previous epidemics — viz., that no drug yet discovered exerts any appreciable power in rescuing patients from the state of choleraic collapse. In several cases I have produced faintness, nausea, vomiting, diarrhoea, sweat, coldness of the surface, and contracted or pinched aspect of the countenance by the application of heat along the spine. In some cases these conditions, or several of them, may be induced as accompaniments of the arrest of haemorrhage (pulmonary or uterine) 8 REMEDIAL POWER OF COLD AND HEAT. by the application of the Spinal warm Water-bag. Now these experiences prove (1) that the spinal and sympathetic nervous centres can be powerfully affected by the application of heat along the surface of the spine, and (2) that by means of heat thus applied the phenomena of summer diarrhoea and of cholera can, in fact, be artificially produced, more or less completely, in persons of preternatural nervous susceptibility at all events. These experiences also suggest the idea that if heat thus applied will produce these phenomena, summer diarrhoea and cholera are really, as I have already asserted, expressions of hyperaemia of the spinal and sympathetic nervous centres, and that those diseases, as well as the artificial imitations of them, are likely to be abolished by cold applied in the same way. That cold thus applied will abolish them experience, in a considerable number of cases, enables me to affirm. I have proved over and over again, and many other persons have proved since I first announced the discovery, that when these several symptoms present themselves as the constituent elements of seasickness, the nature of which is, as I maintain, very closely allied to that of summer diarrhoea and cholera, they can, as a general rule, be thoroughly subdued by the application of the Spinal Ice-bag. Moreover, when each of these symptoms presents itself associated with some other disease, it can, I affirm, be more easily controlled or got rid of by the use of the Spinal Ice-bag than by any other agent; and, as vomiting is one of the formidable symptoms of cholera, I may add that that troublesome form of vomiting so often experienced by pregnant women, and so notoriously uncontrollable by drugs, can be completely put an end to by the Spinal Ice-bag, and, if it be judiciously used, with perfect safety. The foregoing facts, as well as many others of different kinds, which, if space permitted, I might adduce, justify the expectation that the Spinal Ice-bag will prove a powerful remedy of both diarrhoea and cholera. That it is so I shall hereafter show. In the treatment of cholera, as indeed of diarrhoea, when of an especially severe type and threatening to merge into cholera, an extremely important remedy co-operative with the Spinal Ice-bag, consists in the simultaneous application of heat to the general surface of the body. lam aware that heat when thus applied, by whatever method, has generally failed to recover patients from collapse, except in favourable cases, in most of which recovery would have occurred without any treatment at all. The reason of this is, that heat so applied does not, and cannot, affect the condition of the bloodvessels ramifying throughout the spinal and sympathetic nervous centres in any great degree. Hence the hyperaemia of those centres being allowed to persist, the arterial spasms throughout the body remain unsubdued, and are too strong to admit of blood being drawn through the vessels to the periphery when heat is applied there. But if, while these spasms are being overcome by the application of the Spinal Ice-bag, heat be simultaneously and energetically 9 DIARRHOEA AND CHOLERA: applied to the surface of the body, its effects will be wonderfully beneficial, because now the relaxed blood-vessels will permit the blood to pass, and the impulse given by the heat to the vital processes in the organic textures causes them again to attract blood to themselves, and thus to revive the circulation. Moreover these local applications of heat are more effective than might a priori be supposed, even from what I have just said, for they do exert a certain amount of beneficial influence on the nervous centres. In slight cases, where the vasic spasms of the extremities are distinct, but not strong, vigorous friction or heat, so applied to one hand or foot as to make it thoroughly warm, will generally so act, as already explained, on the nervous centres related to the limb as to cause them, by reflex action, to relax the arteries of, and thus to insure warmth in, the corresponding limb. And deductively, I conclude that this law obtains in every segment of the body.* The importance of applying heat as described to facilitate the operation of the Spinal Ice-bag in relaxing the arterial spasms throughout the surface of the body is attested by a fact mentioned to me by Dr. Brinton — viz., that if equal doses of opium be given to two dogs of equal size, and then if one dog be kept in a room at a low temperature, say 50°, and the other in a room of a higher temperature, say 70°, the former will die, but the latter will live. The cause of this difference in the fate of the two animals lies, I doubt not, in the fact that the constringing action of the opium on the peripheral arteries was assisted by the external cold in the case of the dog placed in the cold room ; whereas the same action was impeded by the external warmth in the case of the dog placed in the warm room, and thus the circulation was kept up sufficiently to sustain life until the poison had been excreted or its force expended. When it is not possible to put the patient in a Turkish, or hot-air, bath, the Spinal Ice-bag being well covered meanwhile by a non-conductor of heat, the most convenient and effective method of applying heat is that by means of hot water contained in indiarubber bags. Directions for the Treatment of Diarrhoea and Cholera according to my Method. In every case of both diarrhoea and cholera a thorough search for every removable exciting cause of the disease should be instituted, and if any such cause be found, it should of course be removed. Simple diarrhoea, that is, uncomplicated with any marked fall of the temperature of the body, or with vomiting or cramps, should be treated * It appears from the records that during the epidemic of 1854, when 208 patients were admitted into the cholera wards of St. Thomas's Hospital, "the general and most successful plan of treatment was the hot-air bath at 130 deg." — See Dr. Clapton* s Report in British Medical Journal, September 2>Qth, 1871. 10 HOW TO TREAT THEM. oy applying the Spinal Ice-bag continuously until the symptoms are overcome, and for some time afterwards at increasingly longer intervals, the patient being kept well wrapped up meanwhile. This will generally be all that is necessary to effect a cure. Indeed, in many slight cases the application of one bag of ice completely suffices to stop the flux and to prevent its return. Severe diarrhoea, sometimes called choleraic diarrhoea or cholerine, is in fact a mild form of cholera, and should be treated exactly as that disease is directed to be treated in the following paragraphs. Cholera. — The effective treatment of this formidable malady by my method implies that the physician practising it possesses accurate knowledge of the principles on which it is based, ability and tact to apply them correctly in each of the different cases — although presenting different physiological conditions differently combined, the exercise of the utmost possible watchfulness and untiring care, and the vigorous resolution to insure the doing of what needs to be done both quickly and thoroughly. While heat to the general surface of the body and ice to the spine are duly applied, the action of the ice must be especially watched, and its application must be modified in accordance with the pathological changes observable. The experience gained from the first trials of my method of treating cholera, strongly impressed each observer of those trials with this conviction. When, in 1865, Dr. Wiblin strongly commended my treatment, he added — "but all your injunctions must be strictly carried out/ Dr. Lake observed, " as with all other remedies of power it requires to be used with discretion, and not continued too long." Dr. Griffin, after recovering from collapse his two cases which he afterwards lost at Freemantle, says that in consequence of their distance from him the application of the ice was continued too long. Mr. Bencraft, in his letter dated October 29th, 1865, says — " I have no hesitation in recording my conviction that if applied in anything like reasonable time, the ice will save every life ; but I also see that it must be carefully watched." Within the limits assigned to this pamphlet, I cannot enter into the physiological and pathological reasons why ice applied along the spine of a cholera patient for a certain length of time may save life, and why if applied for a longer time it may endanger or even destroy it ; I may observe here, however, that the same power which can reduce the amount of blood in the spinal cord and in the ganglia of the sympathetic from a state of hyperaemia to the normal state, may also be so used as to render those nervous centres anaemic, and that such a state is always attended with danger. It is therefore absolutely necessary to determine by careful observation of the symptoms when the ice has been applied long enough, when it needs to be reapplied, whether its application should be extended along the whole or along only a part of the spine, and if along only a part, which part. When about to apply the Spinal Ice-bag, it is of the utmost im-> 11 DIARRHCEA AND CHOLERA : portance to select one of suitable size, in respect to both length and breadth. The Spinal Ice-bags 24 and 26 inches long are suitable for men, those 20 and 22 inches long for women, and, of course, those still shorter and narrower for children. The widths of the bags vary with their lengths. It is therefore necessary to secure one of right length in order to secure one of right width. [The agents for the sale of the Spine-bags supply, gratuitously, with each bag purchased a pamphlet, which contains important directions how to select a suitable bag in each case, and also how to prepare and apply both the Spinal Ice-bag and the Spinal Water-bag. I especially request all persons who intend to make use of these bags to give careful attention to those directions 7\ If the lungs are healthy, the ice may as a general rule be applied in the first instance along the whole spine, or rather — and this is what I always mean by the phrase " the whole spine " — from the upper part of the cervical to the middle of the lumbar region, and no lower. As soon as the whole of the ice in the bag is quite melted, the bag should be emptied, refilled with ice, and immediately re-applied. The applications should be continuous until the symptoms abate. If the circulation in the head becomes thoroughly re-established first, the ice may then be omitted from the upper cell of the Ice-bag. As soon as the vomiting ceases, and the chest and upper extremities have become warm again as a consequence of the re-establishment of their normal circulation, the ice may be restricted to the lower half of the spine until the alvine discharges cease also, and the lower extremities begin to become warm. In cases in which collapse continues after both vomiting and purging have ceased, the medical attendant, guided by the special character of the symptoms in each case, must use the ice in such a manner as he judges most likely to subdue them. At the Hopital St. Antoine, Paris, which I visited in 1865, there was an instructive case of this kind. An elderly woman under the care of Dr. Buchet, had already been treated by the method he then practised, and which chiefly consisted in sponging the patient all over with water, and in then wrapping her up carefully, covering her with an abundance of blankets, and applying hot bottles to the limbs. The measures adopted wholly failed to recover the patient from collapse. She lay in a state of profound stupor : seemingly there was no cerebral action at all. The head was thrown backwards, the mouth was open; when addressed in a loud voice she gave no sign of consciousness ; and she looked exactly as if dead. The head and upper extremities were deathly cold ; the lower extremities were, however, slightly warm. She was quite pulseless. There was neither vomiting nor purging, and no evidence of cramps. I applied ice to the upper half of the spine only, and altogether three bags of ice were used. The treatment began about ten o'clock in the morning, and was continued until about four o'clock in the afternoon. At this time, the temperature of the upper half of the 12 HOW TO TREAT THEM. body had increased very decidedly, the head became warm, the pulse perceptible, and the mental power had returned to such a degree that the woman answered questions intelligibly and easily. I restricted the ice to the upper half of the spine in this case for the following reasons : — First, because as the woman had been extremely drained by the discharges which had occurred in the previous stages of the disease, and therefore had but little blood in her body, I deemed it expedient in view of her peculiar condition to concentrate all the spasm-relaxing effects of the ice upon the head and chest ; and Second, because, inasmuch as there was some activity of circulation in the lower part of the body, it seemed to me that if I had placed ice along the whole spine, and had thus relaxed still further the arteries in the pelvis and lower extremities, the afflux of blood would have become still greater there, and my chances of recovering the cerebral circulation would have been less than they were by the method I actually pursued. While the Spinal Ice-bag is being applied to the spine, be very careful to retain whatever heat is still being evolved in the patient's body, by means of an ample supply of blankets, which should so effectually surround him, as he lies in bed, that the extremities as well as the trunk of the body are constantly well covered. In this respect unremitting effort must be made to counteract his throwing off the clothes by his frequent tossings. Apply heat unremittingly along the extremities to co-operate with the Spinal Ice-bag in overcoming the spasmodic contractions of their arteries, and thus in re-establishing the normal circulation of blood in them. Apply heat over the abdomen and hips for the same purpose. Allay the extreme thirst during the stage of collapse by nonstimulating or but slightly stimulating fluids, as hot as can be comfortably borne. It is well to give the patient the choice of several beverages, and indeed to vary them as he may feel inclined, for it is of the utmost importance to secure the co-operation of mental influences, which are no insignificant aid in allaying sickness. Good beef-tea, temptingly flavoured ; arrowroot made with water, flavoured, but only favoured, with brandy, and made thin, so that it may be easily drunk; hot weak tea and coffee, with but little milk while sickness still continues; hot lemonade, and hot barleywater, may each be given alternately or successively with advantage. If the purging should subside before the vomiting, injections of warm beef-tea, or of arrowroot, or of a mixture of both, should be given frequently. Strychnia, opium, and all drugs which act as nervine stimulants, should be scrupulously avoided. And this remark applies to strong solutions of coffee and tea. [It is impossible to state too emphatically that in cases of cholera under treatment by my method the life of each patient depends in great measure on the nurse in attendance. The remedial power of the 13 DIARRHCEA AND CHOLERA: Spinal Ice-bag can only be exerted while it is rightly applied. It must be kept exactly along the centre op the spine : IP IT is not it will do harm, and had better not be used at all. The only method of keeping it in its place which does not involve incessant watching on the part of the nurse, is that of employing the " Ice-bag Jacket," described at page 33 of my volume on " Diarrhoea and Cholera ;" and even then in cases of extreme restlessness slight readjustment may be necessary occasionally. To insure the proper application of the bag ; to keep each of its cells, when all are used, duly filled, and duly replenished, when needful, with ice ; to keep the surface of the patient clean and dry ; to insure the continuous application of heat along the four extremities and over the surface of the body ; and duly to attend to the other and various wants of even one patient — all this is a considerable task, and one demanding for its adequate fulfilment considerable intelligence, a resolute will, and a strong sense of duty. I am painfully aware how difficult it is to secure these qualities in attendants on the sick, and how strong in the eyes of many will seem the objection to my method that its successful practice necessitates not only first-class nurses, but many more of them in proportion to the number of patients whom they attend than are usually provided in public hospitals. To this objection I can only reply : no easy method of curing cholera is yet known ; drugs have been proved useless; and it behoves all whom the matter may concern, to ask themselves, " Is the life of the patient in question worth saving at the cost of providing the conditions mentioned ?" If the answer is affirmative — then, as in cases of cholera, life is destroyed very swiftly, it will be well to insure those conditions not only completely, but promptly : an hour, half an hour, nay, a few minutes, lost in delay may seal the fate of the sufferer whose life might have been saved by swift as well as judicious action.] The foregoing directions wholly relate to the treatment of the incipient and algide stages of cholera. A large number of patients whose lives are prolonged through these stages sink during the period of reaction, the fever, feverishness, or local congestions of which need the most studious attention, in order that they may be prevented or remedied by the judicious use of heat to the appropriate part of the spine. I have already suggested that in cases where cerebral or pulmonary reaction has become established while vomiting, purging, or coldness of the lower parts of the body persists, the ice should be omitted from the upper segments of the spine. But cases occur in which purging, at all events, as well as coldness of the lower extremities, co-exists with a full reaction, merging into slight or severe congestion of the brain, and sometimes, though less frequently, of the lungs. In these cases it may not suffice merely to omit the ice from the upper half of the spine, but it may be necessary, while still controlling the purging by retaining the ice in the lumbar and 14 HOW TO TREAT THEM. lower dorsal regions, and while aiding its action in relaxing the vasic spasms of the lower extremities by heat directly and effectually applied to them, to effect some contraction of the cerebral and perhaps pulmonary blood-vessels by the application of heat along the upper third, or upper half of the spine. To do this effectually, and at the same time not to overdo it, calls for the utmost discrimination and care — discrimination with reference to the controlling force needed, and care with respect to the temperature of the water used, and the length of time during which it is applied. The changes in the circulation which may be induced by the Spinal Water-bag are much more rapid than those inducible by the Spinal Ice-bag, therefore the action of the former must be watched even more carefully than that of the latter. If heat be applied in order to prevent or subdue cerebral congestion, the forehead and pupils of the patient must be scrupulously examined every few minutes in order to ascertain whether the temperature of the former is falling, and whether the size of the latter is increasing : if so, the bag should be immediately removed, even though it may be desirable to apply it again a short time afterwards. The condition of the lungs may be ascertained not only by the feelings of the patient, by the sputa, and by the degree of ease with which he breathes, but of course much more surely by auscultation ; and the use of heat must be determined by the symptoms. If there should be no special but only a general feverishness, or even a decided reactionary fever, this condition may be controlled by the application of heat along the whole spine. It may be stated as a general rule, that in proportion to the gentleness and slow graduation with which the fever, feverishness, or local congestion is controlled, the more satisfactory will be the result, and the less the chance of relapse. If, for example, in order to diminish cerebral hypersemia, water of a high temperature in the Spinal Water-bag be applied along the upper third of the spine, the head will, in many cases, become rapidly and extremely, and it may be, in some cases of cholera, fatally, cold. After such rapid and extreme contraction of the cerebral arteries, and the necessarily sudden removal of the Spinal Water-bag, there is danger of vigorous reaction. I advise that the temperature of the water used in these cases be the lowest consistent with slowly attaining the desired end. The vascular system of many patients may be influenced by water at 105° Fahr. It will, however, be found most available at 110°, and may range, particularly if the patient's body be well clothed with fat, to 115°, or even higher. It must be well understood that the application of heat along the spine is capable of producing vomiting and purging after they have been thoroughly subdued by means of ice, and of causing the body again to become cold. It is impossible, therefore, to overstate the importance of the advice to use these agents only when they are absolutely needed, and to watch their effects with the utmost possible care. The intensity of the cold or heat which is applied, and 15 DIARRHOEA AND CHOLERA : the length of time it is used, must be judiciously determined and modified according to the exigencies of each case. The chief things required by patients who have fairly passed through the algide and reactionary stages of cholera are good nursing and good nourishment. No medicine is absolutely necessary, unless to meet some special symptom ; but lam of opinion that a gentle tonic is desirable, and that that tonic should consist of the citrate of iron and quinine. I cannot conclude these directions more appropriately than in the following words of Sir Ranald Martin, for it is impossible to over-estimate their importance : — " In cholera, in common with the last stages of violent fevers and dysenteric — as, in fact, in all diseases of great exhaustion — the patient will always owe much to the horizontal position, and to careful and unremitting nursing. The most careful nursing and the most attentive watching of the patient are both of the utmost importance in this disease ; and so easily is the balance of circulation fatally overturned, that a strict attention to the recumbent posture is absolutely necessary to success. In no other diseases are these simple matters of so great importance to be attended to, and in the disease under special notice I have seen many a life apparently lost from inattention to them." Cases of Diarrhoea. Case I. — Mrs. T., set. sixty, suffering from diarrhoea, consulted me July 22nd, 1865, 11 a.m. Her bowels had been moved that morning four or five times. She complained of feeling excessively "low" and of slight abdominal pain. She was remarkably pale, and looked very ill. I prescribed the application of the Spinal Icebag, containing ice in each of its three cells, along the spine from the middle of the cervical to the middle of the lumbar region, the application to be continued until the symptoms should subside. The bag was immediately applied, but only during one hour. From the time it was applied until 8 p.m. the bowels were not moved at all, and no pain was felt. Meanwhile she was extremely excited and troubled by hearing a piercing scream from a lady in the same house who had been seriously hurt, and at 8 p.m. the diarrhoea recurred, the bowels being moved again three times. At 9.30 p.m. the patient went to bed, applied the Spinal Ice-bag by lying upon it, and fell asleep. In about an hour she awoke, removed the bag, and then slept continuously till 6 o'clock the next morning. July 23rd. — Between 7 and 11 a.m. the diarrhoea returned vehemently, the bowels being moved six or seven times. The patient felt cold ; her arms and hands were covered with a cold sweat; the features were sunken; and she felt so ill as to be seriously alarmed. At 1 L a.m. the Spinal Ice-bag was applied as before. At first the feeling of coldness seemed to increase, but at the end of ten minutes her whole body had become warm. " I 16 CASES OF DIARRHOEA. felt," she said (July 25th), " a glow of heat all over me, which has continued ever since." Meanwhile she had no return of the diarrhoea, and became in all respects quite well. Comment. — This case shows the necessity of continuing to use the ice-bag for some time after the bowels have ceased to be moved, otherwise the malady may recur : in fact, such a sedative influence should be made by the ice on the nervous system as will put an end to its excessive stimulation, not only of the mucous membrane and muscular coat of the intestines, but also of the muscular coat of the arteries in all parts of the body. Not until the morbidly excessive energy of the sympathetic ganglia, which holds the arteries throughout the body in a state of spasmodic contraction, has been so subdued as to facilitate the re- establishment of a free and vigorous circulation of blood through the peripheral blood-vessels, is the disorder completely overcome. How admirably the Spinal Ice-bag fulfils this indispensable condition is well exemplified in this case by the " glow of heat" which the patient felt " all over" her ; and my experience justifies me in saying that had she, on the occasion of the first attack, used the bag during several hours instead of during only one, the surface " glow" would probably have been induced during the first day, and that the diarrhoea would not have recurred at all. Case II. — C. T., est. forty-four, was attacked July 24th, 1865, with violent diarrhoea. During several days previously he had not felt well, and his bowels had been open more freely than usual. A three-celled Spinal Ice-bag was applied from the middle of the cervical to the middle of the lumbar region. At the time the ice was applied he felt an urgent need to go again to the water-closet, but the first effect of the ice was to cause that feeling to subside. Only in half an hour afterwards were the bowels again moved, and from that time he did not experience an unpleasant symptom. Comment. — The " first effect" said to have been produced by the ice in this case is often experienced by patients suffering from diarrhoea, and who use the Spinal Ice-bag, and is a striking exemplification of its power over the nervous system. Case 111. — A. 8., a gentleman upwards of forty years old, first seen June 25th, 1866, is suffering constantly from slight diarrhoea, which has been of long continuance, and to which he has been peculiarly liable for several years past. This is associated with great " nervousness," which consists in a feeling of numbness at the back of the head, a kind of hysterical depression, weakness of the extremities, of the upper the most, and most of all of the left arm and hand. Though he has never lost the power of writing with the right hand, he has lost the power of writing steadily. Cannot carve the meat at dinner. His ailments so trouble him that he shrinks from going into society, avoids dining out, or going to evening parties. He has never slept well, but has slept somewhat better lately ; he lies awake for long periods at a time, and if he c 17 DIARRHCEA AND CHOLERA : ever sleeps heavily, he knows that he is in worse health than usual. Does not suffer from headache; but very frequently indeed, especially when he is exhausted, the head is extremely cold. Also when in this state a film sometimes comes over the eyes. The pupils are often exceedingly dilated at night. He is always troubled with some irritation of the bladder, often with slight involuntary micturition, and during the presence of diarrhoea the urine is pale, very abundant, and very often voided. The diarrhoea is also associated with pain, in the lumbar region. Pulse 88, full and strong. I recommended this patient to apply the Spinal Ice-bag along the whole spine thirty minutes each morning and forty-five minutes each night, and to take as follows — R Quinae disulphatis gr. j, acidi sulphurici diluti h\x, ex aqua, bis die. I saw this patient again July 11th, or sixteen days afterwards, when he gave me the following report : — He felt the effect of the ice very strikingly during the first application, especially in making the lower extremities along their whole course " quite hot." He had used no medicine of the kind he had ordinarily resorted to with a view to restrain the diarrhoea, and nevertheless had not suffered from the malady at all. The peculiar feeling at the back of the head was almost wholly removed. The head had not been cold once; on one occasion only had the film come over his eyes; and he has gone out to evening parties without hesitation. He had slept " wonderfully well " since he began the ice. The power and sensibility of the left hand had greatly improved ; in evidence of the general improvement of the upper extremities, he said that he could write much more steadily than before, and that he had managed to carve up a fowl with becoming expertness. The urine was less abundant, and of a healthier colour. The slight involuntary micturition was almost wholly overcome. He remarked that the fasces had a considerable amount of mucus in them; this had long been the case. Pulse 76. Comment. — There are four important facts observable in this case which are well worth noting. Firstly, the head of the patient was frequently very cold, a film coming over the eyes at the same time, especially during exhaustion ; this denoted hyperaemia of the sympathetic ganglia governing the cerebral arteries. Secondly, the urine is said to have been very abundant and pale ; this denoted that the kidneys were unduly stimulated, and hence that the source of their stimulation, the lower segments of the spinal cord, were hyperaemic. Thirdly, while the diarrhoea existed there was pain in the lumbar region ; this denoted the same condition. Fourthly, the faeces are said to have been covered with a considerable amount of mucus ; this denoted excessive activity of the mucous glands, induced again by the hyperaemie spinal cord. Conformably with this interpretation of the phenomena in question, the production of comparative anaemia of the spinal and sympathetic nervous centres should, theoretically, be the surest way of curing the patient. The Spinal Icebag as applied is the most effective method of producing that anaemia : the patient's report of the results speaks for itself. 18 CASES OF DIARRHOEA. Case IV. — James H. H., set. eighteen months, brought to me July 28th, 1866, at 9 A.M., suffering from cholerine, has had a little diarrhoea " off and on " for a week past. At 8 o'clock last night he began to be violently purged, and at 3 o'clock this morning began to vomit. During the night he has been purged nine times, and has vomited four times. " The stuff that comes from his stomach and bowels," says his mother, " is like water and slime." He cried very much in the night, and, this morning, as if in pain, drew up his legs, seemingly cramped. The face is very pale and thin-looking, the eyes are rather sunken, and around the lower part of the orbits the skin is of dusky, or rather very light purple hue. The face and arms are remarkably cool; the legs and feet are cold. The child has suddenly become extremely weak. Pulse 132 — distinct. To apply the Ice-bag to the spine, and heat to the extremities, until the symptoms subside. 3 p.m. — Three bags of ice have been applied. In two or three minutes after the first one was put on, the child fell asleep, and slept a full hour. During the second and third applications he also dozed repeatedly. He has had two motions since the treatment began, more natural than before. He has been sick twice — once after taking milk-and-water, and once after taking arrowroot. He is generally warmer, and much more lively. Pulse 120. To put on afresh bag of ice every two hours, and to keep the limbs well covered with woollen clothing. July 29th, 10 a.m. — Has had eight bags of ice applied since last visit, the last at 7 o'clock this morning. His mother says — " He sleeps every time the bag is put on : he seems to like it ; he holds his head down to let the bag be put on directly I tell him the bag is coming, so I think it must be a comfort to him." Since yesterday he has had five motions ; the last, which was at four this morning, was natural in colour, and of the consistence usual in ordinary diarrhoea. He has not vomited once ; and has become much warmer. He slept altogether about four hours last night. Yesterday he ate some toast and arrowroot, and this morning had toast again." " He seems even fatter to-day," his mother says. He is now running about, amusing himself. " Yesterday morning," as she remarks, "he couldn't have stood ; he would have fallen down if I had tried to set him on his feet." To continue the ice throughout the day and night, applying a fresh bag every four hours. July 30th, 10 a.m. — Bowels moved at 2 and 11 p.m. yesterday, and at 3, 7, and 8 o'clock this morning. Stools partly faecal, with very offensive smell. Vomited once slightly, and was troubled with wind and spasms about midnight. Slept or dozed as usual when the Spinal Ice-bag was applied. His head and arms were hot all night, his belly and thighs cold. To apply ice along lower half of spine only, but continuously if the symptoms persist. To foment the abdomen if it is cold. July 31st, 8 p.m. — Is altogether better. Had four bags of ice applied during the whole of yesterday, the last at 9 p.m. To-day c 2 19 DIARRHOEA AND CHOLERA : three have been used — one at 7 a.m., one at 2, and another at 6 p.m. He slept during the whole time of application of two of the bags yesterday, and of the one last night, and continued to sleep till five this morning. He did not sleep (evidently not needing sleep) during the use of any of the bags to-day. His bowels were moved at 7 a.m. and at 2 and 6 p.m. to-day. The stool to-night was natural in all respects, except that it was of unusually light colour. This afternoon he was once very slightly sick ; but he has eaten very well indeed to-day, and seemed to enjoy everything he has had. His thirst has abated. To-day he has been in capital spirits ; has played about, and is evidently much stronger even than he was yesterday. He also looks much better. His mother says — " Throughout his illness he has shown signs at times of spasmodic pains," and that he has long been in the habit of having spasmodic jerks, or " a sort of tendency to convulsions." To apply two bags of ice, successively, during the night if he should be awake — not otherwise ; and to-morrow to apply a bag every four hours. August Ist. — Ice was applied at 11 o'clock last night : the child slept at once, and did not wake till 5 o'clock this morning. Ice was applied at 7 and 11 a.m., and at 3 p.m. to-day; He slept during the two first applications. Has not been sick at all ; the bowels have been moved only once; they were not in the least relaxed; the stool was healthy. He is warm, in very good spirits, and has recovered his usual strength. To continue the ice two or three times a day. August 9th. — The child has continued quite well. Case V. — D. D., male, act. forty, consulted me in August, ] 866, when he was suffering from diarrhoea, which had continued more or less during several days, but which had at length become severe. His skin was cold and peculiarly clammy ; his features were pinched and sunken ; he was altogether much enfeebled, and his abdomen was specially cold. I ordered heat to be applied over it and to the extremities, and ice to be applied simultaneously and continuously along the spine — the bag to be replenished with ice each time the previous supply should have melted. Ice was thus applied about eight hours uninterruptedly, and afterwards a short interval was allowed to elapse between the application of each bag. The purging became gradually less frequent, and by the following morning had wholly ceased. It was not until the purging, which left him extremely weak, had quite ceased that the surface of the body regained its natural warmth. The patient used the Spinal Ice-bag afterwards during a few days, at increasingly wider intervals, and then left it off. His strength was quickly restored, and he continued quite well. Case VI. — Mrs. P. was attacked in the night of September 22nd, 1866. During the previous morning she passed an extraordinarily large quantity of pale urine. After experiencing several alternations of heat and cold she became very cold ; and her skin was suddenly 20 CASES OF DIARRHGSA. contracted so as to leave its papillae in extreme relief, imparting to it the peculiar aspect well characterized as " goose-skin." The abdomen was especially cold and very hard. The arms became rigid, and attempts to move the fingers caused "very great pain" in the flexor muscles. The head was particularly cold. There was a most distressing sense of suffocation ; and a feeling — especially when she stood vp — as if she was going to faint, accompanied with a loud noise in the ears " like the roaring of the sea." She had also severe abdominal cramps, which seemed to extend to the womb ; convulsive twitches or jerks in various parts of the body; and forcible flexure of the toes, which she could not move by an effort of the will. Vomiting and purging, both extremely profuse, came on very early in the morning, and recurred at very frequent intervals. I saw her soon after daybreak : her face was then of a dark or brown colour, resembling that of oak or bronze ; she was extremely cold, restless, anxious, faint, and exhausted, her pulse being very feeble, though quite distinct. Her bowels had already been moved seven or eight times, and the vomiting was almost incessant. The stools retained their faecal character, and the ejections from the stomach consisted chiefly of bile in extraordinary abundance. She informed me, with some surprise, that she had not passed any water since the previous morning. I ordered ice to be procured at once; but during the time (about an hour) which elapsed before it was obtained, she grew very much worse: she reeled and needed support when she got up each time her bowels were moved ; and the vomiting and purging, which were simultaneous, became more frequent. As soon as the ice was brought I laid her upon a twenty-two-inch. Spinal Ice-bag ; applied heat to the feet ; covered her with several blankets as she lay on a feather bed; and gave her hot weak tea, as much as she would drink from time to time. She was calmed and comforted, and the discharges were restrained with astonishing rapidity. Within five minutes she became sleepy, and within half an hour she was in a sound, refreshing sleep as she lay on the ice. During the forenoon she vomited and was purged two or three times, but the vomiting was slight and without distress, and, as she said, her feelings when the bowels were moved were more natural ; but what was much more striking, she found when she got up the first time after lying on the ice, that not only had the suffocative oppression and sense of faintness ceased, but that she had suddenly recovered her strength, so that she could again walk with her usually elastic step. The skin quickly relaxed and resumed its wonted smoothness ; she became quite warm meanwhile ; and at the end of about an hour all abnormal phenomena of the muscular system had vanished. After the first hour ice was applied at intervals during the morning for about fifteen minutes at a time. By mid-day vomiting and purging had quite ceased; at 2 p.m. she took some food, and enjoyed it; at 4 p.m. she passed a very small quantity of water, for the first time since the morning of the day before, and then felt a further and 21 • DIARRHCEA AND CHOLERA: specially notable improvement in herself in all respects. At the same time her countenance had already become lighter and of more natural hue. Ice was applied along the lower half of the spine twice more before 11 p.m., during about thirty minutes each time; meanwhile she was progressing satisfactorily. But about 5 o'clock the next morning she found herself again distressed, much in the same way as she had been the previous morning before the vomiting and purging supervened. She felt the threat of a fresh attack most especially in the same oppression at the chest and difficulty of breathing which she had experienced before. Fortunately, as I had recommended, an Ice-bag, properly filled with ice and folded in a thick blanket to prevent the ice from melting, had been provided and kept in the room ; this was applied about half-past 5, and very soon it put an end to every unpleasant feeling. The patient afterwards slept, and then on rising felt as well as usual, except that she had been weakened by the attack. Nothing more was done, and she continued wholly free of any vestige of the malady since that date. Comment. — The effects of opium, in even very small doses, on the brain of this patient are so extremely distressing and injurious, that she absolutely refuses to take it ; and the predominance of spasmodic symptoms would have made me fear to prescribe either it or sulphuric acid, lest by so doing I should have intensified the disease. In this position I should have despaired utterly of being able to combat it successfully by means of medicines ; and its character was such that, had it not been arrested, it was more likely than not to have developed into choleraic collapse. Though the malady was stopped at an early stage, it presented several features proving its affinity with true cholera — viz., disorders of both the voluntary and involuntary muscular system ; faintness, tinnitus aurium, dyspnoea, coldness and discoloration of the skin, and suppression of urine. Case VII. — May Bth, 1867. — William P., act. seven months, suffers from frequent attacks of convulsions. Ice to be applied along the whole spine in an 8-inch Ice-bag, during twenty minutes, three times a day. May 17. — Is already much better, and looks so. The treatment to be continued. June 26. — Has been quite free from any sign of convulsions a considerable time. Treatment discontinued. July 3. — Has remained quite free from all convulsive attacks ; but since the ice was left off diarrhoea has come on, and has continued six days. Ice to be applied continuously till the diarrhoea stops. July 10. — The diarrhoea ceased completely on the 6th instant. Ice was used till it melted, only once daily. The child is quite well in all respects. Case Vlll.— Sept. 14th, 1867.