* AN ESSAY | ). ¦ ON THE ly^ NATURE OF THE EPIDEMIC USUALLY CALLED ASIATIC CHOLERA, &c. 

/- 

VTITH THE 

REASONS WHY IT SHOULD BE REGARDED A 9 AW EPIDEMIC DIARRHOEA SEROSA, 

INSTEAD OF 

COMMON CHOLERA MORBUS; 

AND AN ATTEMPT 

TO FOUND THE TREATMENT 

UPON THE 

PATHOLOGY OF THE DISEASE: 

BEING THE ANNUAL COMMUNICATION TO THE MEDICAL SOCIETY OP THE STAT^OF NEW-YORK. 

BT THOMAS SPENCER, ME, D. Presibekt 

" / 

HONORARY MEMBER OP THE KENTUCKY AND PHILADEr.PHIA MEDICAL SOCI1TIE!, CORRKSPOrTDIITG MEMBER OT THE ALBANY LTCECM OF NATURAL HISTORT, &C. 

ALBANY: 

PRISTED BT WEBSTER AMD SKIKNERS. 

1833. 







Page. Preliminary Discourse, 7 Chapter v Of the causes, symptoms, appearances oa dissection, and analysis of the blood, ----- 10 1. Causes, ib-2. Symptoms of the first stage, 11 3. " " second, 12 4. " " third, 13 " " " (a) Collapse, (b) Reaction, 14 5. " " fourth stage, 15 6. Prognosis, ------- 16 7. Appearances on dissection, --------17 8. Changes of the blood, 20 Chapter ii. Division of symptoms into constant and occasional, --- -_.-21 1. Of the constant symptoms, -------- ib. 2. " occasional symptoms, -------25 Chapter hi. Of the pathology of the first stage, - - - 27 1. Remarks on epidemics and their laws, ----- ib. 2. Modus operandi of the epidemic influence, - - - 31 3. Of intemperance and filth as predisposing causes, - 36 4. Recapitulation, - __._.. 37 Chapter- iv. Of the pathology of the second stage, - - ib. 1. Of the origin of the intestinal discharges, - - - ib. 2. Of the immediate cause of the discharges, - - - 42 3. Of their effects upon the circulating fluids, - - - 43 4. " circulation, ------ 45 5. " respiratory & capillary functions, 48 6. secretions and excretions, - - 49 7. " absorbent system, - - - - 52 8. functions of animal life, - - 53 9. Recapitulation, 60 Chapter v. Of the pathology of the third and fourth stages, (a) collapse, (b) reaction, (c) consecutive fever, 60 Chapter vi. Of the pathological relations and complicaktions of diarrhoea serosa with other diseases, - - 65 1. Of its relations to other forms of diarrhoea, - ib. 2. " complications with other diseases, - - 68 





Chatter vii. Of tire name and diagnosis of the epidemic, 72 Chapter vnr. Of the non-contagious character of the disease, 76 Chapter ix. Of the treatment of the first stage, - - - 81 1. Of the individual means of avoiding the disease, ib. 2. " public means of preventing the epidemic, 84 3. " remedies for the first stage, - - - - 90 Chapter, x. Of the treatment of the second stage, - - 93 Chapter xi. Of the treatment of the collapse, - - - - 102 Chapter xn. Of the treatment of the consecutive fever, - 113 Appendtx— Cases, - 119 

4 



TO THE READER. 

In the following Essay, I have principally written the results of my own observation. To the labors of others I have however been much indebted. Nearly three weeks had been spent amidst the epidemic, before arriving at the views here presented of the nature of the disease. A treatment against which strong prejudices had been previously entertained, but founded upon this pathology, had been subjected to the test of successful experiment equal to the most sanguine expectations ; and the belief was fully entertained that all th phenomena of the disease could be satisfactorily accountec for, and that the remediate means could be conducted upon those rational principles which govern the treatment of other diseases, whose nature is understood, before the idea occurred that it was the Diarrhcea Serosa of medical writers. It 

will hence appear, that this name has not been adopted for the purpose of coming in collision with my medical brethren, but as a deduction from pathological views previous ly entertained. No farther consideration is asked for thes views, than their candid subjection to those tests which are an unerring guide to truth — a divinity to which every mcd ical practitioner should pay unceasing homage. If they wil not bear this test, let them be rejected. The pathology was deduced from a separate analytical examination of each phe- 

nomenon of the disease, not in the order here presented, for 



TO THE READER. 

in conducting these researches, I often found myself like the traveller without a guide, in a land unknown, wandering in the labyrinth of uncertainty, and occasionally finding truth a a resting place. Although satisfied of the general correctness of these views, yet exemption from error is not claim cd. It is notwithstanding, a task of exceeding difficulty to conduct others by the same route by which we ourselves ar rive at results, or to satisfy them that they are true. The symptoms of the latter stages were first subjected to examination, but it was soon found that the first dawnings of the disease must be fully traced, and their relations as effect must be connected with the original causes, in order satisfactorily to account for the concatenation of phenomena which constitute the entire disease. In the hope of contributing my mite towards improving the knowledge of its nature and treatment, and of aiding the investigations of those who have not witnessed this terrific epidemic, the following essay is submitted to a candid public. 

6 



Spencer on Asiatic Cholera. 

Art. VI. Annual Address, on the Nature of the Epidemic, usually called Asiatic Cholera, fyc. Delivered he- 

fore the Society, Feb. 5, 1833. By Thomas Spencer, M. D. President, Honorary Member of the Kentucky and Philadelphia Medical Societies, Corresponding Member of the Albany Lyceum of Natural History, fyc* 

Epidemics have in every age excited the dismay of mankind, and swept from the stage of human action a vast proportion of the inhabitants of the globe. The apprehension they produce is greatly enhanced by the rapidity of their movements, and the mysterious character in which these insidious enemies are enshrouded. It therefore becomes peculiarly important that the nature of every disease prevailing under this form, should be carefully investigated, and that the symptoms and mode of treatment found most successful, should be faithfully recorded. This may serve as a beacon in after time, to guide the enlightened physician in his prescrip tions, whenever such disease recurs, and tend greatly to miti gate the terror which severe epidemics universally bring in their train. In performing the duly imposed by the ordinances of this society, I cannot perhaps offer any thing more accepta ble than the result of my observations and reflections upon the disease which has recently produced such general devastation throughout the habitable globe. 

