HAWTHORNE - CHOLERA ARMY MEDICAL LIBRARY FOUNDED 1836 WASHINGTON, D.C. 1849, 0 H O Is E R A, ITS CURE AND PREVENTION. THE TRUE PATHOLOGICAL NATURE OF CHOLERA, AND AN INFALLIBLE METHOD OF TREATING IT. IN A SERIES OF LETTERS. BY GEORGE STEWART HAWTHORNE, M.D., LATE SENIOR PHYSICIAN TO THE BELFAST GENERAL HOSPITAL, &C, &C. WITH INTRODUCTORY REMARKS BY D. C. MOREHEAD, M.D. FROM THE SECOND LONDON EDITION. NEW YORK: W. H. GRAHAM, BRICK CHURCH, NASSAU STREET. B. Craigbead, Printer, U2 Fulton Street. INTRODUCTORY REMARKS. " Plain facts, plainly spoken," is the desire of those inquiring about a disease so alarming in its character as Cholera. And we may say at the outset that the reason such universal alarm exists regarding this disease, is that so little has been plainly spoken on the subject — of Theory and Speculation there has been more than sufficient. The following letters by Dr. Hawthorne are an exception. The author states boldly that Cholera in certain stages can always be cured by the proper means, and then as plainly proceeds to show what are these means. His reasoning he supports by facts, and these facts are of the most reliable and important character. The letters are in every respect calculated to allay fear on the general subject of Cholera, and to impart that confidence which is so essential for safety when an individual has been attacked, and which is the safest guard from its insidious approach. The writer has very lately had peculiar opportunities of testing the truth of many of the assertions contained in the following pages. He was on the Mississippi river, and in the cities of 4 INTRODUCTORY REMARKS', Memphis, Vicksburg, New Orleans, dec, during the months of last January and Febraary, when the Cholera was most prevalent. He has seen cases treated in various modes, and all of these modes successful ; but there is no question 1 that the Hawthornian system, so far as the writer's experience is concerned, was by far the most successful. The question at present is not what theory is correct, but what treatment is the best. "Show us how to save our lives, and we will believe your theory without further proof," That Dr. Hawthorne has had great experience in the disease and great success in its treatment, there can be no question. In fact, it has been unexampled. The late Sir Francis W. McNaughton, in forwarding to Dr. Hawthorne an address in behalf of certain parishes which had been the scene of his labors, says : " I can add from my ownknowledge, that no individual wfroj at the commencement of his disease, had the fortune to fall under your care, was lost to his family ; that shortly after your arrival, mortality ceased — that implicit reliance upon you was manifested by all — and that despair was relieved by the most cheering expectations." The letters are so foil and explicit in themselves, that it is unnecessary to allude to any peculiar points. The reader will readily perceive that the pith of Hawthorne's theory is that Cholera is a NERVOUS disease, and that the plan of treatment is to act promptly on the Nervous System. If this be done timely, the disease is overcome and the threatened danger is passed. His idea that the disease is produced by a disturbance of the Electro' 5 INTRODUCTORY REMARKS. producing functions of the lody is not new, and is of little import at present, save that it gives authority to the important suggestion regarding the application of Electricity or Galvanism as a preventive, and we take pleasure in referring to the advertisement on the cover of this work. As a conclusion to these remarks the following case may be of interest, illustrating as it does the principles of the treatment here laid down. A friend of the writer, who was a passenger on board a Steamer from New Orleans to St. Louis last January, arrived in the latter city after a tedious trip, during which several passengers on board had died of Cholera. The afternoon of his arrival he felt as well as usual, but about dusk he felt a strange sensation, accompanied with unusual debility, which seemed to oppress him. He sat down to supper at the Planter's House, but though he had taken little dinner, found he could eat nothing. He rose from the table, walked about the corridors for half an hour, and then retired. Though much fatigued, his attempts to sleep were in vain, and though the night was sultry, he felt quite chilled. Suddenly he became dizzy j his thoughts appeared to wander, and his consciousness was only aroused when he was startled by sudden cramps in his legs. The idea now flashed upon him that these were the symptoms of Cholera. He immediately attempted to rise in his bed to procure assistance, but was additionally alarmed on finding that he had scarcely the power to do so. After some exertion, however, he succeeded in getting up and ringing the bell. In a few minutes I was by my 6 INTRODUCTORY REMARKS. friend's side. His pulse was rapid, and he was greatly alarmed. I endeavored to reassure him, and immediately ordered the servants to make a large and blazing fire in the room, to bring up two additional blankets and a pitcher of strong, hot brandy-toddy. These missions were soon effected. The cheer and warmth of the fire rapidly dissipated the gloom and fear of my friend, the blankets were spread over him, and he swallowed a full pint of the hot brandy-toddy, which he pronounced " very strong and very good." In a few minutes he said, " How much easier I feel !" The chills now left him, and in less than eight minutes he was in a complete perspiration. His pulse was calm, his breathing, which was previously somewhat labored, now became natural, and in about five minutes more he was in a sound sleep. I then left an attendant with him, desiring to be called during the night if anything occurred ; but not being called, I visited him early in the morning, when he was still asleep, and did not awake till the ringing of the breakfast-bell. In the two succeeding days he was rather weak, but in every other respect