— H. 8., act. eleven months, has 22 CASES OF DIARRHOEA. suffered during the last fortnight from diarrhoea, which, during the last few days, has become increasingly severe. The discharges, the mother says, u are almost transparent like water;'' they are very frequent, but most so in the night. The skin is dry and hot. To apply an eight-inch Ice-bag along the whole spine, until the ice has melted, every two hours, and continue to do so till the diarrhoea abates, then gradually increase the time between the applications. Sept. 18th. — The child became much worse before the ice was applied : it was purged at least fourteen times in the daytime of the 14th before the ice was procured. It was applied four times on the 15th. The child slept each time he was laid on the Spinal Ice-bag over two hours at a time; the bowels were moved about six times. On the 16th the improvement continued; on the 17th he was still better, the motions having more substance in them again. To-day he has had no ice, and is very irritable. The child's mother is greatly astonished by the fact she attests, that on every occasion the child slept on the ice. To continue its use as before. Sept. 28th. — The ice was applied only three times after last visit ; the child has had no diarrhoea since, and is well, except that the faeces, which are now quite solid, were tinged with blood to-day. This was also observed before the diarrhoea came on. Case IX. — Sept. 14th, 1867. — F. S., act. two years and three months. Has been ill three weeks ; became feverish ; a week afterwards diarrhoea set in, and has continued with but slight relief from medicine. Four days ago blood and mucus began to appear in the stools, which approach the rice-water character. To apply a teninch Ice-bag along the whole spine, until the ice shall have melted, three times a day. Sept. 18th. — The ice has been applied only twice a day, but each time till it was melted. The blood disappeared from the stools on the 15th, there are still about four motions daily; but they are of a more natural character, though still fluid. The child has slept each time the ice has been applied. To apply it four times daily. Oct. 9th. — After last date the ice was used a full week — four times daily, for two or three days, then twice or three times daily. By degrees the diarrhoea lessened, and had quite ceased at the end of the fourth day; since then the bowels have continued quite regular. The child has slept well, and has a good appetite. Her mother says, '* She was well contented with the Ice-bag, and each time it was applied slept on it." CaseX. — Sept. 21st, 1867. — G. M., printer, act. forty, began to be ill on the 18th ; has been up two nights, nearly the whole of each night suffering from excessive diarrhoea ; during the last twentyfour hours has had sixteen motions tinged with blood. He complains of nausea, but is not actually sick. To apply a twenty-four inch Ice-bag along the whole spine, till the ice melts, four times daily ; oftener if the diarrhoea continues. Sept. 25th. — -Applied ice only twice altogether — once September 23 DIARRHOEA AND CHOLERA: 21st, after which the diarrhoea stopped. It inclined to recur on the 23rd, when the Ice-bag was again applied, and again it relieved him at once. On the 21st, the patient slept during the whole time the ice was applied, and a long time afterwards. His wife remarked, "He dropped asleep at once, and he said ' the ice makes me warm.' " Case XL— Sept. 28th, 1867. — A. P., act. twenty-three, has recently suffered from an inflamed breast, and now she is troubled with nettle-rash over the whole body, even on the scalp, and with profuse diarrhoea, which began at 6 a.m. yesterday. She thinks her bowels have been moved " quite twenty times" during the last twenty-four hours. Faeces very dark and watery; to apply the Spinal Ice-bag along the lower half of the spine continuously until the diarrhoea abates. Oct. 2nd. — The diarrhoea stopped completely within three hours from the time when the application of the ice was begun. The nettle-rash also disappeared with almost equal rapidity, and no trace of it remains. The patient feels and looks wonderfully better. Case XII. — Oct. 2nd, 1867. — G. T., male, act. five, suffering from very severe choleraic diarrhoea. Skin cold, clammy, and darkcoloured ; features sunken ; patient extremely enfeebled. The treatment I prescribed consisted only in the application of a Spinal Ice-bag several times a day, and of heat to the extremities and general surface of the body. At the end of three days from the time the treatment began the patient had completely recovered. Case XIII. — E. W., male, act. nineteen, came to me July 22nd, 1868, stating that he had been suffering during three days from diarrhoea, and that he had about six movements of the bowels a day. He said, " I have awful sharp pains in my inside." Became very cold each night during the attack, up to the time I saw him. I advised the application of the Spinal Ice-bag along the whole spine three times a day until the ice should melt. July 25th. — The patient applied the ice during an hour on the 22nd and 23rd, and yesterday, the 24th, he applied it at 10 a.m., 3 p.m., and 9 p.m., also during an hour each time. On the 23rd he had about six motions, yesterday three, and to-day none at all. Says that he became very warm after the application of the ice, and felt strongly that he was deriving great benefit from the use of it. He declares that he has not been cold at all during the last two nights. He now looks well and says he feels so. Case XIV. — July 29th, 1868. — J. T., male, adult, complains of having suffered from diarrhoea during the last three nights. Bowels moved about six times in the twenty four hours. Breaks out in a cold sweat, after which he shivers. Has become extremely weak. Pulse 60. To apply the Spinal Ice-bag along the whole spine till the ice melts, three times a day. August sth. — Has used ice six times. Applied it for the first time in the evening of July 29th. That night his bowels were not moved at all. On the 30th 24 CASES OF DIARRHOEA. the bowels were moved three times, and since then, only once each day. Has neither had " the cold sweat nor the " cold feeling" about his body since. Pulse 68. Case XV.— Aug. 26th, 1868.— A. A., female, act. fifty-five, had severe diarrhoea, with cramps, a month ago. Was three days in bed with " dreadful cold perspirations." Says " she felt as cold as a stone." She has never been free from diarrhoea since, and is often purged four or five times a day. Is very weak ; no appetite ; sometimes feels extremely cold. Apply two cells of the Spinal Ice-bag, until the ice melts, along the lower two-thirds of spine twice a day. September 2nd. — Diarrhoea much lessened. The stools have become more solid. To-day the bowels were opened twice; yesterday, three times. She feels stronger. To continue the same treatment during another week. No medicine. September 9th. — Bowels no longer relaxed ; treatment discontinued. September 26th. — Has continued quite free from diarrhoea. Case XVl.— September 26th, 1868.— F. S., male, act. five months, suffers from profuse diarrhoea which has lasted a fortnight, and which has been treated by sulphuric acid in vain. The child has cut two teeth, is remarkably feverish, and the back of the head is very hot. To apply a ten-inch Spinal Ice-bag along the spine until the ice shall have melted twice daily ; also on separate occasions apply the same Ice-bag across the occiput, using the bag as an ice-pillow during three-quarters of an hour twice a day. September 30th. — Diarrhoea lessened, but not stopped; the back of the head is cooler, and the child is generally better. Continue treatment as before. October 3rd. — Diarrhoea ceased ; feverishness and heat of head subsided ; to give the child a warm bath during thirty minutes each night. To apply ice along the lower half of the spine if the diarrhoea returns, and across the occiput if it should again become hot. October 14th. — The diarrhoea has not returned, but the child is very irritable. To continue the warm bath, and to apply ice along the whole spine during three quarters of an hour twice a day. November 4th. — All irritation has subsided, and the child is quite well. Treatment discontinued. Case XVll.— September 30th, 1868.— E. 8., female, act. thirteen months, is suffering from diarrhoea and convulsions. Was in convulsions the greater part of last night. The diarrhoea has continued during the last six days, and is increasingly severe — especially in the night, the skin is hot both night and day. The child looks like a little old woman. She has often been troubled with diarrhoea during the last three months. The belly is usually distended and hard. To apply a ten-inch Spinal Ice-bag along the whole spine during an hour three times a day, the last application being late at night. No medicine. October 3rd. — All feverishness has subsided ; has not been convulsed at all ; the countenance is much improved, and the discharges 25 DIARRHOEA AND CHOLERA: are less slimy, but scarcely less frequent. To continue the Spinal Ice-bag as before, and to give the patient a prolonged warm bath each night. October 7th. — No return of any symptom of convulsions ; the child sleeps much ; but though the faeces have become more solid, the bowels are moved four or five times a day. To continue the Spinal Ice-bag as before, and to give a teaspoonful of cod-liver oil in warm milk twice a day. October 17th. — The bowels are now open from one to three times in twenty-four hours. The faeces are solid ; the stomach is much softer; the child sleeps all night; its appetite is good, and her mother reports her well in all respects. Treatment discontinued. Case XVlll. —October 12th, 1869.— 5. H., female, set. five months, has been suffering between two and three days, both day and night, from vomiting and diarrhoea with excessive frequency. The child is so exhausted that its chances of life seem small. Its head and extremities are cold. To apply an eight-inch Spinal Icebag, replenishing it each time the ice is melted with fresh ice, and continuing its application until the diarrhoea abates. No medicine. October 15th. — The Spinal Ice-bag was applied each time until the ice was melted three times on the night of the 12th, four times during the 13th, and three times during the 14th. Almost every time the ice was applied the child went to sleep upon it. The diarrhoea lessened on the 13th before the sickness ; and now the bowels are moved about three times in the twenty-four hours. There is scarcely any sickness at all. No ice has been applied to-day. To apply it at once, and continue three times a day. B> Vini ferri 3j bis die. October 22nd. — Quite recovered ; sitting up bright and vigorous. The ice was continued until the 20th inst. ; the diarrhoea completely ceased on the 17th. One tooth has just come through, another is coming. To apply the Spinal Ice-bag across the occiput, and to continue the medicine. I did not see this patient again. Case XIX. — October 15th, 1869. — R. H., male, act. forty-four, suffers from diarrhoea, which has continued three days, and from what the patient calls a distressing working about of the bowels. To apply the Spinal Ice-bag along the whole spine until the ice is melted twice a day. October 19th. — The ice has been used as prescribed. The patient says, " I like it very much ; it has made me feel a great deal better. The diarrhoea has quite ceased." Case XX.— January 27th, 1870.— W. A. 8., male, act. fifteen, is suffering from diarrhoea, which has continued nearly a month. He has been treated by " a chemist" without any benefit, and since the 11th inst. by me by means of sulphuric acid with the effect of restraining the discharges somewhat ; he has had seven or eight 26 CASES OF DIARRHOEA. during the last twenty-four hours. To apply a sixteen-inch Spinal Ice-bag along the whole spine continuously, replenishing the bag when needful till the diarrhoea stops. No medicine. February Bth. — The Spinal Ice-bag was applied after each motion during four days. The discharges steadily lessened, and at the end of the fourth day the diarrhoea had quite ceased. The bowels have been regular since. The patient steadily improved in all respects, and became notably warmer meanwhile. Case XXI. — June Bth, 1871. — C. R., male, two years and a half old, suffers from convulsive starts and diarrhoea. The starts have troubled him at frequent intervals during the last twelve months. When they are most severe, he is very relaxed in his bowels. During the last month his " starts " have been much worse, and during the last eight or ten days he has suffered severely from diarrhoea, which still continues. He is much troubled with wind, the abdomen being greatly and almost habitually swollen. He coughs much in the night, but not at all in the day-time. He drinks an extraordinarily large quantity of cold water : if a pint is given to him, he will drink it in a few minutes, and clamours for water many times a day. To apply the Spinal Ice-bag, 12 inches, along the lower half of the spine during an hour twice a day. June 13th. — The convulsive starts and the diarrhoea are much lessened. The patient is livelier and has a better appetite. His mother says, "lie doesn't drink anything like the quantity of water he did. He doesn't want it at night at all, and his cough is almost gone." June 27th. — Continues to improve ; he generally sleeps on the Spinal Ice-bag each evening, and last night would not go to sleep till he had had it : he insisted on having it. To continue its application as before, and also to apply it across the occiput until the ice is melted once a day. July 18th. — Has not had a start during the last ten days. The action of the bowels has become quite normal, he is no longer thirsty, and his abdomen has ceased to swell. Treatment was discontinued on the 14th instant. Case XXII. — June 13th, 1871. — Sarah S., a laundress, is suffering from profuse diarrhoea and vomiting, which began on the 11th instant: feels chill. To apply the lumbar Ice-bag along the middle half of the spine while the symptoms last. B> Infusi calumbae 3J bis die. June 20th. — The Lumbar Ice-bag was used as directed twice on the 13th, three times on the 14th, twice on the 15th and 16th, and once on the 17th. Not since. The patient was sick when she applied the bag the first time : she says the ice stopped the sickness directly, and that she was never sick again. She became quite warm while she had the ice on the first time. The diarrhoea did not stop till the 15th. 27 DIARRHOEA AND CHOLERA: Nevertheless she felt much better from the first, while wearing the Ice-bag; and on the 16th, when she went to work, at ironing, she found she could not work without the ice, because of the pain in her back, and felt as if she should be sick again, if she did not wear it. She is now quite well. Case XXlll.— August 15th, 1871. Mrs. G. W., set. 48, has suffered from diarrhoea nearly the whole of her life : during the last twenty years she is quite sure that she has never been free from the malady for longer than a week, and that even such slight immunity has been a very rare occurrence. Her bowels are moved on an average five or six times a day. She is also, as she says, "very nervous," and is often troubled with violent jerks or starts, so that her limbs suddenly shoot out, especially in the night. Owing to the condition of her chest I judged it expedient to apply two cells only of a 20in. Spinal Ice-bag along the lower two-thirds of the spine during an hour, three times a day. This treatment was persisted in during three weeks, and then, owing to my absence from town, was discontinued. During that short period the diarrhoea was already so far controlled, that at the end of a fortnight from the beginning of the treatment, the bowels were only opened twice or three times a day the third week. Moreover, she declares that her nervousness has left her, and her husband, whose experience of her jerks and starts in the night was no doubt of an impressive character, has informed me that they have ceased. I expect to resume treatment of the case, which, in consequence of the existence of a tendency to bronchitis, will require especially careful watching, and as it is a very remarkable one, I intend, on some future occasion, to publish my further observations of it. Case XXIV. — September 7, 1871.— T. 8., male, act. five, was suffering from " very bad " diarrhoea, which had continued all the previous night. The child belongs to the landlady of one of my patients (Mrs. V ) at the Farringdon Dispensary, whom I am treating for neuralgia by means of ice, and who, knowing, she says, that it had done her " a great deal of good," was tempted to try it on the child whom she thought " at all events it would not harm ." She applied the ice along the spine about 7 a.m., placing the child upon it. " Very soon afterwards," while she was holding his hands he fell asleep, slept until about noon, when he awoke and asked for " some dinner." The woman, who was not aware that the Spinal Ice-bag had already been used as a remedy for diarrhoea, closed her narrative of what to her seemed an astonishing fact, by saying — " And, though I know you wont believe it, sir, but it's quite true, the child was not purged once after he was put in the ice, and (September 13) has been well ever since." The method of treatment exemplified by the above cases has already been tried and emphatically approved by several medical 28 CASES OF DIARRHOEA. men, some of whom have either supplied me with records of their observations, or have published them themselves. Case XXV. (under the care of Dr. J. C. Williams, of Liverpool) — July 12th, 1865. — George 8., act. eighteen months, was suffering from severe diarrhoea. He had been ailing for some time previously. Astringent mixtures proved of no avail ; * vomiting came on, and by July 28th serious fears for the child's life were entertained by the parents. All medicines were then stopped, and a Spinal Ice-bag was applied, the child being well wrapped up meanwhile. " While the ice was on, the child became quite warm and free from pain, and in fifteen minutes was asleep, whereas it was crying bitterly before the application." July 29th, 10 A.M. — ¦ "After the ice was applied last night the child fell into a comfortable sleep, which continued till 7 o'clock this morning. An hour afterwards the bowels were moved once, a tolerably firm stool. Nothing more was done, and the child remained quite well when I left home, August 9th." Case XXVI. (also under the care of Dr. J. C. Williams). — July 28th, 1865. — J. J., male, act. thirty-seven, was attacked with summer cholera. I saw him first on the 30th. He was then so bad that I should have considered the cholera Asiatic, but for the bile vomited. He had three doses of chlorodyne to relieve the cramps, and ice was applied to the spine. He was quickly relieved of the vomiting and purging, but the cramps were very troublesome on the 31st. He applied the ice three times, for an hour each time. August Ist. — " Cramps gone ; skin warm ; bowels not moved ;no vomiting, but the patient continues thirsty. Nothing further was done, and he was quickly well." Case XXVII. — Dr. J. Moorhead, of Weymouth, in a letter which he addressed to me, Oct. 31st, 1865, says : — "Having recently suffered from a most severe attack of diarrhoea, for which I took largely the usual astringents, with opium, but without avail, I applied an ice-bag to the lumbar region, which proved most grateful, and immediately arrested all the symptoms." Case XXVIII. (under the care of Mr. Munro, Director of the Hydropathic Establishment, Melrose, N.B.) — " A very intelligent gentleman, who for a long time suffered from chest disease, had an attack of sickness and diarrhoea;" after the Spinal Ice-bag had been applied to the middle and lower third of the spine during about an hour, while the patient was in bed, "he was able to report the removal of sickness and pain, a warm glow over the limbs, and ere long, the entire removal of the diarrhoea. On a subsequent occasion, when the same disorder was brought on by over- fatigue, the same remedy was employed with like success." Case XXIX.— Dr. H. Fitzgibbon, of the West Indian Steamship St. Thomas, published in the Medical Press and Circular, April Ist, 1868, an important case of " diarrhoea" with vomiting, cramps, and abdominal gripings, cured by means of the Spinal Ice-bag. Dr. 29 DIARRHOEA AND CHOLERA : Fitzgibbon says of the case — " It seems to me interesting as supporting Dr. Chapman's statement, that cases of diarrhoea which resist the usual treatment, and even threaten to terminate fatally, as cholera, may be subdued by the application of an ice-bag along the spine." I have been informed by Mr. J. Mardon Wilson, of Philadelphia, that his brother, Dr. Wilson of that city, has found by experience of many cases, that my method of treating cholera infantum is very successful. Dr. J. S. Hackett, of New Amsterdam, Berbice, British Guiana, has stated in a letter addressed to a friend of mine, that he has treated several cases of diarrhoea by means of the Spinal Ice-bag, and invariably with success. Dr. J. Waring-Curran, has published in the Medical Times and Gazette, seven cases of " infantile diarrhoea," complicated with, or accompanied by, convulsive seizures, and which were treated by the same method. " The result of that experience was," he says, " that I found that the ice controlled the diarrhoea in a striking manner, and that it ultimately arrested it. Moreover the power of the ice in subduing the convulsions was most forcibly demonstrated : kept in abeyance when the ice was applied, they recommenced when it was removed." In a paper, entitled, " The Treatment of Epilepsy : Principles and Practice," read by me at a meeting of the London Medical Society, March 18th, 1867, I gave evidence of the marvellous power of the Spinal Ice-bag in stopping convulsions, and especially the convulsions of children. During the debate on that paper, two of the members stated that their own experience confirmed my statement. Dr. Routh, who " had tested the principle [of treatment] in several cases of infantile convulsions," said, "In one case the child had twelve convulsions in one day, and of course, under ordinary circumstances, could not be expected to recover : the convulsions ceased as soon as the Spine-bag was applied, have never recurred, and the child is now quite well." Dr. Rogers said — " One of his children had convulsions during thirty-six hours : ice applied to the spine completely stopped the fits. And quite recently, in two cases under his care, of whooping-cough followed by convulsions, the convulsions ceased to recur after the Spinal Ice-bag was applied."* Of the cases of diarrhoea given above, there are only two — viz., Cases VII. and XVIL, in which convulsions occurred, but in both these cases they were quickly and permanently arrested by the Spinal Ice-bag. Moreover, " the spasmodic pains" in Case IV., the tonic spasms, convulsive twitches, and abdominal cramps in Case VI., * Sec summary of the paper and of the debate published by the Medical Press and Circular of April 3, 1867. 