This epidemic commenced at Jessore, a city nearly one hundred miles northeast of Calcutta, in August, 1817.* It was at first regarded as a new disease ; and it is still considered by many as such, but it is believed that a similar one has been described by Hippocrates, Sydenham, Morgagni, and a host of other distinguished teachers, and practitioners of the healing art. If the present epidemic has spread more universally than most others of the same character, which have preceded it, yet we cannot but be forcibly struck with the marked similarity in the description of symptoms which obtains in almost all the writers from the earliest records of 

v Brigham. 

7 



Spencer on Asiatic Cholera. 

medicine. A few discrepancies could indeed be pointed out, but they are sufficiently explainable from the known diversities in the character of every epidemic disease, as it returns at different periods. In the brief limits which custom has assigned to an annual communication to this society, it cannot be expected that I should go fully into the history of the disease under consideration ; and indeed, if time would permit, it might be regarded as a labor of supererogation, so fully and ably has this been done by others. I shall, therefore, principally confine myself to a detail of the symptoms and the practical results to which my observation and investigations have conducted me. 

The recent epidemic has a received a diversity of appellations at the different periods, and in the various places in which it has occurred. In the East Indies, where it frequently appeared previous to 1817, it received the name of " mort-du-chien," and is probably the same disease which at an earlier period was designated as the cold plague. Since 1817 it has by some been considered a malignant fever, has been denominated phlegmorrhagia, but has more commonly received the name of cholera, eithe tingly, or coupled with some qualifying word, as epidemic Indian, malignant, contagious, asphyxia, typhoides i spas modic, or Asiatic cholera. Names are of little consequence unless they lead to erroneous views in relation to the na ture and treatment of disease ; but whenever this occurs a corrective becomes important. It is conceived that this ha happened in relation to the present disease; and I have in a hasty and brief essay heretofore announced to the public, the opinion that it is a disease long known by the name of diarrhoea serosa, appearing under an aggravated and malignant form, as an epidemic. Since the epidemic commenced in India, every writer has seemed to consider himself at liberty to give it such a name as his views of its nature or the presence of some accidental symptom dictated. This circumstance has contributed to involve our ideas of this disease in very great confusion ; and I freely confess, that my 

8 



Spencer on Asiatic Cholera. 

anxious examination of the various publications upon its nature and treatment, previous and preparatory to witnessing its phenomena, only tended to render " confusion worse confounded." Names of diseases, as well as every thing else, are .conventional, and every author has of course the right to use them in such sense as he pleases, provided he seasonably apprises us of his meaning. In the medical profession, a frequent change of the names of diseases is often productive of mis chief; and it is believed that an error of name and diagnosi has greatly added to the fatality of the present epidemic. Thi error has Jed physicians to overlook the first stage of the dis ease, in consequence of a change of name when it advances and the severe symptoms appear ; and also to confounc two diseases essentially different in their nature in their firs stages, which as they advance to a dangerous or fatal perioc present a similar train of symptoms. It is intended in th sequel to use the terms Cholera and Diarrhoea Serosa, in th sense which was generally attached to them by the professio previous to 1817. By cholera, is meant " vomiting and f re quent purging of a bilious humour, anxiety, gripes, spasm of the legs."* By diarrhoea serosa, is meant, " watery loose ness. The dejections almost entirely liquid, frequently me tastastic, and still oftener produced by elaterium, or othe drastic purgatives. Sometimes urinous, occasionally tingei with blood."\ This definition of Dr. Good describes the phe nomena of the disease much better than his description of th *' cholera spasmodical a complaint which he had not wit nessed, when he wrote his nosology ; and this sufficiently explains the circumstance of his having given two names t the same disease in his arrangement, especially as this, lik ,all other maladies, assumes an aggravated and altered cha racter on becoming epidemic. Sauvages and Young describ it under the same term. It is called by Hoffman, Parr, am others, diarrhoea aquosa ; and it has been known amon, writers by this term, or one expressing the same meaning 

* Cullen's Nosology. 

f Good's Nosology. 

9 







Spencer on Asiatic Cholera. 

from Hippocrates to the present day. The term cholera, has been much more vaguely used than diarrhcea serosa, and it is believed that the former being applied to the present epidemic, has been a principal cause of its pathology remaining so long unknown. The term cholera has become so much associated with our ideas of vomiting in intestinal diseases, that it is too often applied to complaints where vomiting should be regarded as an accidental symptom. The probability that this epidemic will frequently recur, renders it a subject of deep and abiding interest. It is proposed, by divesting it of mysticism ; and by establishing the identity of the seat and nature of disease in diarrhcea serosa, and the epidemic; by accommodating the remedies to the varying conditions of the system, in the different stages ; to rescue the treatment from empiricism, and establish it upon a rational and an enduring basis. This is a desideratum of such immeasurable importance to the profession, and to the paramount interests of humanity, that however diffidently I may commence, or imperfectly perform the effort, may I not be cheered by the consolatory reflection, that even an attempt of this kind will be duly appreciated by an anxious and indulgent public. 

CHAPTER I. 

Or THE CAUSES, SYMPTOMS, APPEARANCES ON DISSECTION, 

AND ANALYSIS OF THE BLOOD. 

1. Causes. — The first and moving cause of this, and all wide spread epidemics, is known alone to Him, who has establishec those general laws by which universal nature is governed. From the history of the disease, which has now extended its ravages throughout the habitable globe, it is evident, that althougl some all of ranks, ages and conditions have been its victims yet its principal fury has been spent upon the intemperate, the filthy and the profligate. We may therefore safely rank among the predisposing and exciting causes, intemperance, 

10 





uncleanliness and profligacy. To these may be added, fatigue, mental and corporeal, grief, despondency, cathartic drugs, indigestible meals, fear, exposure to cold, debilitating diseases, and whatever enfeebles the constitutional powers. 