apparently as well as ever. From many similar cases that I have seen, I believe this to have been a case of Cholera in its first stage ; and the ease and success in its treatment was owing to the prompt use of the means adopted. In one hour more, the patient might have been in a state of hopeless collapse. It may be added that the subject of the above case had been slightly troubled with Diarrhoea previous to his 7 INTRODUCTORY REMARKS. arrival at St. Louis. This, however, is common with all travellers on the Western rivers, and though there is ordinarily no cause for alarm, it is a symptom which is worth heeding, and which should be instantly checked while Cholera prevails. There was no vomiting in this case, and the disease is sometimes rapidly fatal when it is not at all exhibited. We can add nothing further in commendation of the following letters, save that we believe they contain truth, which is of the most important and valuable character to the public at the present time. D. C. M. Note. — We commence with the second letter of Dr. Hawthorne, the first being merely a brief notice of the Report of the London Sanitary Commissioners on Cholera, and of little interest to the reader. THE REMEDIES. LETTER 11. Gentlemen : Having, in my last letter, joined issue with the London Sanatory Commissioners on the alleged incurability of Cholera, I think it right here to state, that I fully agree with them in the opinion they have expressed upon the non-contagiousness of the disease — a subject with regard to which, also, it is of great importance the public mind should be properly instructed. The opinion that Cholera is not contagious has not, I am satisfied, been hastily adopted, but has been founded on extensive and acute observation. From my own observation upon the disease, I had long since arrived at the same conclusion. Quarantine restrictions never retarded the entrance of Cholera into any country for a single hour. They never did good, but always a great deal of mischief. They embarrassed commerce, and injuriously excited the fears and cramped the industry of the people. It will be a great blessing to the community, in case of another invasion of the disease, if the alarm of the people be not increased, and all the concomitant evils aggravated, by any unnecessary and useless precautions. How the disease is propagated and by what laws its progress from country to country is governed, are subjects involved in absolute mystery. It is pre-eminently " the pestilence that walketh in darkness." All the phenomena, however, attending its former and present progress over the earth go to fortify the opinion, that it is not propagated by contagion. We find it starting up in many places simultaneously, leaving intermediate towns, even where the intervening traffic has been extensive, untouched. Its mode of travel has been unprecedented, and by its eccentricity, it has set all speculation as to the laws which regulate its course, at defiance. In making its present career towards us, a truly remarkable fact 1* 10 CHOLERA, ITS CURE AND PREVENTIVE. to be observed is, that it follows, as nearly as may be, precisely the same course as formerly ; and, more remarkable still, it leaves untouched those places it formerly passed over. Altogether it is the most abnormal scourge that ever swept our earth. Unsubjected to those laws which have been observed to mark or retard the course of other pestilences, it surpasses them all in the width of its range, and outstrips them in the destructive rapidity of its progress. If, however, we cannot by any precautionary measures avert the approach of the disease, it must be satisfactory to know that, when it does make its attack, it is within the power of the medical art successfully to cope with it. To explain by what way this can best be done is the object I have set before myself in these letters. I confess myself surprised that, in this enlightened era of medical science, Cholera should have been so extensively fatal as it undoubtedly has been. The more so, because I have never met with a disease which, when scientifically treated, was more manageable or more easy to cure. I found it to become formidable only when neglected, or injudiciously treated. That it has not, generally, been judiciously treated is a fact which cannot be denied. It has been too much the practice among medical men blindly to follow the opinions of others,without examining or thinking for themselves. The inductive method of arriving at the truth cannot be of more use in any department of science than in medicine. Every physician should take care to compare the conclusions arrived at by other practitioners with his own observations of facts. Many of those who have written on Cholera in these countries have been mere theorists, without experience, and, of consequence, the practice in that disease has too often been the sheerest empiricism. There has been no rational system universally pursued ; nor has there been any regular plan of treatment generally adopted. Could there be a greater proof of the ignorance that has too much prevailed on the subject, than the observations of a correspondent of a London medical periodical, of deservedly high character, who stated that what cured the disease in one street would not cure it in another ! A mode of treatment which will not cure the disease alike in all streets, will cure it nowhere. Nothing could be more absurd, or indicate more forcibly the want of that correct knowledge of the disease, which observation and CHOLERA, ITS CURE AND PREVENTIVE. 