30 EFFECTS OF THE SPINAL ICE-BAG. the " convulsive starts" in Case XXI., which had lasted twelve months, the " violent jerks or starts" in Case XXIII., the pain (probably due to cramps) in Case XXV., and the cramps in Cases XXVI. and XXIX., were rapidly and completely stopped by the ice. The Vomiting, which was a distinctive feature in Cases VI., XVIIL, XXIL, XXVL, XXVIIL, and XXIX., subsided scarcely less swiftly than the cramps just mentioned. The rapid restoration of heat throughout the body, by means of the Spinal lee -bag, in those cases of summer diarrhoea in which a notable fall of bodily temperature shows their affinity with cases of cholera, will, 1 presume, be held to be a decisive proof of the power of the remedy to effect a beneficent and thoroughly constitutional change of the kind most urgently needed in these cases, and one which no known drugs can be relied on to achieve. That the Spinal Ice-bag can do this is strikingly attested by the experience reported in several of the foregoing cases. In Case I. the patient, who but a short time before complained of being cold, and whose upper extremities were covered with cold sweat, reported " a glow of heat" all over her. In Case 111. the patient " felt the effect of the ice very strikingly during the first application, especially in making the lower extremities along their whole course ' quite hot.' " In Case IV., at 9 a.m., the skin of the child was of " a light purple hue," its face and arms were " remarkably cool," and its legs and feet were " cold :" at 3 p.m. of the same day, after three bags of ice had been applied, he was " generally warmer and much more lively." In Case VI. the whole body was cold, and the head was particularly cold, yet during the first morning of treatment the circulation and normal amount of animal heat was fully re-established throughout the body. In Case X. the patient said to his wife — " The ice makes me warm." In Case XIII. the patient, who " became very cold each night during the attack," said he " became very warm after the application of the ice," and that he had not been cold at all during the two subsequent nights. In Case XIV. the patient, who before using the Spinal Ice-bag broke out in cold sweat, which was followed by shivering, had neither " the cold sweat," nor the "cold feeling" after the treatment began. In Case XX. the patient became " notably warmer" during treatment. In Case XXII. the patient " became quite warm while she had the ice on the first time." In Case XXV., " while the ice was on the child became quite warm." In the case of "summer-cholera," No. XXVL, the Spinal Ice-bag was first applied July 31st, and the next day the medical attendant found the " skin warm." In Case XXVIII. the patient reported " a warm glow over the limbs" within an hour after the ice was first applied. The sleep-inducing power of the Spinal Ice-bag is also signally demonstrated in many of the above cases. In Case I. the diarrhoea recurred at 8 p.m. At 9.30 p.m., having applied the bag to the spine by lying upon it, she fell asleep, and, excepting a few minutes, slept 31 DIARRHOEA AND CHOLERA: continuously till 6 o'clock the next morning. In Case IV. the child fell asleep "in two or three minutes" after the ice was applied, and slept a full hour; and in this case the like fact was observed on almost every occasion when the ice was re-applied. In Case VI. the patient became sleepy within five minutes after the ice was applied, and within half an hour she was in a sound refreshing sleep as she lay upon it. In Case VIII. the child's mother was greatly astonished by the fact she attested, that on every occasion when the Spinal Ice-bag was applied the child slept on it. In Case IX. the child " was well contented with the ice, and each time it was applied slept on it." In Case X. the man "dropped asleep at once, slept during the whole time the ice was applied, and a long time afterwards." In Case XVII. it is reported that "the child sleeps much." In Case XVIIL, " every time the ice was applied, the child went to sleep upon it." In Case XXI. the mother of the child says — " He generally sleeps on the Spinal Ice-bag each evening." In Case XXIV. the patient, who had been awake all night with diarrhoea, fell asleep in a few minutes after he was placed on the ice, and slept five hours. In Case XXV., within fifteen minutes after the Spinal Ice-bag was applied, says Dr. Williams, " the child was asleep, whereas it was crying bitterly before the application ;" and again he says — " July 29th, 10 a.m., after the ice was applied last night, the child fell into a comfortable sleep, which continued till 7 o'clock this morning." The rapid renewal of strength by the Spinal Ice-bag is a fact noted in some of the preceding reports, and very often observable in cases of diarrhoea. This result of the treatment in question is scarcely less remarkable than the others just noticed. In Case IV., the child, which on July 28th was utterly prostrate, incapable of standing, in fact partially collapsed, was running about the room, and amusing himself, July 29th. In Case VI. the lady, who at 7 a.m. reeled and needed support when she attempted to stand or walk, " found, when she got up the first time after lying on the ice, that not only had the suffocative oppression and sense of faintness ceased, but that she had suddenly recovered her strength, so that she could again walk with her usual elastic step." The application of the Spinal Ice-bag is generally felt to be peculiarly comfortable, and in many cases positively pleasant. In Case IV. the child's mother says, "He seemed to like the ice-bag; he holds his head down to let the bag be put on directly I tell him the bag is coming, so I think it must be a comfort to him." In Case IX. the child's mother says, " She [the child] is well contented with the ice-bag." In Case XXI., the child, who usually slept on the Spinal Ice-bag each evening, " would not go to sleep till he had had it : he insisted on having it." And Dr. Moorhead, relating his own experience, Case XXVII., says, "The ice-bag proved most grateful." The Director of the Hydropathic Establishment at Melrose, who reported Case XXVIII., writes — " One thing has 32 PATHOLOGICAL INFERENCES. much struck me — viz., the liking that sensitive chilly patients have for the cold bag to the spine, although frightened to think of it before they make trial." Dr. Druitt on one occasion saw some of my patients with me in order to inform himself of the results of my treatment of paralysis and epilepsy. After confessing that he was agreeably surprised by those results, and stating that " there was no mistaking the testimony of the patients that those results had been most beneficial," he adds, " I learned from all the patients that the treatment had made them more comfortable ; I mean as regards their general feelings of health and animal sensations, without reference to the relief of particular symptoms." In several cases of sea-sickness — a malady having, as I affirm, an essential affinity with diarrhoea and cholera — the patients have reported their sensations induced by the Spinal Ice-bag to have been peculiarly agreeable. In fact, a remedy which steadily subdues and finally abolishes every symptom constituting or associated with the malady against which it is directed, can scarcely fail to operate pleasantly. The mode of action of the Spinal Ice-bag in producing the several special effects just reviewed claims a moment's reflection, for in my opinion due consideration of it may throw "a flood of light" on the nature of not only diarrhoea, but of cholera also. The action of prolonged cold on living organisms is that of a sedative on the part to which it is applied ; and the most manifest and characteristic result of the sedative influence of ice is diminution of the amount of blood and retardation of its movement in the part which is immediately acted on. The Spinal Ice-bag is applied over the spinal cord and collateral ganglia of the sympathetic nerve; and, as shown above, when thus applied it stops convulsions, it stops cramps, and the pains associated with them ; it re-establishes the peripheral circulation, and makes warm the patients who were previously cold ; it renews their strength with remarkable rapidity — sometimes with astonishing suddenness ; it stops the vomiting and purging ; it soothes the excited, and gives the restless sleep ; and, withal, it substitutes for that deadly feeling of sinking and utter prostration peculiarly characteristic of severe diarrhoea, as well as of sea-sickness and cholera, a sensation of refreshment and of returning life and energy — a sensation which, under the circumstances, is the most agreeable of any which could be bestowed. Now if the application of the Spinal Ice-bag produces these several results, and produces them, as explained, by lessening the circulation in and consequently the energy of the nervous centres acted upon, the conclusion that the immediate or proximate cause of summer diarrhoea and its frequent concomitants — vomiting, cramps, infantile convulsions, coldness, frequent restlessness and sleeplessness, and great prostration, physical and mental — consists in hyperaemia of those nervous centres, is, in my opinion, inevitable. But if with respect to summer diarrhoea and its frequent concomitants the doctrine which I have propounded D 33 DIARRHOEA AND CHOLERA : be thus verified and established by actual experience, this experience almost necessarily suggests the idea that inasmuch as several of the cases reported above which were especially severe, presented, though in a relatively mild form, all the leading and characteristic symptoms of cholera, and inasmuch as all these symptoms were abolished by the Spinal Ice-bag, cholera itself, even of the severest type, is in respect to its nature and mode of origination, essentially identical with summer diarrhoea — is, in fact, but a great and terrific development of that disease, and is capable of being treated most successfully by practically recognising the fundamental principles which have dictated the treatment exemplified in the preceding cases. The correctness of this idea is, I believe, demonstrated by the following cases : — Cases of Cholera. Case I. — I was summoned in the morning of March 14th, 1865, to see Mrs. D. Just as I reached her room at 7.30 a.m. she had been got up to the night-chair. Immediately she rose from the chair she stood still and speechless, and* anxiously beckoned to her attendant, who rushed to her, and caught her as she was falling. She was got on to the bed, where she lay for some time as if dead. The window having been opened she was raised and held up, when she soon recovered from what seemed to be a fainting-fit. At 8 a.m. she had another motion, and experienced such extreme dyspnoea, that she appeared to have quite lost the power of breathing. She gasped ; her countenance rapidly changed — became quite dark coloured and remarkably pinched and contracted. Her hands were purple and icy cold. The attack began two days previously with diarrhoea, which had continued ever since. During the night of the 13th the patient was purged several times, became alarmingly weak, and suffered much from cramps in the abdomen and lower extremities, which quite doubled her up. While I was with her, between 8 and 8.30 a.m. she was agonized with cramps, especially in the thighs, and she vomited repeatedly during the morning. Not until 8.30 a.m. was it possible to procure ice. I applied it immediately, and within jive minutes she was in a placid sleep ! She slept forty-five minutes, and was then woke up by the leaking of the ice-bag. She had another motion immediately — nothing but a serous-like fluid, with flakes of mucus floating in it — a true " ricewater stool." As she was menstruating, and only a few days before had had a severe attack of haemoptysis, I dared not use the ice freely and continuously along the whole back, as I otherwise should have done. But it was used so far as was necessary to keep the vomiting subdued; and whenever the vermicular movements and cramps of the bowels, which especially distressed her, became distinct and considerable, they were arrested by applying ice for short periods at a time in the dorso-lumbar regions. 34 CASES OF CHOLERA. Thus the malady which, owing to the state of the lungs and womb, could not be suddenly cut short, was gently and gradually subdued. But the patient continued fearfully weak during the 15th, 16th, and 17th, although the choleraic symptoms were completely controlled. Comment. — The treatment of this case was peculiarly difficult : much blood had recently been lost from the lungs ; and much was still being lost from the womb by excessive menstruation : ice along the whole spine continuously would probably have caused the haemoptysis to recur, and would certainly have increased the menstrual flow; hence, though ice freely applied would have promptly arrested the choleraic symptoms, and would, by increasing the flow of blood in the peripheral arteries, have prevented the frequent fainting fits which occurred, I could only use it safely during a few minutes at a time. [Cases 11. to VI. inclusive were kindly placed in my hands for treatment either by Dr. Cheeseman or by Mr. Bencraft, surgeon, of Southampton.] Case II. — Mrs. F., act. twenty-nine, eight months pregnant, living in one of the worst parts of Southampton, first seen by me on October 4th, 1865, 11 .30 A.m. Has had diarrhoea about ten days. On the 2nd inst., in the afternoon, felt faint, and at 7 p.m. took to her bed. Had previously begun to be purged "dreadful." Since then has been purged continually every ten minutes, or oftener. Cramps have occurred at intervals during the ten days, but on Monday night they became very bad, recurring continually, has not had five minutes' sleep at a time for them; skin cool, but not very cold. Ate an egg this morning, and, as her first act of vomiting, has just thrown it up. No headache, but is very giddy; cannot stand one moment. Head decidedly cold ; eyes deeply sunken ; tongue cool. " Feels," she says, " tight in the chest, and hot in myself." Very slight pain in bowels; passes water. Pulse 108, thin, and very feeble. Applied ice at 11.45 a.m. along the whole spine, and ordered it to be removed at once if any hypogastric pain were experienced. 2.45 p. m. — Was soothed during the first forty minutes, then began to have pain in the region of the womb, but continued the ice; cramps much lessened; bowels moved but twice; has been sick twice; pulse 1 04. Continue the ice every other half-hour, and give beef-tea. 7.15. p.m. — Bowels moved twice, sick twice, but retained the beef-tea. Cramps have subsided, but still has pain in the hypogastric region and down the thighs ; is very comfortably warm all over. To apply the ice only between the scapulae every other half-hour as before : to remove it at once if internal pain is induced. 11.15. — Has slept several times during the evening. Hypogastric pain continues; bowels moved once ; sick twice : continue as before, 1)2 35 DIARRHOEA AND CHOLERA : sth, 8.30 a.m. — Bowels moved twice ; sick four times, twice provoked by medicine prescribed before I saw the patient, and given without my knowledge. Pulse stronger ; warm all over ; no cramps. Still has dull pain in hypogastric and lumbar regions ; nothing however of the nature of spasms. Has retained her beef-tea, and says the ice comforts her. To reapply it along the whole back, until it melts, unless hypogastric pains increase. 5 p.m. — Is altogether better ; pain lessened ; no cramps ; warm all over ; bowels moved but once ; stool decidedly faecal ; has vomited a little after drinking ; sleeps often, and feels rather heavy in the head. 7th, 9.30 a.m. — Used ice three times since last evening. Has been sick three times. The bowels have not been moved since yesterday morning. Still warm; no cramps; pulse 104; has eaten two eggs and some fish. To use ice only if coldness, cramps, sickness, or diarrhoea should recur. To eat anything she may fancy. 10 p.m. — Has been much better all day; neither sickness nor movement of the bowels. Is now asleep. Bth, 9 a.m. — In the middle of the night began to "wander," and got up. Does not answer questions coherently this morning. The eyes have a peculiar aspect, as if expressive of cerebral oppression. Head, chest, and extremities warm ; pulse rather strong and rapid. She has been neither sick nor purged. Loud bronchial breathing, but no respiratory murmur at back of each lung ; breathing rather laboured. I thought the breath had a diabetic smell. Still no movement of bowels. To discontinue the ice, and to apply heat between the scapulae, and to renew the warm water in the bag every hour. 4 p.m. — The heat gave immediate relief, both to the head and chest. In a few minutes after its first application she became quite coherent, broke out in a perspiration, and felt much better. Has had a long sleep — the longest since she has been ill. Says, " I'm wonderfully better ; I only want a cup of tea to be all right now." Still neither vomiting nor purging. To renew water-bag at intervals of ninety minutes. 9th, 9 a.m. — Feels a great deal better in herself; slept two or three hours ; still no sickness and no movement of the bowels ; passes urine freely ; skin cool ; pulse 112 ; tongue coated. To continue water-bag once every two hours, and to have a saline mixture. 4 p.m. — Still better and stronger ; has slept much; tongue cleaner; no sickness; bowels still unmoved. Says she feels now that she only wants plenty of good food. On this occasion I ordered the use of the water-bag to be discontinued, and took my leave. Comment. — As this woman was pregnant, peculiar care and patience were needed in her treatment by means of ice, otherwise a miscarriage must have been induced. Foreseeing before ice was first applied the danger of its prolonged use at one time, I ordered its removal at once if hypogastric pains were caused by it. It will be seen that my precautions were needful, but that by careful management such tolerance of the ice was ultimately established as 36 CASES OF CHOLERA. to enable me to overcome all symptoms of her malady. The experience of the effects of the heat in restoring sanity, inducing sleep, causing perspiration, and relieving the lungs, is not less striking than instructive. Case 111. — Mrs. L., act. twenty-nine, first seen October 6th, 1865, at 4 p.m. Began to have diarrhoea and vomiting at 6 a.m., stools being yellow. Cramps began at 10 a.m. ; at 11 a.m. the skin became cold and discoloured. Symptoms gradually increased. At 4 p.m., when seen by myself, Mr. Bencraft, and Dr. Welsh, she exhibited the choleraic countenance in a very striking degree : eyes deeply sunken ; lips blue ; the whole surface of the body cold ; cramps violent ; ricewater purging and vomiting. Ice ordered to be applied continually. 10 p.m. — Decidedly improved. Markedly warmer ; cramps and sickness much lessened. The cramps only recurred when the ice had melted and the bag had become warm. October 7th, 10 a.m. — Aspect and voice much improved; lips red; whole surface of body quite warm; pulse 100. Cramps only occurred onee — when the bag had become warm. Bowels moved three times ; vomited once. To continue ice as before. 8 p.m. — Body nice and warm. Pulse 94, fuller and stronger; slightly sick once ; no cramps ; bowels moved twice ; the stools have a faecal smell. Very thirsty and weak; indisposed to take nourishment. Had some beef-tea and milk, and kept it. To apply ice till it melts, then omit for half an hour, then repeat it in the same way. Bth, 10.30 a.m. — Has had rather a restless night, wanting sleep, and troubled with hiccough. Warm all over. Pulse 90. No vomiting; bowels moved but once; no cramps. To apply warm water-bag along cervical and upper dorsal region, and to renew it every two hours. B> Ferri et quinae citratis, gr. v, ter die. 11 a.m. — Called again and found her asleep. 4 p.m. — Found she had slept about an hour — twenty minutes on three different occasions. Bowels moved once. To have tea and milk. 9 p.m. — Feels and looks much better ; comfortably warm all over ; pulse, as Mr. Bencraft said, " capital " — B4 ; no. vomiting or cramps throughout the day ; bowels moved once. Enjoyed her tea, milk, and sago. The face is looking clearer. Now she expresses a fancy for food — viz., ham. To apply ice in lumbar region at 2 a.m. to-morrow. 9th, 11 a.m. — Ice was not applied as ordered. Has had a restless night, and between 4 and 6 a.m. had four motions, with copious amount of bile in them. Is generally warm ; pulse 72. Complains of headache if she rises up. Tongue rather darkly furred on dorsum, clean at edges. Has had neither sickness nor cramp. Has taken half a cup of tea with milk ; could not swallow any meat. To apply ice in lumbar region thirty minutes every four hours; but if diarrhoea returns to apply it continually. 8 p.m. (Report from Mr. Bencraft) — "Mrs. L. is doing well. Pulse 72. She is not so restless or feverish ; has taken some tea with milk, two good cups of beeftea, and a fruit tart which she fancied." 37 DIARRHOEA AND CHOLERA: Comment. — It will be observed that on the night of October Bth, I ordered ice to be applied at two o'clock the following morning, although both vomiting and purging had ceased. I did this because as patients are most frequently attacked with cholera early in the morning, so will they be most liable, as it seems to me, to relapse at that time. There being no ice in the house on the night in question, none was applied; and, as I anticipated, diarrhoea recurred. The power of the warm water-bag in inducing sleep is exemplified in this case quite as strikingly as in the previous one. Case IV. — Ellen S., act. fifteen, first seen October 6th,1865,l 2p.m. Began to menstruate five months ago. Of late years has had pretty good health, but has always been delicate in the chest ; eight years ago had a severe attack of diarrhoea and " slow fever." This morning, at 7.30, had a stool, and complained of pains in her chest and stomach. She continued to be purged and to vomit at times, and at 4 p.m. assumed the ghastly cholera aspect, and said she thought she was going to die. Since then the purging and vomiting have been almost incessant. She is very cold all over, the wrists and tongue especially so; the head alternately cold and hot. Pulse almost wholly imperceptible ; cold perspirations ; very bad cramps ; rice-water stools. When first seen the peculiar choleraic countenance was more striking than I had seen before : it was appallingly deathlike. Had "a bilious pill" at 10.30 a.m., and pill of calomel and opium (gr. \of the latter) at 11.30 a.m. I ordered ice to be applied to the whole spine every two and a half hours. October 7th, 9 a.m. — Is strikingly better ; warm all over ; tongue considerably warmer; pulse very distinct, 116 ; head comfortable; countenance immensely improved ; no cramps at all; has vomited but once. The faeces, which are still passed under her, have a distinct faecal smell. Has had a cup of tea. Ordered to apply ice during an hour ; then to omit it half an hour ; then to resume it for the hour, and so continue. To have beef-tea as often as she can take it. 2 p.m. — Continues warm ; tongue warm; no cramps. Has been sick once, at 9.30 ; not since. Bowels not moved since 11 a.m. Has dozed a little ; no headache. Has had half a cup of beef-tea, and has kept it. 8.30 p.m. — Thinks she does not feel quite so well. Warm all over, except the feet ; pulse 1 04 ;no cramps ; sick once ; bowels moved once ; stool faecal. Has had two half cups of beef-tea, and has kept them. Had the ice on every alternate hour. To continue the ice an hour, omit half an hour, and repeat continually in this way. Bth, 10 a.m. — Is still warm all over, especially the chest. Pulse 116. Has been sick and purged ten or twelve times during the night. The last stool was quite of the rice-water character, and contained a large round worm which was dead. She complains of pain in the chest, and I cannot hear respiratory murmur at the lower part of the back of the lungs. Has recently slept about half an hour. To apply ice to lumbar region only, and continually. To 38 CASES OF CHOLERA. apply warm water between scapulae every hour. 4 p.m. — Found her asleep. Feels easier in the chest ; vomiting and purging much lessened ; stools have strong faecal odour. Has had more beef-tea. Continue. 