2. Symptoms of the first stage. — The disease has generally been divided into four stages, and although nature has not as in many other complaints drawn a certain line of demarcation between them, yet it is deemed expedient to conform to this division. The first has been denominated the " premonitory stage;" but, for reasons to be fully detailed as we advance, the diarrhoea has the highest claim to be considered as the first stage of an uninterrupted chain of phenomena, which, with the exception of consecutive fever, constitute the entire disease. The earliest symptom that has been observed, is a furred, white, slimy tongue ; generally accompanied by distress and faintness at the pit of the stomach. Diarrhoea, generally of a milky or watery character supervenes, which is of uncertain duration, sometimes making its onset suddenly anc severely, soon running into the second stage, at others continuing several days alternately checked or aggravated. Involuntary discharges from the bowels have often taken place while the person is standing in company; scarcely a pain an nouncing the existence of the enemy within, and which i insidiously undermining the constitution. The features become sharpened from emaciation, the patient complains of languor and debility, and evinces an indisposition to corporeal and mental exertion. The food remains many hours unchanged upon the stomach ; and even wine has been vomited almost unaltered, some twelve or fourteen hours after it was swallowed. Slight nausea, cold clammy feet, and a sensation as if the whole bowels were to be expelled, when little passes them, are frequent symptoms. The pulse is not greatly changed from the standard of health, being at times increased in frequency, and exhibiting evidence of slight febrile action. There is a dryness of the surface, also scantiness of urine, which is at times voided with difficulty. Although there may occasionally be an admixture of biliary matter, giving the 

11 



Spencer on Asiatic Cholera. 

evacuations a yellow or dark colour, yet the intestinal evacuations generally evince an entire suspension of the hepatic secretion. 

3. Symptoms of the second stage. — Almost all the organs on which life depends becoming primarily or secondarily drawn into deranged action, this may properly be denominated the stage of commotion. Dizziness, deafness, difficulty of making water, and a violent agitation and rumbling in the bowels, generally with little pain, but occasionally attended with gripings, usher in this stage. Vomiting and purging of a watery fluid, unmixed with bile, now come on. Discharges sometimes rice-coloured, at others the colour of dirty water, again assuming a reddish hue, resembling the washings of beef, but frequently so clear and transparent that you can see to the bottom of the vessel, are evacuated in immense quantities. They are of a saline taste, and have occasionally a urinous smell. Small flocculae are generally seen floating upon the surface of these discharges. Spasms frequently supervene as the disease advances, and rouse the patient from an apparent condition of ease and quiescence, and he often calls anxiously upon the bye-standers to make use of frictions to the extremities. The muscles rise into hard balls, remaining contracted for some time. In general these spasms affect the muscles of one limb, or part of the body at a time, although cases occasionally occur, in which a large proportion of the muscles seem to be simultaneously affected with tonic spasms. In a few instances convulsions suddenly supervene, upon the patient assuming an erect posture, but they soon subside. At other times a tremulous motion of the muscles is observable. Vomiting and spasms are by no means uniform symptoms. Intense thirst attends this stage, but in the advanced part the patient seems to evince little anxiety for any thing else but drinks. The breathing is in general slowly performed, and in the intervals of spasms and vomiting, the patient is in a half dosing posture, seeming scarcely to exert his intellectual faculties. Great dullness of mind exists, and patients who had previous to the attack, indulged 

12 



Spencer on Asiatic Cholera. 

the most fearful apprehensions, appear regardless of the result; yet on being roused, not the slightest aberration of intellect is observable. Exceptions may be occasionally found in which the functions of the brain seem to participate in the overwhelming impression of the disease upon all the organs, evinced by suspension of the mental operations. In the early part of this stage, the pulse is somewhat contracted and accelerated ; as the stage advances, it becomes more and more feeble, not generally, though at times rapid, varying in frequency, according to the position of the patient and the treatment which has been pursued. Coldness of the surface constantly increases as this stage advances ; profuse sweating and corrugated hands supervene, and the skin progressively assumes a purple or dusky brown hue. The muscular power frequently remains in a remarkable degree, enabling the patient to turn himself in bed, and even get upon his feet. In the erect posture he is liable to swooning. When the discharges are of the colour of dirty water, the smell is somewhat feculent, while those that are rice coloured or clear, are inodorous, or of a urinous smell. 

4. Symptoms of the third stage. — This is usually denominated the stage of collapse, but it is deemed expedient to include the reaction in it, which is unattended with the full developement of febrile excitement. Collapse is marked by profuse sweating, shrivelled hands, a marble coldness of the whole surface, the pulse imperceptible, or the merest thread frequently receding and returning; intense thirst, and burning heat in the epigastrium. The respiration is slowly performed, and the intervals gradually lengthen as the patient sinks. Spasms occasionally rouse the patien-t, and hurry the performance of respiration, which at times is convulsively performed. The tongue is moist, cold and pale, exhibiting scarcely any return of redness after being pressed with the finger. The breath is cold and hot; injections are soon returned cold. The muscular power is sometimes entirely prostrated, although generally it is retained in a remarkable degree, enabling the patient to turn in, and even get out of 

3 

13 



Spencer on Asiatic Cholera. 

bed. The intestinal evacuations generally cease, although n passive vomiting or involuntary stools sometimes continue to the last. The urinary discharge is entirely suspended. The intellectual function is in numerous instances regularly, although dully performed : reason maintaining her empire to the last moment. A morbid sensibility of the surface is often present, rendering external remedies exceedingly annoying to the patient. The voice becomes almost extinct, the patient confining himself to the feeble and plaintive utterance of the single word, water. Hiccup is an occasional symptom. Suffusion or ecchymosis of the eyes is often present, and there is a waxy inelastic feel of the skin, which when pinched up, remains sometimes in that position. 