11 reflection should furnish to a medical practitioner, than the various nostrums for its cure which have lately found their way, from different quarters, into the London Times newspaper. The observing of these impressed me, additionally, with the importance of losing no time in having the public mind rightly informed upon such an important subject. Cholera, like all other diseases, should be treated on rational principles. The object of a physician should be, first, to ascertain what diseased action tends, either directly or indirectly, to destroy life ; and then, when that is ascertained, and not till then will he do so with propriety, he should address himself to the counteraction or removal of that diseased action. The first step, then, towards devising a plan for the successful treatment of Cholera is to ascertain, with as much accuracy as possible, what is the morbid action which, in this disease, so potently, and with such sudden violence, invades, and if left to itself, so soon annihilates the springs of life. To this end we must pause, and contemplate the symptoms which present themselves at the commencement, and throughout the course' of the disease. The pathognomonic symptoms are, sudden debility, tremors, numbness, and general uneasiness, pain of stomach less or more severe, occasionally headache, whiteness and clamminess of the tongue, and prtecordial oppression, succeeded by purging, vomiting, and cramps. The disease varies, more or less, in its modes of attack, and in the general symptoms. The following, however, is the order in which the symptoms, generally, manifest themselves. The patient first complains of general weakness and languor, and what he calls a lightness in his head, an unusual feeling over the body, weight and oppression about the heart, with a disposition to sigh, accompanied with a sensation about the stomach and bowels, which he describes as a feeling of emptiness ; his countenance is pale and his features shrunk — the fluids appearing to have receded from the surface. These symptoms are followed by a rumbling sensation through the bowels. The sphincter, losing its contractile power, gives way, and the contents of the intestinal canal are discharged. The bowels are affected at intervals of a few minutes, and the discharges become more and more fluid, till they present the appearance of whey, or of rice or barley water — becoming, in many instances, nearly as clear and transparent as rock water. The 12 CHOLERA, ITS CURE AND PREVENTIVE. relaxation and weakness increase with each discharge. The stomach becomes sick, and the contents are thrown off. The patient now feels a desire for drink, but as soon as he has swallowed it, it is immediately rejected. The sickness and retching complete the relaxation and dilatation of the discharging vessels, and the whole fluid part of the blood escapes. In proportion to the escape of the serous or watery fluid from the bowels, the temperature of the body decreases, till it becomes as cold as if dead. The pulse sinks in the same proportion, till it ceases to be perceptible at the wrist. Cramps then come on with torturing severity, and the voice is hoarse and stridulous. The breathing becomes laborious, with a severe pain in the region of the heart ; and the patient tosses himself about, anxiously, and in vain, looking for relief, which change of posture cannot afford. A profound coma calms the closing scene. This is a description of the symptoms as they occur in this form of the disease ; and the whole process described is sometimes completed within the space of one hour. In many cases the symptoms more gradually develope themselves. The discharges from the bowels are at longer intervals — the first consisting of the natural contents, the next of whitish matter, which becomes more gradually fluid and colorless, till it presents the almost transparent appearance already described. Such modifications, however, differ merely in degree. They are produced, no doubt, by peculiarity of constitution, or habits of life, or by the greater or less intensity of the exciting cause. Now, a careful study of the symptoms thus described, as developed by the disease, is of the utmost importance towards enabling us to arrive at a just knowledge of what is the nature of the diseased action here indicated, as upon such knowledge alone can a rational mode of treating the disease be based. I shall, therefore, enter into a brief consideration of the pathology of the various symptoms, giving my views of the nature of the morbid action which in its several stages gives rise to them. And to this part of my letter I beg particular attention, as, upon my views on this subject, I found my mode of treatment. Before, however, proceeding to do so, I may, perhaps, opportunely, pause to say a word upon what may be alleged as to the exciting or generating cause of the disease. Upon this subject much has been written : and the views entertained by the several writers who have treated of it have been widely various. Ingenious 13 CHOLERA, ITS CURE AND PREVENTIVE. arguments have been adduced by all, in support of their peculiar views; but the evidence by which they seek to substantiate their theories is so conflicting, that to enter into a discussion of the points at issue, would require more space than is consonant with the limits I have at present prescribed to myself. I shall content myself with observing, that my opinion is, that the disease is produced by some specific agent, of disturbing influence on the animal economy, forced from the bowels of the earth by subterraneous commotion. The sudden devastations of the disease in particular places, at great distances from each other, ¦and at the same time, can be accounted for, in my mind, on no other principle ; and_ the fact that the disease is now retracing its former course, goes far to substantiate such a view. Those fissures in the earth, which gave vent to the deadly agent before, are doing so again. Whatever the character of the agent may be, it seems to me to act in some powerful manner in disturbing the electroproducing functions of the body (if I may so speak). That electricity is largely concerned in the animal economy is a fact now well established ; future discoveries will throw much additional light upon this interesting subject ; and the bringing of this animal electricity into some abnormal state appears to me to be the remote cause of all the symptoms