10 p.m. — Still better; has slept an hour; pulse 100. Mr. Bencraft, who saw her with me, is struck with the improvement in her appearance. To use the ice as before, and the warm water every two hours. 9th, 10 a.m. — Has had rather a restless night, and complains of pain in the bowels. Pulse 92 ; breathes comfortably ; sickness at intervals. To discontinue the application of the warm water-bag, and to apply ice continually in lower dorsal and lumbar region only. 4 p.m. (Mr. Bencraft's report) . — " Sickness lessened; bowels moved twice. Still restless and complaining of pain in the stomach." Mr. Bencraft, who kindly promised to keep a record of the further progress of this patient after I left Southampton, subsequently informed me that she improved steadily and completely recovered. Comment. — As this patient has a weak chest, it was necessary to watch carefully the effects of the ice, and to apply it as symptoms suggested. Hence it was that although she had been much troubled with both sickness and vomiting during the night of the 7th, I next morning restricted the ice to the lumbar region, and ordered heat to be applied between the scapulae. It seems to me not improbable that in the preternaturally sensitive and excitable state of the bowels the dead worm which she passed caused the purging to recur. In this case, again, the warm water-bag not only relieved the chest, but speedily induced sleep. I must insist emphatically, however, that heat can only be thus used advantageously in cholera cases when great care is exercised, both in respect to the length of time it is applied and to the temperature of the water used, as heat, even between the scapulae, tends to prolong the sickness. Case V. — Mr. 8., a strong man, accustomed to work at the Docks, was attacked on the morning of October Bth, 1865. I saw him with Mr. Bencraft in the evening of the same day, when he complained of incessant vomiting, purging, and cramps, and evinced great anxiety and distress ; but though the skin was rather cool, it was not cold ; and as therefore no marked algide symptoms were developed, the case was not thought to exhibit the characteristic symptoms of cholera in a form so decided as to be a desirable one for testing the efficacy of my method of treatment. He was therefore treated by medicine only. October 9th, 11 a.m. — I was again requested to see the patient, the algide symptoms being now very marked. Indeed all the characteristic evidences of cholera were present; but just before I reached the patient, Dr. Lake had applied an Ice-bag along the spine. I did not see this patient again. Dr. Bullar, however, who called upon me the same day just as I was leaving Southampton, informed me that by twelve o'clock a favourable change in the patient was observable, and that he was already becoming warm ; 39 DIARRHOEA AND CHOLERA: and I have since received a note from Mr. Bencraft, dated 9 p.m. the same evening, in which he says : — " B. is much better, warm all over, a capital pulse, but still sick ; no cramps." He quite recovered. Case VI. — Mrs. T, act. forty-two; first seen October 4th, 11.30 a.m., 1865. Has been suffering from diarrhoea for several days. On the 29th ult. she suffered much from cramps. Yesterday she was very ill with diarrhoea, and this morning her bowels have been moved six or seven times. There is no faecal matter in the stools, which are wholly of the "rice-water" type. Complains of giddiness and deafness. Skin generally cool; legs and feet cold. Ice was applied at once. 3 p.m. — Feels better, and has had but one motion. 7.30 p.m. — Has felt inclined to be sick, but was not so. Had two motions, but no longer of the " rice-water" kind. Has eaten fish, and kept it. To continue the ice. 11 p.m. — Head and upper extremities very warm ; lower extremities cool ; pulse 80, intermittent. Has vomited once, provoked to do so by medicine prescribed before I saw her, and which I did not intend her to take. Had one motion. To apply ice in the two lower segments of the bag only. October sth, 8.30 a.m. — Is warm all over except the feet. Pulse 80, intermittent. Has not been sick : bowels moved three times, but the stools more substantial ; feels weak ; is taking ground rice boiled in water, grapes, and preserve. To apply ice every four hours until the ice melts on lower third of spine only. 6th and 7th. — This patient progressed satisfactorily, but during the night of the 7th no ice was used, and early the next morning she was purged three or four times. Bth, 12 a.m. — Has eaten an egg and had some milk; is fairly warm all over; no cramps, and the last stool recently passed is semi-solid. To continue ice, as last ordered, three times a day, and at two o'clock in the morning. B> Ferri et quinae citratis, gr. v, ter die. 9th, 9.30 a.m. — Has had a considerable amount of sleep, but about 2 a.m., before ice was applied as ordered, the patient was violently sick, and purged several times ; no cramps ; skin nicely warm ; pulse 80 ; tongue thickly coated in parts, and beefy-red in others. Has had an egg and half a pint of new milk this morning. To continue the ice along the lower half of spine, and to take a saline mixture. 4 p.m. — Patient feels much better, and is in good spirits, both she and her husband believing that she will soon be well. Having given such general directions as I thought desirable, I took my final leave. She completely recovered. Comment. — The experience in this case again justifies the belief that the liability to relapse is greatest shortly after midnight, and that it is especially necessary to take precautions to avert this result by applying ice immediately after midnight, at all events until the patient is fairly out of danger. The more cholera is studied, the more it will be found, I believe, that the violence of the disease is 40 CASES OF CHOLERA. exhibited in different patients in different parts of the body : in one the skin exhibits the most marked symptoms, in another the voluntary muscles, in another the stomach, in another the bowels ; and in hot climates the head is often so suddenly and powerfully affected as to result in death from coma almost immediately after the attack. The patient whose case has just been described has been a long sufferer from deficient and painful menstruation, and from coldness of the feet — facts which denote that the lower half of the nervous centres along the back have long been in a state of chronic congestion. Hence it was to be expected, as experience has proved, that the choleraic attack would chiefly expend itself on the bowels and lower half of the body. For the first time during a long period the feet of this patient have become permanently warm. Case VII. — This case is described in the following letter which I received at the end of July, 1866 : — " Calcutta, March 4th, 1866. " Sir, — In the Times newspaper of the 11th October, 1865, I read an article bearing your signature on the subject of cholera, and its cure by ice. As lam in the habit of making notes, or preserving articles, that may possibly turn out useful some day or another, I cut out the article and inserted it among a number of other curious contributions to the press : at the time I little thought that it would turn out useful. I have a house in the country about fourteen miles from Calcutta, at a place called Tetaglun, close to the military cantonment of Barrackpore. On Sunday, the 25th February, I had a number of bullock carts coming from Calcutta ; and finding that all had not arrived, I made inquiries and learnt that some had not arrived by reason of one of the cartmen having been attacked by cholera, but that some of the other cartmen had gone back to bring him on. At 10.30 the man arrived, and a worse case of cholera I have never seen — incessant vomiting and purging — in fact, the latter was flowing from him. The pulse was scarcely perceptible, and the legs and arms quite cold. Voice almost entirely gone. Medicine I had none. I had forgot to bring with me my small medicine chest which I generally carry. I sent one of my servants round to my neighbours for medicine, but did not succeed in getting any. At last I recollected your article on the subject of ice, and managed to procure some. At 11 a.m. I put a bag of ice on his spine from between the shoulder blades right down to the bottom. I used the leg of a pair of flannel trousers for a bag. The man was in great agony, and appeared to be sinking fast. I was determined, to the best of my ability, to give the ice a fair chance ; so I sat on the ground by the patient and did everything myself. I had not had the ice on the man half an hour when I could perceive a change for the better. I asked the man whether he felt easier, and in a whisper he said yes. The cramps began to lessen visibly, and the involuntary purging to stop. He never 41 i DIARRHOEA AND CHOLERA: vomited once from the time I applied the ice. After the ice had been on about an hour I found that the melting of the ice had made the cold a wet cold; and one of my natives suggested that I had better put the ice into a preserved fruit bottle, which I did, and dried the spine before I applied it. As I found the vomiting and purging had ceased, I put the bottle lower down the spine. I was much surprised about half-past twelve to find the pulse gradually getting stronger, and the legs and arms gradually warmer. I put my hand under the man's arm-pits and found a slight warm moisture. This warmth went on increasing until at half-past one his body, except where the ice was, became hot, as in fever. On this, at 1.30, I removed the ice from the man's back; and as I had to go away, I left orders with a trustworthy native, that in case the fever increased, he was to put a hot-water bottle between the shoulder blades. I returned again at 4.30 and found the man asleep, and a more ghastly object I never saw. A little before six he awoke, and I gave him about a pint and a half of congee, with a good wineglass of brandy in it, and well sweetened. This he drank with avidity ; and having passed water, he fell asleep again almost immediately. At daybreak next morning I went to see my patient, and, to my surprise, I found him sitting up and smoking the everlasting hookah, which, rightly or wrongly, I took away from him, and made my servants make him a good mess of chicken broth, which he speedily demolished. About 9 a.m., as he was recovering fast, I questioned him as to his feelings on the day previous. He said he felt as if he was carrying three mounds (a weight equivalent to 240 pounds) on his back, and that he felt a burning pain in his stomach. That soon after he had the ice upon him, he felt his stomach getting cool, and the weight on his back became only two mounds, and that gradually the weight became less and less, until it disappeared altogether. The above are the facts, and you may use them as you like. My letter will show I am not a medical man. I am a lawyer, and have had an experience in India of nearly forty years off and on. I have seen many, many cases of cholera, and many cures, and more deaths, but I never saw a case, apparently so hopeless, cured so easily. The natives around me attributed the cure to Jadoo, or the evil spirit, and in that idea I have let them remain. In the evening of the following day the man's relatives all came from Calcutta to bury him, as they thought. He was taken away alive, but almost convalescent. I have sent the particulars of the case to the local journals, in which it has been inserted. As you ask medical men to publish the results of their experience, I send to you, as the discoverer of what seems likely to be one of the greatest discoveries of the age, the results of my experience, with permission to you to make what use of it you think fit. Allow me to remain, yours very obediently, " A. T. T. Peterson. " Dr. John Chapman, " 25, Somerset-street, Portman-square." 42 CASES OF CHOLERA. On Friday, July 10th, 1866, 1 received a telegram from Mr. Bencraft, Surgeon, of Southampton, as follows: "Plenty of cholera; using ice. Will you come down ?" I started for Southampton the next day ; passed a week there among cholera patients ; was allowed to treat several of them ; and obtained notes of all who had been treated either in the ordinary way or by means of ice by the four medical men who have either used ice or have requested me to apply it to their patients. Of the following cases, Cases VIII. to XI. inclusive, were under the care of Mr. Bencraft. Case VIII. — Kate Legget, act. seven, became ill on the night of July 13th, 1866, and was first seen by Mr. B. at 9 a.m. on the 14th, when she had all the symptoms of cholera, and was quite pulseless. Ice was applied continuously, and reaction was perfectly established by 2 p.m. of the same clay ; a good pulse having returned, she continued to do well, and quite recovered. Case IX. — Mary Ann Gregory, act. twelve, was attacked July 12th, 1866, at 11 p.m., with vomiting and purging, and cramps in the legs, which continued to increase, and in the afternoon of the 13th she was collapsed and livid. The Spinal Ice-bag was applied at 1.30 P.M., the cramps and vomiting speedily ceased, and by 5 a.m. of July 14th the purging had ceased also. The ice was continued uninterruptedly till I saw her in the evening of this day. She was then warm all over, had a good pulse, and was seemingly out of danger. I advised that the ice should now be applied at intervals, and that ice should be given internally. July 15th. — Continues to improve; the Spinal Ice-bag was applied once this morning. Finding the head hot, I ordered warmth to the cervical region, the use of the Ice-bag being discontinued. This patient steadily recovered. Case X. — Emily Eliza Gregory, act. seven, sister of the above (under care of Mr. Bencraft, treated by me), was attacked July 16th, 1866, at 2 A.m. with vomiting, purging, and cramps; became collapsed and quite pulseless. Ice was applied for the first time at 10 a.m., and was continued uninterruptedly until 4 p.m., when the countenance had become much less choleraic, and the vomiting, purging, and cramps were already greatly subdued. I then recommended the application of ice in the lowest cell of the ice-bag, and in the middle one up to the top. Warmth was simultaneously applied to the extremities in this as well as in the preceding case. From this date the child continued to improve, and is doing well. Case XL — Mrs. Witt, act. sixty-three (under care of Mr. Bencraft, and treated by me). After suffering from diarrhoea for some days, while assisting to nurse the children just named, she was attacked with cholera. She entered the room when I was there, suddenly sank down, uttered an exclamation, became deathly pale, strikingly cold, the lips turning livid, and the sweat exuding in large drops 43 DIARRHOEA AND CHOLERA: over her face and upper extremities. I found her quite pulseless, her head being cold. She was carried to her own house, when it appeared there had been a discharge from her bowels as she sat. I applied the Spinal Ice-bag immediately along the whole spine, and in about five minutes afterwards her pulse became distinctly perceptible, slight colour returned to her face, and in a few minutes more she said, " I am better." Ice to the spine and heat to the extremities were continued at intervals for some days. She steadily improved, and was out of danger when I left Southampton. On several occasions, when for want of ice in the house none was applied to the spine, vomiting and purging returned, to be again subdued when the Spinal Ice-bag was reapplied. Cases XII. to XIX., inclusive, were under the care of Dr. Griffin. Case XII. — Mary Goodwin, set. nineteen, was attacked July 12th, 1866, became collapsed and nearly pulseless. The attendant of this patient having procured ice, but having no Ice-bag, placed lumps of ice in a row, supported on each side by sawdust, and then caused the patient so to lie upon it that the ice came in contact with her along her spine. An Ice-bag was subsequently applied two or three days. The patient completely recovered. Case XIII. — Charles Adams, act. seven, attacked July 12th, 1866, became completely collapsed; had the Spinal Ice-bag applied " off and on" during two days, and quite recovered. Case XIV. — Mrs. Peters, act. twenty-four, was attacked July 15th, 1866. Had all the symptoms of cholera. The Spinal Ice-bag was applied at intervals during many days. She was quite rescued from collapse, had no consecutive fever, but miscarried. She was slowly recovering when I left Southampton.* Case XV. — A girl, named Feltham, act. six, was attacked July 19th, 1866. She became collapsed, in a slight degree however, and continued to have a slight pulse. Under the use of the Spinal Icebag she was recovering when I left Southampton. Case XVI. — Mr. Willis, act. fifty-six, was attacked July 18th, 1866; became collapsed, his pulse, however, continuing perceptible. He was treated by means of the Spinal Ice-bag, and was recovering when I left Southampton. Case XVII. — Penny, a girl, age about twelve, attacked July 18th, 1866, became collapsed, but continued to have a slight pulse; she was first treated by Dr. Griffin, who applied ice to her spine, and subsequently she came under my care. She was recovering when I left Southampton. Case XVIII. — A patient of the name of Fielder, of whose age or sex I have no note, was attacked July 19th, 1866, in much the same * After I left Southampton this woman had a relapse, and finally sank. 44 CASES OF CHOLERA. manner as the patient last mentioned, was treated in the same way, and was also recovering when I left Southampton. Case XIX. — George Thorn, act. eleven, was attacked July 15th, 1866, with very profuse vomiting and purging (rice-water stools) and violent cramps. Ice was applied to his spine during the whole day of July 16th, and at night all active symptoms had subsided. On the 19th, he was up again and at play. Cask XX. — (Under the care of Dr. Oliver, treated by me). Mrs. E. Allan, age about fifty, has suffered during six or seven days from diarrhoea and vomiting, and many times from cramp; was admitted into Anspach House in a state of collapse, July 19th, 1866, 5.30 p.m.; was vomiting constantly, very cold, pulse just perceptible. I applied ice at once along the whole spine, and heat to the lower extremities : no heat was applied to the upper extremities, there being no suitable means of doing so at hand. In the course of a few hours her skin improved, she became warmer, especially in the lower half of the body, her pulse became stronger, and when I last saw her, in the morning of July 21st, the purging and vomiting, according to the statement of the nurse, had subsided. Ice was applied to this patient from 5.30 p.m. of the 19th until about 7 p.m. of the 20th.* Case XXl.— (Under the care of Dr. Oliver), July, 1866. Agirl, named Maguire, about ten years old, had been suffering for some days from cholerine; she was treated successively by astringents, calomel, and arsenic, each of which failed to arrest the vomiting. She was therefore placed under my care. I treated her by means of ice along the spine, by which the vomiting was speedily and completely subdued. The girl was steadily regaining her appetite and strength when I left Southampton. Case XXII. — (Under the care of Dr. Cheeseman.) Eliza Randell, attacked July 16th, 1866, with cramps, vomiting, purging, and partial collapse. Dr. Cheeseman gave her a grain of calomel every half hour and ice internally : the cramps were relieved, and the purging lessened, but the vomiting persisted. She was then treated by dilute sulphuric acid, which was also powerless to arrest the vomiting. She was therefore sent to Anspach House and placed under my care; in the evening of July 17th one bag of ice was applied along her spine, she vomited once, but expressed herself as immensely relieved and comforted by the application. She begged to have another bag during the night, which, however, the nurse did not supply. She rallied rapidly notwithstanding, and ascribed the beginning of her improvement to the use of the ice. The next morning Dr. Cheeseman found her much better, and then saying * I have been informed that after I left Southampton ice was no longer applied to this patient, that she was then treated by hypodermic injections, and died shortly afterwards. 