Reaction. — If the system rallies from this low condition, it presents some diversity in the train of symptoms, which require to be noticed, and carefully distinguished from the consecutive fever — a frequent sequel of the disease. In the most favorable cases of the reaction, the skin becomes gradually warmer ; the profuse sweating and corrugation of hands subside ; the breathing becomes more full and free, and the system progressively and uninterruptedly returns to health and vigor : the patient who has apparently been in the lowest state compatible with life, being able soon to tray about the neighborhood. But this favorable progress of the case is by no means generally to be looked for, and the organs of the >ody on being roused from this state of semi-death, are thrown nto irregular action, the carotids beat powerfully ; the heart hrobs, beating at times irregularly faster or slower, or its mlsation is felt in the epigastrium. The pulse is sometimes ull, but not as frequent and wiry as in the consecutive fever. The dreams, if the patient falls asleep, are often interrupted, and he awakes as if from sudden fright. Light delirium may come on, from which the patient can readily be recalled to consciousness. In this condition, the tongue generally remains moist, and the thirst somewhat urgent, but by no means as intense as in the preceding collapse, or in the consecutive ever. The respiration sometimes becomes hurried, and is iregularly performed, accompanied perhaps by sighing. Throb- 

14 



Spencer on Asiatic Cholera. 

bing pains are sometimes complained of, and the temporal arteries are found beating with uncommon force. If the patient appears somewhat comatose, he can be readily roused. Quiet sleep sometimes dissipates this perturbed condition of the organs, like a charm. The skin is at times considerably warmer than natural, but does not produce the burning sensation to the hand given by the heat of the consecutive fever. This state of reaction strikingly resembles an attack of ephemeral fever, in which the agitated condition of the organs soon resume their original calmness. 

5. Of the symptoms of the fourth stage. — This has been denominated the stage of consecutive fever. It by no means uniformly follows, and should not be considered as constituting an essential part of the disease. On the contrary, it should be regarded in no other light than as a fever of a low type, liable at all times to attack the system after hemorrhages, or other exhausting discharges, resulting from whatever cause, in enfeebled conditions of the system. Although regarded in this light, it is deemed expedient briefly to describe its symptoms with a view to distinguish it from the reaction, and to establish more definitely the remediate indications in each. The tongue becomes loaded with a whitish fur, which soon changes to a darker colour, and brown sordes often collect upon the teeth, as the disease advances. The edges and tip of the tongue become reddish, and a tremulous motion is often observed when it is protruded. In the reaction the tongue sometimes becomes covered with a thin white fur, but the vessels of the edges and tip are by no means as much injected as in fever. The headache in the fever is more steady than in the reaction, in which it is often throbbing. In the reaction the headache is not generally such as to interrupt the motions of the patient, while in fever the indisposition to motion and mental exertion is a prominent symptom. The urine in this fever, is in many cases entirely suspended, and when passed, it is high coloured and scanty. The pulse is X rapid, small and hard in fever than in reaction, and the are more suffused and drowsy. In the progress of the 

15 



Spencer on Asiatic Cholera. 

fever a dull expression and flush of the countenance come on, resembling in a marked degree the low stage of common typhus ; the temperature of the surface changes, and the skin from being hot and dry, becomes cooler than natural. If the head becomes the seat of local disease, the pain is generally fixed, and the patient appears to avoid any sudden motion, while consciousness remains. A delirium or coma comes on, from either of which the patient is with difficulty roused, and to these are added the other symptoms usually attendant upon diseases of the head. Cough and difficulty of breathing, indicating pneumonic disease, or soreness of the epigastrium and abdomen, with other symptoms indicating that local disease of the abdominal viscera is superadded to the general fever, often make their appearance. 

6. Of the prognosis. — The danger in the first stage is very little unless the remedies are improperly delayed or unskilfully employed. In every part of the disease the immediate danger is proportioned to the extent and rapidity of the intestinal discharges, varied only by the constitution, age previous habits, and idiosyncrasy of the patient. Cases in which the diarrhoea has been of several days' continuance are always more dangerous than those in which it has been o short duration, previous to the supervention of the same symp toms. When the patient continues anxious for recovery his chance is better than when he is indifferent to the result In general, when active vomiting comes on early, little dan ger needs be apprehended. Broussais, in his Lectures remarks, " when the symptoms predominate in the upper parts, and the diarrhoea has ceased, I venture the opinion that the disease is more easily cured." When free warm perspiration follows vomiting, and especially if bilious matter appears in the dejections, the patient may be considered safe. In general, patients sink more rapidly into collapse when spasms are absent than when present. Dr. Kirk, remarks that " when the spasms cease, I have always observed that the cases are most incurable." Dr. Scott observes, " in the low and most dangerous form of cholera, whether 

16 



Spencer on Asiatic Cholera. 

European or native cases, spasm is generally wanting, or is present in a very slight degree.* In the collapse, the symptoms being otherwise alike, those cases which have come on suddenly a-re much more likely to recover than those which advanced slowly. A profuse perspiration, shrivelled hands, marble coldness, and creeping pulse, denote great danger. If the passive exhalation of the skin and shrivelled hands abate, notwithstanding the skin remains cold, and the pulse scarcely if at all perceptible, considerable hope nmy be entertained. The respiration becoming frequent and full, if not convulsive, and the senses remaining clear, are favorable omens. We should never despair, while the powers of breathing and swallowing remain. In the consecutive fever great danger always attends, and it is enhanced by the presence of local disease in proportion to the importance of the organ involved. 

7. Dissections. — On the subject of dissections, I cannot laj claim to much knowledge from personal experience, having witnessed but one post mortem examination — that of a colour ed man, who died in the Utica cholera hospital, on the 23t of August last.f This man had been sick about four days reaction had been in some measure established after collapse but no high excitement followed, and stimulants had been moderately used. No urine had been voided since collapse. The brain and membranes were found slightly congested, and there was considerable serous effusion near the base of the brain and medulla oblongata, and in the ventricles. In the thorax the surface of the lungs was beset with small coloured spots of a line in diameter. The cavities of the heart were filled with a dark grumous blood, without coagula. In the abdomen the peritoneal covering of the intestines appeared slightly injected. The liver healthy, except a little paler than natural, the gall bladder filled with a dark fluid, nearly of the colour but of thicker consistence than the blood in the cavities of the heart. The large vessels of the liver some- 

* Madras Report. 

t Dissection by Dr. Wall, resident physician. 