which manifest themselves in cholera. A very remarkable fact, indicative of such supposed electrical disturbance, is, that the bodies of those who have died of Cholera are, for several hours after death, affected with startings and contractions of the voluntary muscles, producing, in some cases, even temporary distortion of the features, and leading the friends to imagine the individuals still alive, thus presenting a phenomenon not to be observed after death under any other circumstances, and exactly similar in character to the appearances produced by the application to the dead body of the wires of a galvanic battery. On this subject, however, lam not in a position to enlarge. I merely throw out these hints as interesting subjects for physiological investigation and research. I would merely add, that a further confirmation of such a theory would seem to be afforded by the fact, that the disease is not contagious. But whatever be the exciting cause of Cholera, of whatever nature or character it may be, a careful study of the symptoms, as I have described them, proves to me conclusively that its primary 14 CHOLERA, ITS CURE AND PREVENTIVE. operation is exerted on the brain and nerves ; and, from this affection of the brain and nerves, all the symptoms, as they develope themselves, flow as necessary consequences.. The effect produced on the brain and nervous system is a paralyzation of their tone and energy, producing directly a diminution of the contractile power of all the muscular fibres of the body. This general diminution of muscular power accounts for the weakness and languor which occur at the commencement of the disease. From the diminished elasticity and contractile power of the vascular system, the blood and other fluids of the body, not being propelled with the usual force, tend to gravitate to the lower and internal parts. Hence the paleness of countenance, shrinking of features, and other symptoms, which indicate a receding of the fluids from the external surface. This gravitation and crowding of the fluids to the internal surfaces account also for the praecordial oppression, pain'of stomach, &c. Further, the circulating power of the bloodvessels being diminished, they do not carry the blood to the brain, either with the usual force, or in the usual quantity. The brain, therefore, being thus suddenly deprived of its accustomed support, becomes further impaired in its tone and energy, and is, thereby, rendered still less capable of exercising its functions. Hence arises the giddiness and lightness in the head, and the further paralysis and relaxation over the body. Again, the contractile power of the abdominal muscles, and of the muscular coat of the stomach, being diminished, these become relaxed, and produce that feeling of emptiness and want of confidence which is always complained of. The excretory vessels (the extremities of the arteries), opening on the internal surfaces of the stomach and intestines, sharing in the same general relaxation, become dilated, so as to permit a too free passage of the fluid which presses into them, allowing, in this way, the serum of the blood to escape. So complete has been the dilatation of these vessels, in many instances, that they have allowed the escape of even the red particles of the blood, giving to the fluid, passed from the bowels, an appearance as if raw beef had been washed in it. The sudden depletion of the vascular system, caused by the escape of the serous fluids, produces the vomiting. The same effect is observable from the extraction of blood, suddenly, from a large orifice ; the patient becomes sick and faintish, and the contents of the stomach are thrown off. The same takes place in uterine and other extensive hemorrhages. The 15 CHOLERA, ITS CURE AND PREVENTIVE. escape of the serous part of the blood causing an effect on the constitution similar to that produced by blood-letting, increases the relaxation. The relaxation and weakness thus increase with each discharge, till the whole fluid part of the blood passes away, the crude part becomes, as it were, stranded, and the vital powers are exhausted. This ushers in the collapse stage. In this last or collapse stage, the patient becomes of a livid or blue color ; an.d the reason of this appearance is easily intelligible. The escape of the serous or^watery part of the blood deprives it of that dilution or fluidity which is necessary to fit it for circulating through the minute ramifications of the vessels through which it has to pass. Hence the crowding of the red particles in the extreme vessels on the surface, which still become darker the longer they are deprived of that due arterialization which they should undergo in passing through the lungs. The sense of suffocation felt in the lungs at this time, and the pain and anxiety felt in the region of the heart, are produced by the viscidity of the blood ; the great excess of fibrine rendering it too crude to circulate through those organs. This, I may observe, has been satisfactorily demonstrated by dissection after death — the vessels of the lungs being found clogged with fibrine ; and polypous masses of the same substance, as has been related by Dr. Joenichen, a Russian physician, being sometimes discovered in the ventricles of the heart, so as in a great measure to obstruct all circulation. It is difficult to prove whether the cramps in the collapse stage are caused by the extensive vascular depletion that has taken place, or by the circulation being retarded by the crudity of the remaining part of the blood. The coma which in the collapse stage generally supervenes is caused by the congestion of blood, and accumulation of fibrine, that takes place in the great vessels of the brain, and sometimes from effusion of serum into its cavities. Such are my observations upon the pathological indications of the symptoms in this disease ; and it has been necessary for me thus to dwell upon these matters, in order to prepare for the right understanding