45 DIARRHOEA AND CHOLERA: she was scarcely a fair case to test the efficacy of the ice, resumed her treatment by means of stimulant salines. Case XXIII. — This case was under the care of Dr. Griffin of Southampton. I received no detailed account of it, and know of it only by means of a letter from Mr. Bencraft, who informed me that Dr. Griffin had " one bad case" of cholera, treated by ice, " that recovered." Case XXIV. — This case of obstinate suppression of urine during choleraic reaction resulting in uraemia and delirium, was treated by Dr. Allen of Brighton, who kindly supplied me with the following report. Mr. X., of Brighton, was attacked in December, 1866, with violent diarrhoea, vomiting, and cramps in the stomach and limbs, attended with intense pain. As the disease advanced the evacuations assumed completely the " rice water " character distinctive of cholera. The eyes were sunken, the complexion and general surface of the body became dark, the fingers and nails were purple; the pulse was so weak as to be almost imperceptible ; there was total suppression of urine, and intense thirst. In short there were, as Dr. Allen said, all the symptoms of " Asiatic" cholera. During the administration of opium and stimulants which he prescribed, all the symptoms, except that of the arrest of the urinary secretion, began to subside at the end of the second day. Notwithstanding the use of diuretics of all kinds, the urine still continued suppressed at the end of a further period of fifty-two hours ; and this condition was followed by the usual phenomena of ureemic poisoning, including a urinous smell of the breath, hiccough, and delirium — making the case apparently hopeless. An ice-bag was then applied along the lower half of the spine, and was repeated from time to time. In half an hour after the first application the patient voided nearly half a pint of urine, loaded with albumen. Two hours afterwards he passed a pint, and during the next twenty-four hours considerably more than the usual quantity of urine, with a gradually decreasing quantity of albumen. From the time the ice was first applied, the patient began to improve, and he continued to do so steadily until he had completely recovered. Probably some of my professional readers, who may compare the number of the foregoing cases of recovery from cholera with the number of the following fatal cases, will be of opinion that inasmuch as many sufferers from cholera recover, even when not subjected to any treatment at all, these recoveries, after treatment by means of the Spinal Ice-bag, constitute no reliable proof that they were consequences of, or due to that treatment. I think, however, that when, as at page 55, the number of fatal cases of complete choleraic collapse treated by my method is compared with the number treated by other methods at the same time and places, the fact that most of those recoveries, 46 THERAPEUTICAL CAUSE AND EFFECTS. at all events, were consequences of the treatment adopted, becomes convincingly evident. Nevertheless, bearing in mind that, as yet, the total number of cases in which my treatment has been tried is small, I consider that the evidence of its value consists less in the proportion of recoveries following that treatment (although that proportion was considerably greater than the proportion of recoveries following other modes of treatment at the same time and place) than in the numerous physiological and therapeutical facts repeatedly observed by myself and others during the practice in question — facts which prove, beyond the possibility of dispute, that in numerous cases the disappearance of the leading s}^mptoms of cholera followed so rapidly the application of the Spinal Ice-bag as to preclude the possibility of doubting the existence of a causal relation between its action and the abolition of those symptoms. Now if such a relation did actually exist, the fact of its existence is of paramount importance; I shall therefore revert here to the most striking of those observations from which the existence of that causal relation was inferred. Case I. — The patient, " agonized with cramps," suffering from extreme dyspnoea, and extremely anxious and restless, was laid on a Spinal Ice-bag, " and within jive minutes she was in a placid sleep." Case II. — Before treatment cramps were occurring continually ; the patient " had not had five minutes sleep at a time for them." She was purged " every ten minutes, or oftener." Her skin was cool; her head decidedly cold. The Spinal Ice-bag was first applied at 11.45 a.m. She was immediately soothed. At 2.45 p.m. the cramps were reported to be much lessened, and during the three hours' interval the bowels had been moved but twice. Before 7.15 p.m. of the same day the cramps had wholly vanished, and she had become " very comfortably warm all over." Case 111. — At 4 p.m. the patient was in complete collapse : " lips blue ; whole surface of body cold ; cramps violent ; rice-water purging, and vomiting." The Spinal Ice-bag was then ordered to be applied continuously. In six hours afterwards, when she was next visited, she was " decidedly improved ; markedly warmer ;" the "cramps and sickness much lessened; the cramps only recurred when the ice had melted and the Spinal lee-bag had become warm." Tho next morning the lips were red ; the whole surface of the body was quite warm ; the cramps had recurred only once ; and again only when the bag had been alloioed to become warm. Bowels moved but three times in the twelve hours ; vomited only once. Case IV. — At midnight the girl was in complete collapse ; " ricewater stools; purging and vomiting almost incessant; very cold all over, tongue especially so ; pulse almost wholly imperceptible ; very bad cramps ; countenance deathlike." Treatment was begun immediately. At nine o'clock the next morning the faeces, which 47 DIARRHOEA AND CHOLERA. though still passed under her, had a distinct faecal smell ; she had vomited but once; was warm all over; the pulse was very distinct, 116; there were no cramps at all; and her countenance was " immensely improved." Case V. — At 11 a.m. the mau presented all the symptoms characteristic of choleraic collapse. A Spinal Ice-bag was then applied : within an hour " a favourable change in him was observable ;" he was already becoming warm ; and at 9 p.m. of the same day, though still sick, he was "much better; warm all over; a capital pulse ; no cramps." Case VII. — "A worse case of cholera," says the reporter, Mr. Peterson, who had seen many in India (where this occurred) he had "never seen." At 11 a.m. the man was suffering from "incessant vomiting and purging;" his extremities were "quite cold;" his pulse was " scarcely perceptible ;" his voice " almost entirely gone ;" he " was in great agony, and appeared to be sinking fast." Ice was applied along the spine, and within half an hour " I could perceive," says Mr. Peterson, a " change for the better. The cramps began to lessen visibly, and the involuntary purging to stop. He never vomited once after I applied the ice. I was much surprised about half-past twelve to find the pulse gradually getting stronger, and the legs and arms warmer. The warmth went on increasing until, at half-past one, his body, except where the ice was, became hot, as in fever." Case VIII. — At 9 a.m., the girl was completely collapsed, and was quite pulseless : the Spinal Ice-bag was applied continuously, and by 2 p.m. of the same day, reaction was perfectly established — ¦ "a good pulse" being observable. Case IX. — At 1.30 p.m. the girl was suffering from vomiting, purging, and cramps, and was collapsed and livid. The Spinal Ice-bag was applied continuously — "the cramps and vomiting speedily ceased." By 5 a.m. the next day the purging had also ceased, and on the same evening she had " a good pulse," and was " warm all over." Case X. — At 10 a.m. the girl was suffering from vomiting, purging, and cramps ; was quite collapsed, and quite pulseless. The Spinal Ice-bag was applied at that time, and continuously until 4 P.M., " when the countenance had become much less choleraic, and the vomiting, purging, and cramps were already greatly subdued." Case XL — The woman was attacked suddenly in my presence. She became deathly pale, strikingly cold, the lips turning livid, and the sweat exuding in large drops over her face and upper extremities. Her head was cold, and she was quite pulseless. In about flve minutes after the Spinal Ice-bag was applied, " her pulse became distinctly perceptible, slight colour returned to her face, and in a few minutes more she said — ' lam better.' " Case XXIV. — " Was apparently hopeless." The man was deli- 48 THERAPEUTICAL CAUSE AND EFFECTS. rious owing to uraemic poisoning caused by the prolonged arrest of the urinary secretion. Within half an hour of the first application of the Spinal Ice-bag the patient voided nearly half a pint of urine, and, beginning at once to improve, continued to do so steadily until he had completely recovered. The other cases of recovery given above are not reported with sufficient fulness to permit of detailed analysis ; but so far as their histories extend, the facts they record do but confirm the evidence furnished by the preceding analyses — evidence which proves decisively that the " rice-water" vomiting and purging, the cramps, the deathly coldness, the voicelessness, and even the pulselessness which constitute the chief elements of choleraic collapse, are each and all capable of being rapidly and completely remedied by means of the treatment in question. Besides the above cases, the Spinal Ice-bag has been used in the following cases which proved fatal. But in all these cases the treatment was so partial and inadequate as to have constituted in no just acceptation of the term an exemplification of my therapeutical method, and therefore the result in each of them cannot rightly be regarded as a test of its value. The knowledge gained, however, from observing the effects of even such treatment as that actually adopted is especially valuable, and goes far to confirm the conviction which a review of the experience of the special effects of the treatment in the successful cases is likely to produce, as it seems to me, in the minds of impartial judges. Hence I think it expedient to advert to each of these cases seriatim. Case XXV. — Mrs. 8., act. forty-six, widow, residing in one of the very worst parts of Southampton, first seen by me October 3rd, 1865, at 9 p.m., when her medical attendant, Dr. Cheeseman, allowed me to treat her. At that time she was suffering from vomiting, purging, and cramps, which had invaded the chest as well as abdomen and extremities. The muscles of the extremities were hard, somewhat board-like, showing them to be in a state of tonic spasm. Chest, arms, and legs cold. No urine had been passed during the previous two days. At 9.50 p.m. I applied ice along the whole spine. At 9.55 p.m. the hard muscles had become soft and flaccid. This fact was also witnessed by Dr. Cheeseman. At 10 p.m. she fell asleep, and, excepting an interval of ten or fifteen minutes, slept an hour and a half. October 4th, 1 a.m. — The upper part of the chest had become warm, and the extremities slightly warmer. Vomiting and purging lessened at 3 p.m. ; the purgiug ceased at 7 p.m. ; the patient had become warm all over, looked less distressed, and the cramps had almost wholly ceased to trouble her. October sth. — Bowels not moved since 3 p.m. yesterday, and the skin is warm all over. Although the algide symptoms of this patient were completely overcome, and the diarrhoea had wholly ceased, and although the last stools which were passed were quite of a faecal character, and of E 49 DIARRHOEA AND CHOLERA : considerable consistence, she ceased to improve, and finally sank in the evening of October 7th. Comment. — This patient was an habitual drunkard, is said to have lived on drink during the week preceding her attack, obtained gin early in the morning of the sth, 6th, and 7th, and during the whole of the 7th, until about 7 p.m., was destitute of food, or the means of getting beef-tea, fuel, and ice. On the evenings of the sth and 6th, I supplied a small sum, directing beef-tea to be purchased, but I fear that my little help was converted into gin. The nurse, who had been up several nights with her, whose apparently unremunerated devotion to her was a mystery to me, and who no doubt was wholly exhausted, was found by a physician lying drunk by the side of the patient. Of course, as there were no means of treatment in the house on the 7th, I avoided visiting the house until evening, when I found the patient in a dying state. Before my treatment began, the patient had had opium and calomel ; forty grains of the latter. Any medical man studying the history of this case in a judicial spirit will acknowledge that the rapid change of the muscles from a condition of rigidity to that of flaccidity ; the arrest of the cramps and purging, and the re-establishment of natural warmth throughout the body, are remarkable facts which attest in a striking manner the greatness of the therapeutical power employed. But even with the use of that power, the chances of saving such a patient as the one in question, and especially under the circumstances described, were of course very small indeed. Case XXVL— October 6th, 1865, 10 a.m.— Mrs. D., set. seventythree, was attacked last night with vomiting and purging,and "fearful coldness and cramps," and continued in that state until I saw her, when I ordered ice along the spine. October 7th, 9.30 a.m. — Has had five bags of ice since treatment began ; is warm all over ; expression improved ; has a little headache ; has a little pain about the bowels, but no cramp ; bowels moved only three times since 7 p.m. yesterday, and has not been sick at all. Has had some beef-tea. October 9th. — No return of the algide symptoms, but extreme exhaustion, and she sank in the course of the &a,y. Comment. — There is a sewer-grate close to the door of the patient's house, and. the husband informed me that a short time since, when the stench from it was worse than usual, she said, "That sewer will kill me." A lady friend, who had taken an interest in them for years, told me that they had often been without food, and that frequently when Mrs. D. had visited her, and was given something to eat, she stealthily divided it, in order to take the half to her husband. It is obvious that her aged frame, already suffering from inadequate nourishment, had been too much shaken by the violence of the attack to live through the reaction following it ; and her chance of surviving was probably lessened by the effluvium from the sewer-grate near her door. 50 CASES OF CHOLERA. Cases XXVII. and XXVIII. were under the care of Dr. Griffin, in October, 1865, at Freemantle, near Southampton. He informed me that both patients were recovered from collapse; but that in consequence of their distance from him the application of the ice was in both cases continued too long. He also expressed his opinion that if they could have had adequate attention the result might have been different. Case XXIX.— Mr. Cooper, late Medical Officer of Health at Southampton, who was one of the victims of cholera during the epidemic of 1865, I never attended at all, and was not consulted concerning him. In respect to the treatment of him I received from a medical witness of it the following statement : — " He was prejudiced against the ice strongly. Ice-bags were certainly applied to him, but he would not allow that or any other treatment to be persevered in. I saw him, and I believe that if ice had been properly applied his life would have been saved." Case XXX. — Caroline Powell, act. thirty-seven, attacked July 13th, 1866, very early in the morning, and died July 14th, about 5 p.m.: ice was applied to the spine about 10 a.m. July 13th, and the application was continued until about 3.30 p.m. the next day. Mr. Bencraft said he was careful to have the ice properly applied ; Dr. Wiblin, however, informed me that he saw the patient, and found that the ice had slipped away from the spine. And although an essential part of my treatment consists in the persistent application of heat along the extremities and over the general surface of the body, heat was not applied at all. Nevertheless, according to the statements of Mr. Bencraft, Dr. Wiblin, and Dr. MacCormack, the patient rallied, considerably during the first jive hours of the application of the ice. She became warmer, and meanwhile her cramps, purging, and vomiting completely subsided, and did not recur. I believe that if all my published directions had been complied with this woman's life might have been saved. Case XXXI. — Una Sophia Gregory, act. ten, attacked July 13th, 1866, at 3.30 A.m. Ice was applied at 1.30 p.m. continuously until the evening of the 14th, when she was seen by me for the first time. Reaction had then become established, conjoined with undue determination of blood to the head, which was hot. I advised discontinuance of the ice to the spine, the application of a small piece of muslin dipped in ice-water to the forehead, and such nourishment as could be taken. The cerebral symptoms continuing, I advised the application of heat (water at 115° in a Spinal Waiter-bag) to the upper third of the spine. I was most emphatic and circumstantial in cautioning the child's mother not to let the water used be too hot; to observe carefully the temperature of the forehead, and to remove the bag immediately she should find that the forehead began to become cool. Unfortunately, as she told me on the occasion of my next visit, the head became stone cold and the back very hot, when soon afterwards the child sank, It seems to me likely that in this B 2 51 DIARRHOEA AND CHOLERA : case if the heat of the water used had been regulated by a thermometer, and if the water had been applied judiciously, and had been withdrawn at the right moment, the child would have recovered. Case XXXII. — Mrs.Macey, act. sixty-seven, attacked July 13th, 1866. Ice was applied, but not kept along the spine, I found it on one side; and no heat was applied to the extremities. She died on the second day of treatment. Case XXXIII. — Shelly, a boy, act. thirteen, attacked July 13th, 1866, was also completely recovered from collapse, but lingered six days suffering from cerebral disorder. Shortly after recovering from collapse he passed a large round worm. It seems to me not improbable that the presence of worms in his intestines may both have predisposed him to suffer from cholera, and may have induced the persistence of cerebral complications which, in his weakened state, would not yield to treatment. Case XXXIV. — Julia Ann Hall, act. five, attacked July 14th, 1866, had ice applied only thirty minutes before her death. As Mr. Bencraft observed, she was already moribund. Case XXXV. — Martha Kerby, act. twenty-four, whose child died of cholera, and was buried July 14th, 1866, was attacked the same night. I saw her for the first time at 10.30 a.m. July 15th, when she was completely collapsed and pulseless. Had continuous cramps and the usual evacuations from the stomach and bowels. She presented the choleraic countenance in a striking degree; the face, legs, and arms markedly livid ; the calves of the legs were very tender on being touched ; the skin generally was cold and bedewed with the usual clammy sweat; and she was extremely restless and anxious. I began to treat her at once. At 12 a.m., or within less than an hour and a half, the skin became drier, its lividity had lessened, the feet had become warmer ; she had had no movement of the bowels, and had vomited but once. Pulse still imperceptible. The Ice-bag being still cold I left her, and promised to return in half an hour. 2 p.m. — Being detained by other patients I could not return to her till now. The Ice-bag had become warm, and her vomiting, diarrhoea, and cramps consequently returned. lat once applied ice again, enjoined the application of heat to the limbs, and left her. 5 p.m. — Has vomited two or three times ; the bowels have been opened once (rice-water stool), and the cramps still continue slightly ; the head is warm, upper extremities moderately cold ; lower extremities warm down to the ankles, feet cold ; she is on the whole decidedly better than at two o'clock, but she is still pulseless. I ordered the ice to be applied in the lower cell of the Ice-bag, and in the middle one filled to the top. Iced water and iced beef-tea ad libitum, warm water-bags to extremities. 11.30 p.m. — 'Cramps, vomiting, and purging have ceased, and she has kept a cup of tea as well as beef-tea ; but she is pulseless, or, as Mr. Bencraft thinks, has a slight flickering pulse ; treatment to be continued. 52 CASES OF CHOLERA. July 16th, 10 a.m. — Has had no ice on since 1 or 2 a.m. ; and all bad symptoms have returned, the skin having become clammy and colder, with cramps, vomiting, and purging as before. Ice to be reapplied as soon as obtainable. 