17 



Speitckr on Asiatic Cholera. 

what filled. Stomach. — Red specks of the size of millet seed near the cardiac orifice, the residue white as natural upon the inner surface. On washing, slight specks of re( appeared occasionally upon the intestinal membrane, but gen erally it was of a natural appearance. The bladder con tracted to the size of a pear, from one quarter to three eighth of an inch thick. Almost all the internal viscera appearet rather drained than filled with blood, what remained being in the veins while the arteries were almost entirely empty Some bile was found tinging the inner surface of the intes tines for a considerable extent. The following summary o the appearances on dissection is prepared from those men tioned by the various writers on the disease. " When we examine a corpse, dead of cholera, we remark a livid pur pie, or blue colour of the skin, over the whole surface of the body, but more strongly marked at the extremities ; the skin of the fingers on the palmar face is wrinkled, and the tips o the fingers and toes have deep furrows within, produced b; this means. The eyes are deeply sunken, and have a dark bluish black ring around the orbits, the conjunctiva is inject ed with blood, and has a ghastly lustre, the flexor muscles are rigidly contracted, the tendons standing out prominen on the extremities, the hands are firmly clenched, requiring an effort to open them."* 

In the head, various appearances are mentioned by writers-, such as the brain and membranes of a healthy aspect ; — congestions ;— serous effusions. 

The spinal cord — healthy ; loaded with blood ; — soften ed ; — slight serous effusions. 

Ganglionic system — healthy ; — ganglions and plexuses injected with blood. 

Thorax — lungs — natural ; gorged with dark blood ;—collapsed into a small bulk ; — hepatized after reaction ;—"; — " The 

* Boston Med. Magazine, for Oct. 1832. Paper by Charlos T. Jackson, M. D. ' on Cholera in Vienna." 

18 



Spencer on Asiatic Cholera. 

l>tilmonary veins contain clots of yellow coagulated lymph, tremulous like jelly." 

Heart — structure unchanged ; — soft, easily torn ; — left ventricle and aorta at times distended with black blood, fluid or coagulated. 

Abdomen — Omcntum — healthy ; — injected with blood. Mesentery, generally filled with blood ; — glands occasionally enlarged. Liver, generally natural ; — paler ; — engorged; — gall bladder filled with bile, generally dark, occasionally yellow :—«: — « all the branches of the abdominal portal veins were empty."* 

Spleen, natural ; — flaccid ; occasionally much shrivelled. 

Bladder, contracted and empty ; — rarely filled. 

Stomach — external membranes sometimes natural, frequently reddened ; — internal membrane healthy ; — paler than natural after death in collapse ; — red specks ; rounded vesicles containing pus ; — streaks of red ; — red patches ; — delicate pink colour ; — granulated ; — thickened ; — softened ; — friable ; — arterial engorgement ; — venous engorgement ; — dark colour after fever ; — sphacelus ; — contents, ingesta unaltered ; — fluids transparent green, dark, flaky j — coagulable lymph ;—; — bloody gelatine. 

Intestines— external membrane occasionally healthy ;—; — generally injected with blood. Internal membrane — natural colour ; — paler than usual when they suddenly die in collapse ; — specks of red ; — red patches ; — vermilion colour ; — pink colour ; — diffused redness ; — dark colour ; — rarely disorganization ;¦ — softening of mucous membrane. Peytr's and Brunmr's glands, at times natural or prominent on pale membrane, with occasional black points at centre ;—; — rarely ulcerated ; — introsusceptions ; — valvulae conniventes flaccid, thickened and swollen. Contents — air, serous fluids of various colours, whitish, oftenest red after collapse, and yellow after reaction ; — flocculae ; — adherent, whitish or greenish mucus ; — feccal matter and bile in the large intestines, about in five of one hundred cases. 

* Ainer. Journal, Nov. 1832, p. 22J. Early DinectioDl at Paris 

19 









S Serous membranes, healthy ; — drier than natural ; blanchappearance ; — slight turgidity and blueness. 

It appears to be a pretty generally conceded point, among medical men, throughout the globe, that little is to be learned from dissections in this disease ; the integrity of every organ remaining entire, when death ensues suddenly in the collapse. Dr. Winslow remarks, that "in the examination o the few cases submitted to dissection, no changes have been discovered adequate to the alarming nature of the symptoms." From the summary made of the various appearances on dissection, it would seem that no organ is uniformly congested or inflamed, and that these appearances are at times found in many organs or tissues. It may, however, be observed, that congestion or inflammatory appearances are much the most frequently found in the alimentary canal. The stomach is in such diversified conditions in this, as well as numerous other diseases, that medical reasonings, founded upon any change of appearances in this organ, must be considered exceedingly uncertain. The alterations observable in all the organs appear greatly influenced by the period of the disease at which death takes place. Cases that progress slowly, exhibit the greatest changes from the normal appearance. 

Of the changes in the blood. — The blood becomes exceedingly dark coloured as the disease advances to the stage of collapse, and chemical analysis has proved that this fluid is greatly changed in the relative proportions of its ingredients, compared with the healthy standard. Its specific gravity is increased, but its most remarkable change is in the great diminution of the fluid ingredients. The crassimentum is more than twice as much, as in healthy blood, while the serum is proportionably diminished.* There is an absence of the alkaline carbonate, and a great deficiency of the saline materials usually found in healthy blood. The fibrin is likewise greatly diminished. The intestinal evacuations have been found upon chemical analysis to contain the same ingredients which 

0 T> [•rtf/iarAi* Thrttntrtn rtf L""|-l j ril^M t'frfi 

20 



Spencer on Asiatic Cholera. 

were found deficient in the blood.* There is some discrepancy in the results as detailed by different individuals, but in the general summary above stated, it is believed a coincidence may be found. 