and ready appreciation of the remedies by which I propose to combat all such symptoms. In my next letter I shall proceed to lay before you a mode of treatment, by which the morbid action may be successfully counteracted in every phasis in which it presents itself, previously to the collapse stage, in which remedies seldom 16 CHOLERA, ITS CURE AND PREVENTIVE. avail. A mode of treatment, which, from the pathology of the symptoms I have laid down, and from what I shall hereafter say on the mode of operation of the remedies, will, I am persuaded, recommend itself even to the most sceptical, as a method of cure, which, when timely and skilfully administered, has just pretensions to be styled infallible. I have the honor to be, Sec, G. S. H. 17 CHOLERA, ITS CURE AND PREVENTIVE. LETTER 111. Gentlemen In my last letter I remarked, generally, yet briefly, upon the history, character, and symptomatic features of Cholera. In the present letter I propose to treat of the means of cure. Before entering upon this subject, however, it is necessary, in a medical point of view, that I speak of the prognosis of the disease, and of the various forms in which it presents itself. As the prognosis in Cholera, I would briefly state it to be— Favourable Symptoms : — The disease commencing with cramps of the voluntary muscles ; heat of skin at or above the natural standard ; pulse soft, full, and strong ; little thirst ; bilious vomiting and purging. Unfavourable Symptoms: — No pain nor cramps at the beginning ; pulse small and feeble ; heat of skin below the natural temperature ; tongue a pale white, clammy, flowing with saliva, cold, relaxed, and broad, having apparently lost all contractile power; no secretion of urine; serous and watery purging, and vomiting ; and no smell emitted from the discharges. Disposing of the prognosis thus briefly, I proceed to observe that the disease presents itself in four distinct degrees of malignity, which it is necessary for me to describe, as information on this subject is an essential preliminary to a judicious use and properly modified adaptation of general rules of treatment. I shall take these up in the order of their malignity. Ist. In t"he least dangerous form of the disease the attack commences with spasms of the stomach, bowels, and voluntary muscles ; heat of the body at the natural temperature; with a strong, full pulse, and slight retching or vomiting, unaccompanied by purging. 2d. The next in point of danger is, when the disease begins with pain in the stomach, less or more severe ; oppression about the prsecordium, headache, numbness of the extremities, with a pricking 18 CHOLEKA, ITS CURE AND PREVENTIVE. sensation over the skin, succeeded by purging and vomiting, or vomiting and purging— in some cases, of bilious matter ; in others, of a whitish-colored fluid. 3d. A more dangerous form of the disease than either of the preceding commences with violent pain of the stomach, increased on pressure ; intense pain across the forehead and in the eyeballs ; flushed face ; pulse quick, hard, and bounding ; a painful sensation felt over every part of the body, similar to that experienced at the beginning of fever; heat of skin increased to a morbid degree ; tongue exceedingly white, deeply coated and furrowed ; intense thirst, with deadly sickness at the stomach ; vomiting and purging — first of the natural contents, after which, the fluid matter discharged from the bowels is of a greyish-white color, granulated, and mixed with particles resembling powdered ochre, and emitting a peculiar and intolerably foetid odour, exceeding anything of the kind observed in almost any other disease. Though this is not the most rapidly fatal form of the disease, still it is fraught with great danger, requiring prompt and active treatment ; and the recovery may be more tedious than even where the disease has assumed the most malignant type. 4th. In the last and most malignant form of the disease, the attack comes on with giddiness of the head, ringing of the ears, and purging — first of the natural contents, then of a fluid resembling thin mucilage or barley water ; pulse small and feeble ; heat, of skin below the natural temperature, without any vomiting, pain, or cramps. Here there is the greatest danger ; and, if the disease be not instantly checked, the patient may go down into collapse in less than half an hour. Upon this form of the disease I would observe, that the most rapidly fatal attacks in Cholera commence without any vomiting, pain, or cramps, or previous warning whatever ; and while, under all circumstances, under all mora or less severe attacks of the disease, the earliest recourse ought to be had to remedial means, I wish to impress the importance of being specially prompt when the disease begins in this its most malignant and most insidious form, in which a delay of a very short period might be attended with fatal results. I have seen much of the fatal consequences of an error of opinion in this respect, the patient imagining that it could not be Cholera with which he was affected, because he had no vomiting, or pain, or cramps, when, in point of fact, it was the most fatal form 19 CHOLERA, ITS CURE AND PREVENTIVE. of the disease ; and when the vomiting and cramps did come on, they were only the fearful harbingers of collapse and death. In the most malignant form of the. disease, the first discharges always take place from the bowels, and the patient does not vomit till the disease has carried him into hopeless collapse, or till he is, at least, verging on that stage. A knowledge of this fact cannot be too strongly impressed on the minds of the public. As far as my recollection serves me, all the cases of hopeless collapse to which I have ever been called, during my experience, were of persons who assured me that they had applied at the moment when the vomiting commenced, and that, in the absence of that symptom, they had attributed the previous purging to 3t>me other cause than Cholera. I would