1 p.m. — Is again much better, and has retained tea and beef- tea, as she did last night, under the influence of the ice. Comment. — The foregoing notes were written immediately after each visit ; and the facts they record prove, beyond the possibility of a doubt, that in this case the disease, which was of an extremely severe type, was amenable in a wonderful degree to the treatment adopted, although it was very imperfectly carried out. I believe I am correct in saying that on every occasion when I called, except at 12 a.m., July 15th, I had to deplore gross neglect in some form : generally the ice in the bag was melted, and the bag had become warm ; at one time there was no ice in the house ; at another the bag was on one side instead of along the spine ; and always the heat ordered to the extremities was applied only partially, or not at all. The woman lay in a small crowded room on dirty things, her clothes and bed being saturated with her evacuations. In the afternoon of July 16th a house for the reception of cholera patients had been prepared, and my hope of saving her was much strengthened by the expectation of removing her thither. I was disappointed : her mother, partially blind and paralytic and powerless to help her, would not consent to her removal. Discouraged by this woman's obstinate folly, I felt it useless to work against such odds; and from that time neglected the case, of which I took no further notes. In looking back upon it, lam sorry I did so ; for the facts I have recorded justify my belief that even under the adverse circumstances mentioned I could have saved her had I persevered. Case XXXVI. — Caroline Seaman, act. thirty-eight, attacked July 16th, 1866, after extreme exhaustion, consequent on nursing her son Shelly, named above. I only saw her once after her attack ; it was impossible to treat her properly, and she was ordered to be removed to Anspach House, but died just as the men arrived for her. Case XXXVIL— W. G. Tucker, act. nine, attacked July 16th, 1866. A spine-bag and ice were supplied; but the mother of the patient told me she could not keep it along the spine. Case XXXVIII. — Nathaniel Vine, act. sixty-three, attacked July 16th, 1866. The first time the Spinal Ice-bag was applied the mouth of it was not properly fastened, and as quickly as the ice melted the shirt and bedding of the patient were drenched with iced-water. Only one bag of ice was afterwards used, and heat was only partially applied. He died the same night. Case XXXIX. — Mrs. Bishop, act. thirty-two, attacked July 17th, 1866. This was the most severe case of cholera I had seen. She was seen two hours after seizure with diarrhoea, and was regarded as a light case. Two hours afterwards she was in profound collapse, and in 53 DIARRHOEA AND CHOLERA : about two hours more ice was applied. Heat was partially applied to the extremities, and even in this case some slight reaction was obtained during three or four hours. She died the next day. Case XL. — Margaret Saxby, act. eight, attacked July 18th, 1866 (in the same house in which the previous case occurred), was drenched with iced-water in the same manner ; was allowed to lie in the cold wet clothes, and had no heat applied. Of course she died also. Case XLI. — Emily Leake, act. twenty-two, attacked July 19th, 1866, and after being in profound collapse for some hours, was removed to Anspach House. Ice was applied along the spine, and unfortunately two accidents occurred in succession : owing to the imperfect closure and leakage of the bag, two night-dresses, one after the other, were drenched with iced water, thus adding to her coldness, and making it necessary to add to her exhaustion by moving her twice to put a dry dress on. The ice having been ultimately applied properly, and heat having under my superintendence been carefully applied to the extremities, the patient rallied. I left her decidedly improved, and having enjoined careful attention to keep the heat well applied to the extremities, was full of hope of saving her. But owing to her extreme restlessness and tossing about it was impossible to keep the Spinal Ice-bag in its place without either the aid of an Ice-bag Jacket, which I did not possess, or the constant watchfulness of an attendant. Moreover, on returning to her in about two hours, I found her limbs uncovered, no heat in contact with them, and the collapse more profound than ever. Noting these difficulties, and anxious to save her by any possible means, I was tempted in an evil moment to give her a dose of dilute sulphuric acid, the efficacy of which about that time was much lauded : it seemed to exert a suffocative influence upon her ; her difficulty of breathing was visibly increased, and she died shortly afterwards. This was the first patient in choleraic collapse to whom I ever gave dilute sulphuric acid, and she will be the last. I now request the reader's attention to the following summary review of these fatal cases. In Case XX my treatment was discontinued, hypodermic injections being substituted. In Case XXV. death was evidently due partly to the constitutional condition induced by habitual drunkenness, and partly to the neglect described in the report ; perhaps also partly to the opium and calomel which had been given before my treatment began. In Case XXVL the great age of the patient (73), her inadequate nourishment before the attack, and the continuance of the sewer-grate close to her house, were so adverse to her recovery that it could scarcely be hoped for. Cases XXVII. and XXVIII. were probably lost because owing to their great distance from the physician having charge of them, the application of the Spinal Ice-bag was continued too long. Dr. Griffin evidently believed they might have been saved if they could have been properly treated. In 54 SUMMARY REVIEW OF RESULTS. Case XXIX. the patient, Mr. Cooper, would not allow the treatment by means of the Spinal lee-bag or any other treatment to be persevered in. In Case XXX. the treatment I recommend was only partially adopted ; no heat was applied to the surface of the body. In Case XXXI. the girl was, I believe, lost simply because, contrary to my urgent injunctions, her mother applied water of too high a temperature, and for too long a time, to the patient's spine. Case XXXII : the Spinal Ice-bag was not kept along the spine, and no heat was applied to the surface of the body and extremities. Case XXXIV : the patient was already moribund when the Spinal Icebag was applied. Case XXXV : the patient was neglected, and my directions were only partially complied with. There can be no doubt but that with due attention this woman would have been saved. Cases XXXVI. and XXXVIL cannot fairly be said to have been treated at all. Case XXXVIII : when the Spinal Ice-bag was first applied, its mouth was not properly fastened, and consequently the patient was drenched with iced-water — a grave misfortune. The bag was only refilled once, and heat was only partially applied. Case XL : this patient too was drenched with iced-water owing to inexperience in closing the Spinal Ice-bag ; she was allowed to lie in her cold wet clothes ; and no heat was applied. Case XLI. was peculiarly unfortunate : the Spinal Ice-bag was insufficiently closed on two separate occasions, and twice, therefore, the poor woman was drenched with iced-water. She also suffered from the exhaustion of twice changing her night-dress which had thus been wetted, and from the fatigue of the journey from her house to the temporary hospital to which she was taken. It is obvious from this review that Cases XX., XXIX., XXXIV., XXXVIIL, and XL. cannot be considered to have been treated by my method; and, in fact, the same remark is applicable to Cases XXXVIII. and XL. So that in estimating numerically the results of the treatment, 7 out of the 19 fatal cases must be dismissed from consideration. Now I have enumerated 41 cases in which the Spinal Ice-bag was used. Deducting from this number the 7 just mentioned, there remain 34. Of these 12 proved fatal, and 22, or sixty-five per cent., recovered. The proportion of recoveries after ordinary treatment at Southampton was very much smaller; in 1865 it was thirty-eight per cent. ; and in 1866, up to July 31st, 42 out of 130 patients, or only thirty- three per cent., recovered. Moreover, impartial judges would not I think allow that in any of the remaining 12 fatal cases my method was fairly tried. In Case XIV. the patient, who had been seduced, concealed her pregnancy ; if she had not done so, her miscarriage and death might probably have been averted. Cases XXVII. and XXVIII., at Freemantle, under the care of Dr. Griffin, in which the application of the Spinal Ice-bag was continued too long after the patients had been recovered from collapse, and Case XXXI. in which, after the patient had so been recovered 55 DIARRHOEA AND CHOLERA: from collapse, she was lost by her mother's neglect of my instructions respecting the use of the Spinal Water-bag, proved fatal, not by any fault of the method, but because it was not rightly applied. In Case XXV., the habitual drunkard, and in Cases XXX., XXXIL, and XXXV., it was inadequately applied ; in Case XLL, it was not only inadequately applied, but the woman was twice drenched with iced-water, and, unfortunately, as I have said, was given dilute sulphuric acid ; and of Case XXXIX. I must remark that the woman when I first saw her was the most ghastly looking and seemingly moribund of any living person I ever saw. Cases XXVL and XXXIII. complete the list, and a glance at the reports of them will render further comment needless. In estimating the remedial power of the Spinal Ice-bag, it is especially necessary to bear in mind that of these fatal cases, XXV., XXVL, XXVII., XXVIIL, XXXL, XXXIIL, were completely recovered from collapse. In Case XXX. " the patient rallied considerably during the first five hours of the application of the ice. She became warmer, and meanwhile her cramps, purging,and vomiting completely subsided, and did not recur." In Case XXXV. the symptoms subsided, the patient becoming warm while the treatment was vigorously continued ; and even in Case XLL the patient rallied at one time sufficiently to assure me that she would recover. It thus appears that out of the eleven fatal cases which were actually treated — though in the very partial and unsatisfactory manner described — six were completely recovered from collapse, two others were recovered to a great extent, and another partially rallied. In the six cases completely recovered from collapse, and in the two recovered to a great extent, the vomiting, purging, and cramps were entirely arrested. In Case XXXV. these symptoms subsided while the ice was applied, returned when it had melted; again subsided when it was again applied, and again returned when it was melted ; and yet again they were subdued by a fresh application of ice. It would be difficult to imagine a more decisive proof of the controlling power of the Spinal Ice-bag over the characteristic symptoms of cholera. Of the whole 23 patients treated by Mr. Bencraft, at Southampton, in 1866, the only four who survived were treated by ice. Again, whereas the whole of the cases of complete collapse under the care of Dr. Griffin, and which were treated by drugs died, 4 out of 10 of those treated by the Spinal Ice-bag recovered. It is not an unreasonable presumption that inasmuch as those medical men at Southampton who applied ice to the spine, or who witnessed its application, were not using or observing the effects of a remedy originated by themselves, their judgment of its effects would be neither perverted nor obscured. Now shortly after I left that town in 1865, I received from Mr. Bencraft the following letters : — 56 OPINIONS OF MEDICAL MEN. Southampton, Oct. 20th, 1865. ' Dear Sir, — Having given Dr. Chapman's treatment of cholera, by applying ice to the spine, a trial in those cases of that disease which have fallen under my care during the past two or three weeks, I have much pleasure in testifying that it has appeared to me one well worthy of a fair trial. It proved itself a remedy of very considerable power ; restoring the heat, relieving the cramps, checking the vomiting and purging. Its use was followed by reaction from collapse, even in cases where the patient was quite pulseless. As with all other remedies of power it requires to be used with discretion, and not continued too long. This treatment appears to have the great advantage of producing reaction from the state of collapse, leaving the patient free from the very large quantities of medicines, which in other modes of cure so often fatally hamper the treatment of the secondary fever. Although my experience of it has not been large, and it has not succeeded in every case, yet I think it deserves a careful and extended trial. Your obedient servant, G. A. K. Lake, M.D., Surgeon to the Royal South Hants Infirmary, To Henry Bencraft, Esq. &c. &c. Marland House, Southampton, Oct. 28th, 1865. My dear Dr. Chapman, — I am very happy to bear testimony as to the use of your ice-bags in the treatment of cholera. The five cases in which I had the good fortune of witnessing their application by you, have sufficiently convinced me of their utility in rousing the patients from collapse, and removing the algide symptoms of cholera. Should I, unfortunately, have any more cases, I shall strictly adhere to your treatment, and conscientiously recommend the medical profession to give it a fair and impartial trial. Wishing you every success, and with best regards, I remain, ever yours truly, G. Cheeseman, Physician and District Med. Officer to the Southampton Incorporation. Southampton, 26th Oct. 1865. My dear Dk. Chapman, — I have been desirous of testing as fully as I possibly can the worth of your ice-bag treatment in cases of cholera ; this motive must plead my excuse for not writing to you before. I have now seen and treated, with Mr. Bencraft and Dr. Cheeseman, six cases of the disease in question, in the stage of collapse ; and what I have witnessed and noted in these cases, justifies me in stating that your treatment is superior to any that I have hitherto seen practised or pursued by myself or others. 57 DIARRHOEA AND CHOLERA : This fact is unexceptionable — indeed, uncontrovertible — that by all other methods, presumed or real, the cases have had a fatal termination. In two cases treated on your principles by Mr. Bencraft, the cures are complete. One treated in a similar way by Dr. Cheeseman is a great success. Based as your treatment is, on sound physiological principles, it deserves a fair and impartial trial ; but all your injunctions must be strictly carried out. The system of boiling patients in mustard and water is too puerile and brutal to do more than refer to it. Were I seized with cholera, I should give your mode of treatment a preference ; indeed, I would submit to no other. Yours sincerely, John Wiblin, Physician. Southampton, Oct. 28th, 1865. My dear Dr. Chapman, — It gives me great pleasure to be enabled to add my testimony to those you have already received from Southampton, in favour of the beneficial results attending the treatment of cholera by means of your ice-bag, applied to the spine. Its power to relieve the vomiting, purging, and cramps is almost marvellous ; and its influence over the circulation, in restoring heat to the surface of the body, and bringing back the pulse where nearly and in some cases entirely gone, must be seen in order to be properly appreciated. For my own part, I have such entire confidence in the method of treatment, that should any more cases of cholera come under my care I shall without hesitation trust to it alone ; and were Ito be attacked with cholera I would insist on being treated entirely by your method. I may state that a very large proportion of the cases treated by ice in Southampton have made perfect recoveries, whilst almost every case that has been treated by other means has proved fatal. With deep feelings of gratitude to you for having made me acquainted with your plan of treatment, I am, my dear Sir, very truly yours, Henry Bencrapt, M.R.C.S.E., L.S.A., Medical Officer to the Southampton Workhouse. Moreover when I left Southampton in July, 1866, Mr. Bencraft again expressed to me his conclusion concerning the treatment in question as follows : — "lf I ivere attacked with cholera I should still wish to be treated by ice ; but I should like to have it applied earlier 58 OPINIONS OF MEDICAL MEN. than seemed to me necessary last year" And Dr. Griffin's last words to me were, " Well, I don't see why suck a dead set is made against the ice; it stops cramps, vomiting, and purging ; it makes the patients warm, and it prolongs life." These two gentlemen, who had charge of nearly all the patients at Southampton treated by ice in 1866, made these remarks to me in the presence of a witness, and in the presence of each other. I presume therefore they carefully considered what they were about to say, and expressed their deliberate opinions on the subject. Now I ask, Is there within the range of professional knowledge any remedy for choleraic collapse except the treatment I have proposed, of which it can be truly said "it stops the cramps, vomiting, and purging, it makes the patients warm, and prolongs life ?" And I also ask, If it does these things, does it not achieve the very desiderata which a real remedy for cholera ought to achieve, and the power of achieving which has long been sought for ? — viz., the annihilation of the cardinal elements constituting the disease, " leaving the patient free" at the same time, as Dr. Lake justly observes, "from the very large quantities of medicines which in other modes of cure so often fatally hamper the treatment of the secondary fever ?" Moreover, having reviewed the results of the treatment which is the direct logical outcome of the pathological principles sketched in the first part of these pages, and having adduced the important evidence concerning these results from the several medical observers of them, whose names are given above, I appeal in conclusion to all competent and impartial judges in full confidence that they will confirm my assertion, that inasmuch as ice applied along the spine "stops the cramps, vomiting, and purging, makes the patients warm," and produces "reaction from collapse, even in cases where the patient was quite pulseless," its action constitutes a practical verification of the doctrine I have propounded — viz., that "the proximate cause of all the phenomena of cholera [before the stage of reaction] is hyperaemia, with consequent excessive action of the spinal cord and of the sympathetic nervous system." For what is the physiological action of ice ? It is powerfully sedative. Obviously therefore if the exertion of a powerfully sedative influence over the spinal cord and collateral ganglia of the sympathetic nerve abolishes the phenomena of cholera, it must do so by lessening the circulation of blood in, and, consequently, the energy of, those nervous centres. But if it does this in cases of cholera, then it follows that the essential condition precedent of recovery from the disease is diminution of circulation in and consequent energy of those nervous centres, and therefore that the proximate cause of the disease (however that cause may have been established) consists in " hyperaemia of the spinal cord and of the sympathetic nervous system." Perhaps to all non-professional and to a few professional readers 59 DIARRHOEA AND CHOLERA: of these pages the facts they record will suggest the question — " But if Dr. Chapman's account of these facts be correct, how is it that his doctrine and practice in respect both to diarrhoea and cholera have received only the slight recognition they seem to have done from the profession during the last five years ?" This question may, I think, be satisfactorily answered. In the first place it is notorious that the reception by mankind in general of new doctrines, however true, and of new practices, however valuable, is almost invariably a wondrously slow process. In the second place, professional bodies are pre-eminently conservative : the recognition of doctrines and practices revolutionary of what during his period of initiation each member learned at the cost of much money and great labour to regard as established wisdom, and what the heads of the profession still teach as such, is a task the performance of which implies the possession of an amount of intellectual humility with which few are gifted, and which, while always difficult, is not seldom very unpleasant. But in the case under consideration special influences have also operated to retard the spread of the doctrine and practice which I have introduced ; and on public grounds, I now feel it my duty to explain what those influences were. When I visited Southampton at the time cholera was prevalent there, in 1865, I presented a letter of introduction from a nonprofessional gentleman to Dr. Wiblin, who is one of the chief physicians of that town, and Medical Officer of the Port of Southampton as well as President of the South Hampshire Medico- Chirurgical Society. After listening to an explanation of my views concerning cholera, he requested me to partake of his hospitality, very kindly invited a considerable number of the members of the Medical Society over which he presided, to meet me, in order to hear an exposition of my notions ; and after I had delivered to them what I fear was a long lecture,* to which however they listened with exemplary patience, he invited the whole of us to an excellent supper. Thus my introduction to the medical circle of Southampton was the best possible, and facilities were immediately afforded me for the treatment of cases of cholera there. The result of that treatment and the impression it made on the medical men who witnessed it have already been described. It would be difficult for any one to express himself in terms of commendation stronger than those contained in the letter of Dr. Wiblin already given ; and that he thought it desirable to make the whole profession acquainted with the views expressed in the lecture given at his house is evident from the following passage, contained in a letter which he addressed to me, and which is dated 12th October, 1865 : — " Why don't you get the address published in a pamphlet, and make it a cheap, small, professional, and attractive contribution to cholera, * A report of this lecture was published in the Hampshire Telegraph. 