CHAPTER 11. 

DIVISION OF THE SYMPTOMS INTO CONSTANT AND OCCA- 

SIONAL. 

1. Of the constant symptoms. — In the preceding chapter a general summary of the causes, phenomena and sequence of this epidemic has been attempted, with a view to make 1 the basis of reasoning on the pathology of the disease. Bu before commencing with this, a preliminary inquiry is re quired into what may be considered as constant, and wha accidental circumstances in relation to the disease. On th causes, there is so general a coincidence of opinion among medical men, that no comment is necessary. On the symptoms this remark cannot be made to the same unlimited extent yet at the present time no great diversity of opinion appear to exist. A white, slimy tongue generally precedes the at tacks of this disease. The attention of the public was di rected to this symptom, by Dr. James M'Naughton, in a pa per published in August last, " On the Epidemic Cholera o Albany." Distress at ihepit of the stomach and indigestion it is thought uniformly precede or accompany the attacks Intestinal discharges, with the symptoms mentioned, constitute the leading and most uniform phenomena in the early stage. Indeed, diarrhoea in a vast proportion of cases commences the disease, and continues until the patient is in collapse, and occasionally until death. This, then, must be regarded as an escential and characteristic symptom through- 

* Paine 

I 

21 



Spencer on Asiatic Cholera. 

Ii Dr. Kirk, of Greenock, first directed the public atteni to the important point that diarrhcea uniformly preceded severe attacks which occurred on the island of Great tain. Dr. Isaac Hays remarks,* " that this symptom is ely altogether absent, though it unquestionably is so ocionally, and when this is the case, it appears to denote a iuliar malignancy in the attack. In cases where little or purging has taken place during life, the intestines have yet n found after death to be filled with rice-water like matter." During the prevalence of all great epidemics, cases occur in which life is extinguished without the developement of the symptoms usually characterizing the disease. The concurrent testimony of the profession in this country seems to confirm the fact of the almost universal precedence of the diarrhcea in the severe attacks. Professor Sewall, of Washington, however w T rites me, that " generally the cholera was preceded by diarrhoea, but there were exceptions to this." But Dr. Kirk spoke of diarrhcea as one of an uncertain set of phenomena, which he denominated " premonitory symptoms," and which the French physicians called " cholerine,' and the disease crossed the Atlantic veiled in mystery. Its masked character greatly heightened the general panic — a concealed and covert enemy being always much more terrific, than he who meets us in open, manly combat. In thus speaking, I would not have it understood, that I do not duly appreciate the labors of Dr. Kirk ; on the contrary, his indefatigable research in establishing this important fact, has done more than almost any thing else in unravelling the mysteries, and destroying the terrors of this disease. Dr. Kirk, however, calls this " diarrhoea cholerica," and intimates the belief that this might be contagious, and be the medium of the rapid dissemination of this epidemic throughout the globe. It became a matter, therefore, of interesting inquiry, what symptoms would distinguish this from common diarrhcea, 

* American Journal Medical Sciences, Feb. 1833, which he obligingly allowed 

22 



Spencer on Asiatic Cholera. 

which never had been considered contagious. With a view to determine this point previous to having an opportunity of personally observing the disease, I addressed letters to several medical gentlemen, living in places where it had prevailed, and requested an answer to the following among other enquiries : Are there any symptoms to distinguish the diarrhoea which precedes cholera, from the ordinary diarrhoea ? This was proposed with a view to a more definite diagnosis of the disease, in its first approaches, and in the expectation that the line of demarcation might be drawn between the common and " diarrhoea cholcricaf and thereby community be put in possession of the means of detecting its eaHy onset. In a highly interesting communication from the late Dr. Jonathan Day, of Syracuse, previous to his falling a victim to the epidemic, I received as answer to the above enquiry : " The diarrhoea that precedes cholera is much like that describee by Dr. Good, as diarrhoea serosa. As I have never before thought diarrhoea of sufficient importance to make much dis crimination in its varieties, I am not able to say whether i differs materially in its symptoms from the ordinary disease." In answer to a like inquiry, Dr. M'Naughton, in his paper already noticed, says, " I know of no circumstance which distinguishes the diarrhoea, which precedes the cholera, from ordinary diarrhoea, unless it be the total absence of biliary secretion in the discharges. Bile, I believe, is never present in the discharges preceding an attack of malignant cholera. If bile be found in the dejection, the cholera will be found of the common kind, should it follow a diarrhoea." On personally observing the disease, the remark of Dr. M'Naughton was fully confirmed, not only as to the cases preceding the attacks of the " cholera," but the universal diarrhoea which prevailed was found to be of the same general character. On enquiry of my professional neighbours, Dr. Knowlton of Cazenovia, and Dr. Mead of Nelson, who resided in villages where the severe grades of the epidemic did not occur, it was ascertained that watery or milky diarrhoea had extensively 

23 



Spencer on Asiatic Cholera. 

prevailed, devoid of biliary admixture. In answer to a letter of enquiry, Dr. Henry Mitchell, of Norwich, where the severe grades of the epidemic did not appear, remarks, " diarrhoeas have been much more frequent during the past summer than I have ever known them before ; they were almost wholly watery, and the functions of the liver apparently suspended." Other letters from various gentlemen throughout the United States, confirm the same fact. The disease seems to have attacked in its mild form the inmates of various public establishments, among which I may mention the " house of industry," in Boston, and the Massachusetts state prison in both of which places, intestinal diseases of a mysterious character, simultaneously made their appearance, but deatl being regarded as a necessary symptom of cholera, it was con eluded they could not be cases of the epidemic. In the Auburn state prison report for August, to Gov. Throop, made by Dr. John G. Morgan, a large proportion of the cases o diseases reported were " diarrhoea serosa," many of which assumed a severe character, but the prompt and efficient means employed, rescued the inmates from danger. It is believed that the assertion may be ventured, that the almost universal diarrhoea throughout the United States, has been serous, and devoid of bile in the dejections. 