observe, that the danger in every case bears a proportion to the rapidity and amount of the discharges from the bowels. Having thus disposed of much preliminary matter, I now proceed to specify the proper remedies to be employed iti the treatment of Cholera; and to state, from the nature of the disease, a malignant case of it could not be cured by any other means. It has been already explained that the primary cause of the morbid action in Cholera is a specific injury inflicted on the brain and nerves, which paralyzes their tone and energy, and gives rise to a train of symptoms which result in the escape of the serous or watery part of the blood ; and that such serous fluid passes off in the discharges from the stomach and bowels. The indications of cure are, to restore the tone and energy of the brain, and to prevent a further escape of serum ; and not only so, but to restore to the blood whatever amount of its natural fluidity it may have lost by the previous escape of the serous fluid ; and lastly, to re-establish in their healthy action all the natural functions which may have been suspended during the attack. Now, the remedies which I shall place before the reader furnish ample means to accomplish all the objects demanded in all these several indications of cure ; and, if promptly and skilfully handled, enable the medical practitioner to set at defiance all the assaults of this hitherto fell destroyer. - These remedies I would briefly state to be — The horizontal posture of the body — Opium— Cordial stitnulants — Perspiration, — the latter to be produced by the application of external heat, and to be continued by the same means, while mild, warm, diluting drink, is to be freely administered, to furnish an abundant supply of 20 CHOLERA, ITS CURE AND PREVENTIVE. suitable fluid to the absorbent vessels which have been first excited to vigorous action by the perspiration. Upon these several remedies, as means of cure, I shall make some general remarks, describing their mode of action, and their fitness for the exigencies of the disease ; and showing how they fully and efficiently meet all the requirements of cure. This I shall do before prescribing in detail the manner in which they are to be used in the treatment of the disease. Such a course will, I conceive, be attended with advantages. When I come to direct the proper mode of treatment, the reader, who shall have brought my observations along with him, will be prepared not only to see the adaptation of the means of cure I shall prescribe, but will almost be able to anticipate me in this matter. I thus hope to carry his understanding and convictiou along with me. I shall take up the remedies severally — First : The Horizontal Posture of the Body. — All who have read attentively the observations in my second letter on the symptoms, and the reason and cause of the symptoms in Cholera, will at once perceive the necessity for immediately placing a patient affected with the disease, or even with its premonitory symptoms, in the horizontal posture. I explained that the primary loss of the tone and energy of the brain in that disease, immediately leads to a loss of power in the circulating vessels ; — that this diminution of the circulating power leads to a further loss of the tone and energy of the brain, and consequently to the increased paralyzation of the resisting power of the vessels to which the fluids in the progress of the disease determine, and through which they make their escape. The advantage of the horizontal posture is, that it aids the weak circulating power, and favors the more forcible influx of the blood into the brain, affording to that organ more efficient bracing and support, and thus contributing to the restoration of its tone and energy. That such is the effect of placing the body in the horizontal posture, when the circulating power is weak, is every day exemplified in the relief afforded by this means to persons fainting from weakness by loss of blood, and other causes. When the individual who has fainted is placed in the horizontal posture, so as to favor the influx of the blood into the head, the brain immediately regains its tone and energy, and resumes its healthy functions. Further, the horizontal posture aids in arresting the escape of the 21 CHOLERA, ITS CURE AND PREVENTIVE. serous fluids into the stomach and bowels. By improving the tone of the brain, it increases the resisting power of the vessels through which the serous fluid escapes ; and it relieves the discharging vessels from the great superincumbent pressure they would have to sustain in the erect posture. The effect of posture in increasing or diminishing the pressure on the circulating vessels is familiarly exemplified in the swelling of the lower extremities from long standing, and in the remedial effect of elevating those extremities, either to a level with, or slightly above the level of the body. Thus much will suffice to illustrate the advantage of confining the patient to the horizontal posture in this disease. Opium is the next remedial agent which claims our notice ; and amongst the few remedies which are really necessary in the treatment of Cholera, this one holds a most important place. Taken internally, opium increases the energy of the brain ; contracts in a remarkable degree the diameter of the circulating vessels, which include, let it be observed, the excretory ducts through which the serum in this disease escapes, and diminishes all the secretions and excretions, except the cuticular discharge, which it increases; — in all these several respects being most precisely adapted to the requirements of cure in this disease : in all these respects being severally fitted for restoring the tone and energy of the brain, for resisting the determination of the fluids to the internal surfaces, and for counteracting the effects of the vascular depletion, which is sometimes so excessive ; and these are precisely the objects upon the accomplishment of which the cure