60 THE REPORT FROM SOUTHAMPTON. dedicated to the President and Members of the South Hants Medico-Chirurgical Society ?" On Friday, July 10th, 1866, I received, as I have already said, a telegram from Mr. Bencraft of Southampton, as follows : "Plenty of cholera ; using ice. Will you come down ?" I went to Southampton the next day, and bearing in mind Dr. Wiblin's previous kindness to me, I of course called upon him without delay. He received me with marked coolness, and during my stay in Southampton at that time, whenever we accidentally met, his bearing towards me continued of the same markedly unfriendly character. A temporary hospital for cholera patients was established at " Anspach House," and a considerable number of patients were admitted into it, but I had only one opportunity of treating a case of cholera on the day collapse supervened in that hospital. Even in that case (XLL), I first visited the patient at her own house, and induced her myself to consent to go to the hospital. Of the other six cases sent to me there, three had been treated for some time by other methods without benefit, and one of these three after being rapidly benefited by means of the ice, was then placed under ordinary treatment again, lest, apparently, her recovery should be ascribed to its real cause. Two, if not three, patients were reserved for some time in a room, untreated by any method, in order to be treated by Dr. Wiblin, when he should come to the hospital, by means of hypodermic injections. Perceiving a decided indisposition to afford me opportunities for a fair trial of my method of treatment, and a resolve to treat the cases which might come into the hospital by means of hypodermic injections, I did not think it expedient to lose my time at Southampton ; and therefore after only a week's stay there I returned to London. But just before leaving I saw the Officer of Health of Southampton, Dr. MacCormack, whose duty it was to keep a record of all the cases of cholera at that town. By way of reply to my enumeration of the cases in which recovery had followed my treatment he exclaimed, " Recoveries ? There have been no recoveries !" I expressed my astonishment at his answer, assured him that he was mistaken, and that I would obtain for him an authentic statement from the medical men whose cases had been treated by means of ice. He then informed me that if I did so he should make no corrections in his register ! Mr. Bencraft and Dr. Griffin were known to be treating some cholera patients by means of ice, and Dr. MacCormack chose to assume that every case of cholera occurring in the practice of those gentlemen was treated by my method, and therefore alleged that every case of death from cholera which they reported was a case in which my method of treatment had been adopted. As a matter of fact, up to the 20th of July, Mr. Bencraft had reported 23 cases of cholera; of these 11 were not treated by ice at all, and they all died. And up to 61 DIARRHOEA AND CHOLERA: the same date Dr. Griffin had reported 35 cases ; of these, 22 cases were not treated by ice at all. Ten of these were cases of cholerine, 5 were cases of slight collapse, and 7 of complete collapse; those of the two first groups recovered, all of the last died. So that, in fact, 11 of Mr. Bencraft' s and 7 of Dr. Griffin's fatal cases are officially reported by Dr. MacCormack to have been treated by means of the Spinal Ice-bag ; whereas in no one of these cases had it been applied at all ! According to him, 31 deaths followed the treatment of cholera by ice in Southampton ; whereas, in truth, only 13 deaths had followed that treatment. And this erroneous record Dr. MacCormack consciously and deliberately refused to correct ! The manifest animus of this man concentrated into one focus the antagonistic influence of which I had become sensible during the week previous to my last interview with him; and, inferring the character of his motives from his expressed determination to keep unaltered his erroneous official report of the effects of my treatment, I was well prepared to appreciate the exclamation of Dr. Griffin, " Well, I don't see why such a dead set is made against the ice !" But unfortunately this " dead set " did not end with Dr. MacCormack's false entries in his register. The letter of the Southampton correspondent to the Lancet and to the Medical Times of August 4th, 1866, contains these words : " The ice-bag applications to the spine are now considered as a thing of the past; indeed unprejudiced observers think them worse than useless." Of course the publication of this sentence in these two influential professional journals operated as an effective discouragement of all medical men who read it and who might otherwise have resolved to try for themselves the efficacy of my treatment of diarrhoea and cholera. I believe all who are acquainted with the facts narrated above will be of opinion that no " unprejudiced observer " could have written the sentence just quoted. If the man who actually wrote to those journals had chosen to send an honest report he would, at all events, have reported the results of the experience gathered by Dr. Griffin and Mr. Bencraft, who treated twenty-four out of the whole twenty-eight cases which were treated in 1866 at Southampton; and who, besides being able to give an authentic statement of the number of recoveries and of deaths following the treatment in question, could have described the physiological action of the Spinal Ice-bag to have been such as to justify the expectation that an agent which even in unsuccessful cases " stops the cramps, vomiting, and purging, makes the patients warm, and prolongs life," may, when applied not only skilfully, carefully, and continuously, but together with the efficient application of heat uver the extremities and surface of the body, become capable of saving nearly every patient suffering from cholera to whom it is thus applied. 62 THE REPORT FROM SOUTHAMPTON. It may be said that possibly the correspondent of the Lancet and Medical Times derived his information from Dr. MacCormack, who, as already shown, recorded eighteen fatal cases to have been treated by ice, which, in fact, were not treated by ice at all. Possibly, and of course if the correspondent were thus misled, the blame is not attachable to him but to Dr. MacCormack, and in that case I could but deplore that an erroneous impression had been made on a person who unfortunately happened to have the power of diffusing far and wide the error he was impressed with, and thus of doing great mischief. I believe, however, that in the series of events in question Dr. MacCormack's false statistics were not a cause but a consequence, and that the correspondent was guided neither by observation nor statistics in framing his report. The character of the report was, I believe, sketched first, and was then shaded in to the required darkness by the friendly help of the Officer of Health. When in Southampton, in 1866, 1 was told that Dr. Wiblin was the correspondent in question ; and I know, from one of his own letters addressed to myself, that he was so in 1865. Now the reader has seen from Dr. Wiblin's letter, printed above at page 58, that at the end of the epidemic of 1865 he considered my treatment " superior to any " that he had " hitherto seen practised or pursued ;" that according to him " it is based on sound physiological principles," and that were he seized with cholera he would give that treatment " a preference ;" indeed, he " would submit to no other." The reader has also seen that at the very beginning of the epidemic of 1866, when complying with Mr. Bencraft's telegraphic invitation, I again visited Southampton, Dr. Wiblin received me coldly. From the end of the epidemic of 1865 to the beginning of the epidemic of 1866 there had been no cholera at Southampton : by what agency then could the judgment of an " unprejudiced observer" have become so completely reversed as Dr. Wiblin's judgment seems to have been during that interval ? It certainly could not have been further experience of my method of treatment, for he had had none, and, therefore, like the German professor mentioned by Mr. G. H. Lewes, he had had no other resource than to go into his study and generate "out of his moral consciousness" the new conviction which, at all events, was fully formed as early as July 11th, 1866. What motive tempted him to adopt this process I am unable to say. lam not really aware of having offended him in any way. I confess, however, with much regret, to an act of discourtesy towards him with which he might justly feel offended. His letter of October 12th, 1865, in which he says — " Why don't you get the address published in a pamphlet, and make it a cheap, small, professional and attractive contribution to cholera, dedicated to the President and Members of the South Hants Medico-Chirurgical Society ?" reached me, as he was aware, just as I was leaving London for Paris, and shared the fate which I fear befel many other letters addressed to me at that time : it was 63 DIARRHOEA AND CHOLERA. left unanswered. This sin of omission was certainly a grave one — the more especially after experiencing, as I had done, at his hands, the marked kindness I have already described. But grave as it was, I venture to think — though perhaps I have no right to be a judge in my own case — that it scarcely demanded the retribution I was made to pay. It has indeed been suggested to me that when the President of the South Hampshire Medico- Chirurgical Society invited me to deliver an address to that Society, and then paid me the compliment of requesting me to publish the address and to dedicate it to the President and Members, I was bound in courtesy to do so, and that he might justly resent my non-compliance with his request. This view may, I admit, be correct ; and, in this matter, I can only plead, by way of excuse, that although glad of the opportunity of explaining my ideas in an extempore address to Dr. Wiblin's guests, and willing to have the address reported in a Hampshire newspaper while there was an epidemic of cholera at Southampton, I do not think that I was bound to present that address (defective as it necessarily was in consequence of having been delivered without any preparation) to the profession at large, the more especially as I was at that time just completing an elaborate work on Diarrhoea and Cholera, which was quickly afterwards published. As a matter of fact I do not know to this day whether Dr. Wiblin was in any degree annoyed or angry because I did not publish that address ; and that I did not imagine him capable of being so is proved by the fact that I immediately called upon him on my return to Southampton. If however he was really offended because I did not comply with his suggestion, 1 still find it difficult to believe that a man of his character and position would consequently cherish such resentment as would impel him to traduce and denounce "as worse than useless," a method of treatment which only nine months before he had pronounced "superior to any other," and thus to stultify himself in order to punish me. I say " stultify himself," because, in 1866, the success of that method, which he then denied, was as great as was that success of it which in 1865 he both affirmed and applauded. I am therefore still at a loss to account for his conduct, and must content myself with having described it. Whatever may have been its motives, it undoubtedly operated effectually to accomplish the object intended ; but though it has succeeded in withdrawing professional attention during several years from both the special pathology and treatment of diarrhoea and cholera, which I have propounded, further experience only serves to assure me that that pathology is true, and that when the treatment which is the logical consequence of it is thoroughly applied, those diseases will come to be ranked among the most easily preventible, controllable, and curable of human maladies. 64 CASES OF DIARRHCEA AND CHOLERA TREATED SUCCESSFULLY THROUGH THE AGENCY OF THE NERVOUS SYSTEM CHIEFLY BY MEANS OF THE SPINAL ICE-BAG. BY JOHN CHAPMAN, M.D. M.R.C.P., M.R.C.S., PHYSICIAN" TO THE FAREIUGDOIf DISPjsNSARY. LONDON : BAILLIERE, TINDALL, AND COX, 20, KING WILLIAM STREET, STRAND. MDCCCLXXI. Now ready, in Bvo, cloth, price 7s. 6d. DIARRHOEA AND CHOLERA : THEIR NATURE, ORIGIN, AND SUCCESSFUL TREATMENT THROUGH THE AGENCY OF THE NERVOUS SYSTEM. JOHN CHAPMAN, M.D., M.R.C.P., M.R.C.S., PHYSICIAN TO THE PARRINGDON DISPENSARY. SECOND EDITION, ENLARGED. " This is a remarkable book, and worthy the serious attention of every one of our readers. . . . It contains a speculation which exhibits the essential features of a well-constructed theory. . . . Dr. Chapman's remarkably ingenious theory of cholera is in harmony with the results of the most recent physiological investigations ; it is clearly put, happily illustrated, logically argued. . . . It is only by a close examination of the detailed application of the hypothesis as a means of rendering intelligible the proximate cause of every special symptom, that a comprehensive conception of the hypothesis becomes possible. .. . Each receives a consistent and intelligible explanation. . . . The strength of the theory lies in its comprehensive and simple explanation of seemingly contradictory phenomena, by the application of a recognised general truth. . . . The chapter on the causes of cholera displays great originality and ingenuity in reconciling and explaining the various modes of action of causative agencies, and a singularly happy power of using his knowledge for the setting forth of new analogies, and the bringing together apparently the most contradictory phenomena for the support of a general law." — Medical Times and Gazette, Nov. 3rd, 1866. " Dr. Chapman applies his well-known views of the pathology of disease and of its treatment, through the agency of the nervous system, with wonderful ingenuity to explain all the phenomena of cholera. His pi'inciple of treatment is confidently recommended as promising the best success in this formidable disease. . . . Apart from all peculiarities of theory on the author's part, the present work will be found to contain a clear and complete account of what is known of cholera, and an acute and instructive criticism of the theories of its nature which have been propounded by different writers." — Journal of Mental Science, January, 1867. " Whatever amount of truth Dr Chapman's hypothesis may possess, his view is worked out with a display of logical reasoning, formidable facts, and erudition, such as is seldom met with in medical essays. ... Of the hundred and one treatises on cholera which have been published during the past year, Dr. Chapman's is at once the most interesting, the most scientific, and the most scholarly." — The Popular Science Review, January, 1867. Edited by Henry Lawson, M.D. " The section criticising Dr. George Johnson's castor-oil treatment and lung-capillary theory is very ingenious." — Indian Medical Gazette, January, 1867. " In conclusion, we feel bound to say that Dr. Chapman's hypothesis embodies a great amount of novel truth ; that it is ingenious, well reasoned, admirably supported, and not only in harmony with, but in advance of, the results of the highest investigations of the time. The subject is treated with real perspicuity and candour, and with a remarkable desire to appreciate every fact at its true value ; and the work, as a whole, lacks nothing that is needed to make it a rare specimen of the application of the severest logic, and the most precise manipulation of language to practical science. Indeed, the book is characterized not only by great ability, by originality of thought, by judicial acumen, and by familiarity with the spirit and tendencies of modern research, but also by a rare power of reconciling apparently contradictory phenomena, and marshalling them together for the support of a common purpose." — The Medical Mirror, March, 1867. "The apparent positive results obtained by the application of the ice-bag in collapse have been the promotion of a more steady reaction and the relief of cramps. One or two of the cases recorded seem to leave little doubt in these respects, and these facts command attention. . . . We cannot afford to throw aside a suggestion supported even by so small a number of cases as Dr. Chapman records. Should cholera again reappear among us, this practical question here at issue should not be left again in doubt." — Half -Yearly Abstract of the Medical Sciences, vol. xliv. CHLOROFORM AND OTHER AN AESTHETICS : THEIR HISTORY AND USE DURING CHILDBIRTH. BY JOHN CHAPMAN, M.D., M.R.C.P., M.R.C.S., PHYSICIAN TO THE PARRINGDON DISPENSARY. Bvo, price Is. LONDON: TRUBNER & CO., 8 and 60, PATERNOSTER ROW. * In the Press. NEURALGIA: ITS NATURE, CAUSES, AND TREATMENT. JOHN CHAPMAN, M.D., M.R.C.P., M.R.C.S., Physician to the Farringdon Dispensary. CONTENTS. Chapter I. Phenomena of Neuralgia. ? 11. Pathological Theories of Neuralgia. ? 111. The Pathology of Neuralgia. ? IV. Visceral Neuralgia. ? V. The Several Kinds of Superficial Neuralgia. „ VI. The Several Kinds of Visceral Neuralgia. ? VII. Painful Excitability of the Spinal Cord. „ VIII. Dr. C. B. Radcliffe's Theory of the Genesis of Pain. „ IX. The Predisposing Causes of Neuralgia. Jt „ X. The Exciting Causes of Neuralgia. ? XL Treatment of Neuralgia. ? XII. Cases. LONDON: J. & A. CHURCHILL, NEW BURLINGTON STREET. Now ready, MEDICAL PATENTS: A Letter on the Patenting of Inventions in connexion with Medicine. By JOHN CHAPMAN, M.D., M.R.C.P., M.R.C.S., Physician to the Farringdon Dispensary. Bvo, price 6d. The following passages are extracted from this " Letter :" — "A right appreciation of the claims of medical science and a due regard for the public welfare have conjointly necessitated professional repudation of men who deal in secretly compounded or quack- medicines, as well as earnest reprobation of the custom, so long as it was continued, of protecting such medicines by royal letters-patent But the same cannot be said of the grant of an exclusive privilege, for a term of years, of making and vending a surgical instrument, or any mechanical apparatus for a medical purpose. This privilege involves no secrecy : any one can make medical or surgical apparatuses for accomplishing the same purposes as those for which the patented articles are designed ; the mode of their construction is not and cannot be concealed ; and all the privilege the patent confers is that of an exclusive right for a term of years of making the patented article .... And I am constrained to affirm that in so far as the policy, the expediency, the morality, the dignity, in short, the principles generally approved by the profession, condemn the ' patenting of [mechanical] inventions in connexion with medicine,' precisely so far do they condemn the holding of copyrights in medical and surgical books, and in the titles of medical journals. All professional proprietors of such books and journals can only be at once logical and consistent either by cordially recognising the right of their professional brethren to patent any apparatus devised by them for surgical or medical purposes, or by surrendering their copyrights pro bono publico.'" — (Pages 6, 10, 11.) " Dr. Chapman is at war with the faculty on a point of etiquette, or, as those who consider the question a grave one would say, a point of ethics Of course the traditions of the faculty, the spirit of conservatism, and so forth, all tend to oppose the patenting of medical instruments ; but beyond these motives of prejudice we see no logical objection to the practice. . . . . It certainly appears hard and unfair that the fruit of a man's brains should fall into the hands of a trader — as in the case of Dr. Richardson's wnpatented Spray-producer — and that the original inventor should only be rewarded with barren honour. It seems to us, therefore, that Dr. Chapman's arguments are in the main perfectly reasonable ; and we cannot but think that the medical journals have displayed a feeling quite out of accordance with the true spirit of the press in refusing insertion to Dr. Chapman's letter." — London Review, Nov. 2nd, 1867. LONDON: TRUBNER AND CO., 8 and 60, PATERNOSTER ROW. Sea Sickness, and How to Prevent it: A*n Explanation of its Nature and Successful Treatment through the Agency of the Nervous System, by means of the Spinal Ice-bag. With an Introduction on THE GENERAL PRINCIPLES OF NEURO-THERAPEUTICS. SECOND EDITION. Bvo, price 2s. 6d. [The work contains reports of Thirty-seven Cases, proving that Sea-Sickness is both preventable and curable by means of the Spinal Ice-bag. Its application is agreeable ; it gives immediate comfort and relief ; while arresting the sickness, as well as any cramps or spasms which may be experienced, it restores the impaired circulation of the blood to its normal standard ; and thus the patient who may be cold, pallid, apathetic, and completely prostrate, quickly regains the ruddy glow and the mental and physical energy of health.] " Certainly, so far as the history of these voyages across the Channel goes, it is highly in favour of the author's ingenious recommendations We advise, both for practical and theoretical purposes, that the pages of this pamphlet be carefully perused." — Lancet, March 4, 1865. " In severe cases, where other remedies have failed, I have very generally found it (the Spinal Ice-bag) do great good. I have applied it to young children, delicate women, and old people. In no case does it do harm ; but in the great majority of instances it soothes the nervous irritability which so commonly accompanies sea-sickness, induces sleep, and so enables the stomach to receive light food, and consequently relieves exhaustion I order it to be kept on a couple of hours ; though, if the patient sleeps, as is often the case, I never remove it until after waking." — Lancet, Dec. 3, 1864 {Letter of S. M. Bradley, Surgeon, Cunard Service.) " Among the thousand and one remedies that have been proposed for sea-sickness, there is one which, in a scientific point of view, towers above them all We are not accustomed to devote our leading columns to the advocacy of any therapeutical system, but we feel it due to a most able physiologist to testify to the necessity of submitting his conclusions to the test of experience. In a short time sufficient facts may be accumulated to confirm the only scientific theory [of Seasickness] which has been put forward ; a theory, be it remembered, of the utmost significance in reference to other more important diseases, and which has been applied by its author to an elucidation of the pathology of Cholera, Epilepsy, Pai-alysis, and other equally diverse conditions. . ... It would seem from numerous instances, that, properly applied, the ice is not only safe, but positively pleasant. Moreover, the soothing effect is so general, that sound and refreshing sleep is frequently induced, so that we constantly read of patients — men, women, or little children — falling asleep on the Ice-bag, and waking up refreshed and hungry." — Medical Press and Circular, June, 1867--" The evidence which Dr. Chapman brings forward in his brochure on Sea-sickness appears to be conclusive. To our minds, the various testimonies from seafarers, as to the benefit they have received from the use of ' Chapman's Spine-bags,' are better than all the physiology and science under the sun, as very often our science leads us into error, and our physiology leads to nothing. The great beauty of Dr. Chapman's invention is its practical utility." — 'The Medical Mirror, Feb. 1, 1869. "The application of ice along the spine has been systematized by Dr. Chapman, and a reason based on physiological discoveries assigned for the treatment. Experiments already made in cases of epilepsy, sea-sickness, and some spinal affections, as well as in diarrhoea and cholera, have been satisfactory enough to warrant a continued trial of vaso-motor (or neuro) therapeutics." New York Medical Record, June 15, 1866. " The case (in question) is as conclusive as a single case can be, in regard to the great practical value of Dr. Chapman's discovery The effects of the application of the Ice-bag were little short of miraculous." — Philadelphia Medical and Surgical Reporter. (Report of " Case of Sea- sickness successfully treated by Ice to the Spine."— By B. Lee, M.D.) ' LONDON: TRUBNER AND CO., 8 and 60, PATERNOSTER ROW. WC 262 C466c 1871 34631140R NLM DSlhVhhfl S NATIONAL LIBRARY OF MEDICINE