Sharpened and emaciated expression of countenance, prostration of strength, indisposition to corporeal and mental exertion, are uniform symptoms throughout, varying according to the intensity and stage of the disease. In the second stage we have added to the above list of symptoms, constantly diminishing force of the pulse, scanty or suspended urine, and thirst more or less urgent, according to the rapidity and violence of the disease. Abdominal pain, frequently very slight, may be mentioned among the symptoms constantly attending. A purple or dusky brown appearance of the skin, marble coldness, low wail of voice, corrugations of the hands, when profuse sweating is present, may be enumerated as uniform symptoms of the collapse. These are symptoms character- 

24 



Spencer on Asiatic Cholera. 

the hands have been much dwelt upon as a characteristic symptom of this epidemic; but Professor Dewees of the Uni versity of Philadelphia, mentions it as a symptom of the col lapse of hemorrhage. Dr. Nathan Smith, in his practical es say on typhus, remarks, "in fatal cases there sometimes ap pears what has been called the iv ash er-w Oman's sweat — which is extremely profuse, over the whole surface of the body and extremities, standing in large drops on the face, am giving to the cuticle on the palms of the hands and soles o the feet a corrugated appearance, and a light colour as if i had long been macerated in water." I believe that thissymp torn is generally present in all cases of profuse sweating, but it may result in some measure from the rapid absorption in the disease under consideration. Passive exudation from the skin cold tongue, cold breath, and hot injections coming away cold are present in collapse, but absent in all the other stages. Al though the cold tongue and cold breath have been much dwelt upon as distinguishing symptoms of the epidemic, ye the opinion is ventured, that these may be found in the collapse of all diseases. 

2. Of the occasional symptoms. — Among the symptom frequently present in the first stage, may be mentioned dryness of the surface, cold clammy feel of the extremities, and a great commotion and rumbling of the bowels. But, the mos prominent of the occasional symptoms, are vomiting am spasms, which have been much dwelt upon by medical wri ters, as among the distinguishing symptoms ; so much so, tha their frequent absence in cases submitted to my personal ob servation, alone satisfied me that they should be considerec in the light of accidental phenomena. In addition to those oc curring under my own prescription, an opportunity present ed of observing the same in the case of Mrs. Snow, of Utica under the care of Drs. Van Zandt and Coventry, aymo hac witnessed considerable of the disease, not only in their own city, but while on a tour of observation to Albany and New- York. In this case I was informed, that a gallon of fluid was discharged every fifteen minutes, until collapse supervened, 

25 



Spencer on Asiatic Cholera. 

and yet vomiting and spasms were entirely absent.* There is this marked difference between vomiting and purging as liptoms, that the first is confined generally to one stage ol disease, while diarrhoea is prominent in all its essential jes. A still farther difference is the frequent absence vomiting. How often it does occur, it would be exceedingly difficult to estimate, until medical men draw the line between the preceding diarrhoea and cholera. The report of cases in public hospitals, where faithful records have been kept, shows different results. In one of the Philadelphia hospitals, a record kept by Dr. Samuel Jackson, shows 12 in 21 cases, where vomiting was a symptom, and in 10 of these there were spasms. In a record of 60 cases kept in the hospital " La Pitie," by James Jackson, Jr. vomiting was absent in two cases, and cramps in five. Dr. Isaac Hays, in the American Journalf remarks, " that vomiting is a prominent symptom in cholera, but there are numerous instances in which it is entirely absent. According to Mr. Scott, in certain visitations in India, there was scarcely an individual case in which it was manifested ;J and Mr. Pinel asserts that in Poland it was absent in three-fifths of the cases. § In Paris, London and this country, this symptom has been observed to be pretty constantly present." 

Vomiting is a frequent symptom in influenza and dysentery, when these diseases prevail epidemically ; although usually absent when cases are sporadic. Indeed, scarcely a disease exists of any severity, but that vomiting is present, or the stomach becomes more or less disordered ; and this organ seems to be the centre of that infinite play of sympathies by which the balance is preserved among the viscera of organic 

* Marcellus Donatus has narrated particulars relative to a woman in whom syncope was occasioned by the excessive serous excretion. So copious was the evacution that a large vessel was filled nt one dejection. Poterius mentions a notary, who, within one day, voided upwards of forty pints of serous matter, and it nearly proved fatal to him. — Cooke's Morgagni, vol. ii. 105. 

Must not the serous discharges in this epidemic come from the same source as in the cases of serous diarrhoea, alluded to and related by Morgagni ? Or, has the organization of the intestines changed since his time ? 

f For February 1833. 

t Madras Report. $ Gar. Med. de Paris, iii, 102. 

26 



Spencer on Asiatic Cholera. 

life, and by which the operations of nature are so skilfully di- Bd in their efforts to throw off disease. It hence appears, vomiting may be properly classed among the accidental omena of this epidemic. Spasms are more frequently abthan vomiting, but more indiscriminately attack all sta ges, although generally occurring even later in the disease Rice-coloured evacuations have been much dwelt upon as characteristic, but those who think this peculiar to the epidemic must have overlooked the appearance in other intesti nal diseases. Although serum is uniformly present, its co lour is wholly accidental. A urinous smell of the intestina discharges does not appear to have been much noticed by wri ters, but Dr. Shipman mentions his having frequently observ ed it, and that his attention was first directed to it by the late Dr. Day, of Syracuse. Dr. Jonathan Eights mentions its presence in the disease at Albany. To the occasional symp toms enumerated may bo added dizziness, deafness, dysuria, various alterations of breathing, chills, gri-pings and convulsions. Among this class may likewise be noticed one which from its being generally present, might almost be arrangec Pong the uniform symptoms, the entire retention of the xtal faculties. Although a dullness of perception is generally observable, yet cases occur in which there is such a retention of the intellectual energy, in the last moments o life as to manifest the independence upon material organiza tion of that immortal part destined to endure when " time shall be no longer." 