chiefly depends. And these objects, opium, in conjunction with the other remedies I prescribe, ' more especially perspiration, will effectually accomplish. I wish it, however, to be particularly understood, that the success of this remedy depends upon its being administered in sufficient quantity ; and the amount of the dose required in each particular case depends entirely upon the malignancy of the symptoms, &c; that is, upon the extent of the nervous prostration, the rapidity with which the serous fluid seems to escape, and the extent to which the vascular depletion may have gone. To this fact I would again solicit the most pointed attention, as it was from inattention to these truths that the fatal results of the general, and, I may say, universal, practice of that disease arose. I have elsewhere stated that the effect produced on the brain and 22 CHOLERA, ITS CURE AND PREVENTIVE. nervous system in Cholera, by the escape of the serous fluid from the body, is precisely similar to that which is caused by the loss of blood. Now, incases of persons sinking from loss of blood, opium, as is well known to the profession, is one of the most valuable medicines we possess for restoring and supporting the vis vitce. In uterine haemorrhages, for instance, no person, unless he had actually witnessed it, could have any idea of the quantity of opium a patient not only can bear, but requires, when the loss of blood hasbeen extensive. But not only in vascular depletions, but also in certain affections of the nervous system, are large doses of opium not only safe, but necessary. In tetanus (lock-jaw), for instance, enormous doses of that medicine may be taken with safety and advantage. A case is recorded in which a patient, affected with this disease, took two fluid ounces of the tincture of opium without experiencing any narcotic effects from it, and was cured by the dose. I prescribe, therefore, large doses of opium in Cholera, not merely from the excessive vascular depletion that accompanies the disease, but also from the great nervous depression which is always present. I would again repeat, that the amount of the dose necessary, will depend entirely upon the malignancy of the symptoms. For illustration (to confine ourselves to the vascular depletion), it must be evident that the specific effect of opium, which, in part, is to contract the diameter of the vessels of the body, and lessen their containing capacity, and thereby to afford a fuller and more forcible supply of blood to the head, and which would be injurious in a plethoric state of the vascular system, would be proportionably salutary in a depleted state of that system. It is equally evident, that the greater the depletion be, the larger will be the dose of the medicine required to produce a given effect. Two grains of opium would produce a greater effect on the nervous system, in the ordinary state of the vessels, than even ten grains where the vascular depletion has been such as to endanger life. Had the profession borne these facts in mind, and noted the nature of the morbid action, in Cholera, they must have, at once, availed themselves of the agency of large doses of opium, in the treatment of the disease. The overlooking of these facts, however, led to the fatal error of trifling with too small doses of that medicine ; and when these inefficient doses failed, or were, perchance, entirely counteracted by being combined with other supposed remedies; as calomel, for instance, it was taken for granted that 23 CHOLERA, ITS CURE AND PREVENTIVE. the disease was incurable. It has been the general practice, even in the worst forms of the disease, to administer the opium in one or two grain doses, repeated at longer or shorter intervals. The consequence of this has been, that in all such malignant cases, the discharges of the serous fluid from the bowels have continued completely unchecked, and the lives of the patients have been lost. Now, in these cases, there might just as well have been given none of this medicine at all; for, if a dose, sufficient to meet the exigency of the case, be not given at once, it will produce no effect whatever, and no repetition of similar doses will answer the purpose. And I unhesitatingly assert, that two grains of opium never cured a malignant case of Cholera. I have frequently had occasion to give ten grains for a first dose. In regulating the dose of opium to be given in a malignant case of Cholera, three objects are to be kept in view ; first, to apportion as much as will be sufficient to counteract the depleted or emptied state of the vessels, then to add what will be necessary to restore the brain and nerves to their natural state, and,'lastly, when the dose has been adjusted to meet these contingencies, the practitioner must still further add a third portion to the dose, such as would stop a case of purging under ordinary circumstances. It need not excite surprise that the disease has been so universally fatal, when, in all parts of the world, this important practical fact has been entirely overlooked. Any cases of Cholera alleged to have been cured by the ordinary methods recommended in publications on this subject (and I have read all of note that have appeared), have been so mild as scarcely to deserve the name of Cholera. — Cases do sometimes occur where, from peculiarity of constitution, the patient will recover without any medicine whatever, or in spite of the remedies, where such have been used. Almost all the recoveries from collapse I ever witnessed, were of persons who refused to take any medicine whatever, and who recovered through the dm medicatrix naturm (healing power of nature). But these were persons of very peculiar habits of body, of whom I would now be able to predicate such a result. The next remedial agents in the order of our arrangement are, Cordial Stimulants. — Upon their mode of operation I shall here observe very briefly. I shall enter more into detail afterwards in prescribing how they are to be used. Amongst the most useful of the stimulants we possess, are camphor, chloric ether, aromatic 24 CHOLERA, ITS CURE AND PREVENTIVE. spirit of ammonia, and alcohol in the form of whiskey or brandy. Such stimulants assist the opium in restoring and supporting the tone and energy of the nervous system. By their cordial effects, they strengthen the stomach and enable it to absorb the opium ; and by their stimulating effect on the brain, they sustain it until the opium becomes absorbed, and exerts its more permanent remedial effect on the system. I now come to speak of perspiration, produced by the application of external heat, and upon this powerful agent in the cure of Cholera I must dwell more fully. Perspiration. — All the early symptoms in Cholera indicate an increased determination of the fluids from the external to the internal surfaces. Perspiration reverses this determination, and directs it to the external surface. By so doing, it relieves the stomach, intestines, and other internal organs, from the symptoms caused by the injurious rush of the fluids; contributes, materially, to the stopping of the discharges, and is an efficient remedy for stopping the remedy, in a malignant case of the disease. — Though in such cases the discharges from the bowels may, for a time, be checked by large doses of opium, yet, if the morbid action be not corrected by changing the determination of the fluids from the internal surfaces to the external by a profuse perspiration, they will assuredly return. When the perspiration has been made to flow freely for a few minutes, the vomiting and sickness at the stomach invariably cease. Let the sweating be suddenly checked, however, or stopped too soon, and not only will these symptoms almost instantly recur, but, if the discharge from the surface be not immediately reproduced, even the purging itself will be sure to return. All medical men are aware of the remarkable sympathy that subsists between the external and internal surfaces of the body. Witness the alternations of sweats and diarrhoea that occur in the last stage of pulmonary consumption. When the latter symptom is checked, the perspirations become excessive; when these again are stopped, the colliquative discharges from the bowels return with violence. Much less opium is required to stop the purging in cases where, by the early application of external heat, profuse perspiration is produced, than where it is neglected. Indeed, where the sweating is promptly attended to, a second dose of that medicine is seldom, if ever, necessary. But further, perspiration does more than merely correct the 25 CHOLERA, ITS CURE AND PREVENTIVE. morbid action ; it gives us the power of repairing the injurious effects produced by it. It has been already stated that in Cholera the escape of the serous or watery fluid from the circulating vessels deprives the blood of its necessary dilution or fluidity, and renders it too crude to circulate, and that death in that disease is in every case caused, either directly or indirectly, by vascular depletion. Perspiration gives us the power of refilling these vessels and of restoring the necessary fluidity of their contents. It may, however, be objected, in liminc, that the drain of the fluids of the body, caused by an extensive discharge from the external surface in perspiration, will produce a depleting effect on the vascular system similar to that which is caused by a discharge from the internal surfaces — an effect the very opposite to that we propose to accomplish ; and I may be asked why I recommend a remedy which produces on the constitution an effect similar to that which is caused by the disease itself? To this I answer, that the class of vessels of whose agency we must avail ourselves in remedying the effects of the disease can best be made to act by this means ; and that when the agency of that system of vessels is brought into operation we have at our command the power, not only of correcting the morbid action by changing the determination of the fluids, but of repairing the injury that has been already sustained. The class of vessels to which I allude is the absorbents. Perspiration excites their action. The exhausting effect produced on the vascular system by the discharge from the external surface causes the absorbents, opening on the internal surfaces of, the stomach and intestines, to act like as many syphons in taking up the mild drink, and carrying it into the circulating vessels. — Thus we have it in our power not only to supply the drain caused by the perspiration, but to refill the circulating vessels, and to restore the necessary dilution or fluidity of their contents. Perspiration, therefore, has the effect not only of correcting the morbid action, but of repairing the injury produced by it. From what I have experienced, I am persuaded that a malignant case of Cholera could not be cured without exciting such perspiration. Upon the general restoratives which may be requisite for reestablishing the healthy action of the several functions of the system after the progress of the disease has been checked, I shall not dwell at present. I shall have occasion to speak of them afterwards. 9 26 CHOLERA, ITS CUKE AND PREVENTIVE. I have thus given an outline of the mode of operation of the general remedies I prescribe. In my next letter I shall describe the specific manner in which they are to be used in the detailed treatment of the disease. I have the honor to b 42 CHOLERA, ITS CURE AND PREVENTIVE. the skin seemed to be sticking to the bones, without any apparent intervening substance; the course of the veins was marked by hollow lines; the body and extremities had become almost dry, and on touching them, their morbid heat and parched state communicated to the hand a very unpleasant sensation ; the respirations were quick, with great anxiety and pain in the region of the heart; and the thirst was most urgent. There had been no discharge from either stomach or bowels after the medicines had been,