CHAPTER 111 

OF THE PATHOLOGY OF THE FIRST STAGE. 

1. General remarks on epidemics and their laws. — Having described the disease, and distinguished the symptoms into constant and occasional, it is now proposed to enter upoi an analytical examination of its essential phenomena, am trace their relations to the causes of the malady, and by that 

27 





means endeavor to arrive at its essential seat and nature* The first question which suggests itself in commencing our enquiries is, what is the original cause of the epidemics which become such wide destroyers of the human race ? The first moving causes of all the phenomena of universal nature are denied to the comprehension of the human understanding, and belong alone to Him, who said " let there be light, and 

there was light." To man is given the humbler task of observing such phenomena, the laws of which become the legitimate objects of philosophical enquiry. Notwithstanding the most indefatigable exercise of human ingenuity, the material substance, if such it be, has thus far eluded our research, and may never be subjected to the examination of our senses. Perhaps the supposition of some generally diffused substances producing these diseases, has led us to overlook the changes which have taken place in some of the elements which constantly surround us, and which have been subjected to the examination of our sensitive organs. Much time has likewise been spent in discussing the question whether this general cause is animalcular, electric, atmospheric, or telluric. If it could be proved to be animalcular, it would be exceedingly difficult for human ingenuity to devise the means of destroying that wide spread microscopic race. If telluric, it must operate at intervals through the medium of our food or drinks, or it must be an exhalation from the earth, mixing with the air, and become atmospheric at last. It seems of little consequence to determine this question, so long as the cause eludes our examination ; and indeed even then we should be unable to remedy the evil, throughout the immeasurable tracts of country, over which epidemics simultaneously spread devastation. Much discussion has likewise been indulged in relation to the particular manner in which malaria, or the epidemic influenza produces its effects upon the constitution. By some, it is strenuously contended that its primary action is upon the stomach, first mixing with the saliva. Others insist that it is received through the medium of the lungs ; or that it merely prevents the usual supply of oxy- 

28 





I for the arterialization of the blood. The nerves of the } are supposed by some to be the parts on which the in> ision is first made, and communicated by sympathy to the n, and from thence reflected upon other organs ; or the i is the part on which it is believed that the cause firs resses its influence. In the attacks of all epidemics, the lach gives early notice of disordered function by the usua ptom of indigestion. The brain likewise exhibks cvi :e of disorder by languor and indisposition to corporea mental exertion. The brain and stomach, which seem to be the centres of the two systems of animal and organic life, and which are constantly and reciprocally dependen upon each other for existence, so far as is yet determined simultaneously give notice of derangement. These are un doubtedly interesting fields of inquiry, and the efforts made to support the respective theories, have been the means of de veloping many valuable facts ; but too little appears as ye known upon this subject to make any of these doctrines the basis of medical reasoning. In prosecuting our enquiries, it is believed of little consequence to determine whether the brain or stomach is primarily affected. At present, it is bes to confess our ignorance, and confine ourselves to the carefui observance of the effects resulting from theso intangible causes. 

The accumulated observation of ages has established the position, that epidemic diseases are all governed by some general laws, to which it may be well briefly to recur in prosecuting our enquiries. The epidemic influence appears to be generally thrown upon some particular tissue or organ, giving it a predisposition, so that slight causes will often excite this tissue into violent disease. This may be exemplified by a reference to influenza, which in its sporadic form of catarrh, excites little apprehension, calling for scarce a medicine, but on becoming epidemic, produces such a predisposition in the mucous membrane of the air passages of the lungs, that every member of the community is liable from the slightest exposure to cold, or other exciting causes, to have the dia- 

5 

29 





i developed, and it now comes to assume a serious characdemanding the vigorous resources of the healing art. remark is likewise applicable to all epidemics, which me much more severe than in their ordinary sporadic . In dysentery, this general predisposition is produced . the mucous membrane of the colon, and during its alence, the same causes which excite influenza, when that is epidemic, now act by producing dysentery. The same remark holds in relation to typhus or intermittent fevers, where they prevail as epidemics or endemics. During the continuance of that particular constitution of atmosphere which produces this appetency to either of these diseases, exciting causes, which under ordinary conditions of the system, might be applied with impunity, will produce the severe attacks. Diseases are innumerable, but the exciting cause* are few. Sudden exposure to cold, for instance, is an exciting cause of a host of maladies, and under ordinary conditions of the system produces disease wherever particular predisposition or accident locates it. But if this general predisposition is disseminated throughout the community, these causes are invited to be expanded upon the susceptible organ, and hence we have that general law, that epidemics chase off other diseases. Dr. Rush, and others, have remarked, that during the prevalence of epidemics, all diseases partake more or less of their nature. This circumstance we should expect, since every malady producing general commotion of the complicated machinery of life, would be likely to develope disease in some degree, in the generally predisposed organ remote from Sseat of the first complaint. In individuals who have sufid repeated attacks of any malady, in a particular organ, becomes the subsequent seat of predisposition, and the al exciters of disease expend their influence more generally upon that part than any other. But if fever, or any general disease attacks this individual, the predisposed organ is exceedingly apt to suffer. It will thus appear, that epidemics are governed by the same laws observable in individual cas- 

30 





2. Of the modus operandi of the epidemic influence. — On 

the appearance of every epidemic, the first object of enquiry should be, on what organ or tissue this general predisposition 

is thrown. At what period of the disease can this last be ascertained ? In the early stage, when the symptoms are few, and easily considered, or at the advanced period, when all the organs of the body are drawn into the disease, and a numerous train of symptoms are to be taken into the account ? Most assuredly the former ; since as the complaint advances, it becomes at times exceedingly difficult to say, whether a phenomenon results from the original disease, or from the disturbance of some part secondarily drawn into the general commotion of the organs, which obtains in the aggravated stage of severe maladies. The cause of the present epidemic must be generally and extensively diffused, since almost every person in the community was afflicted more or less during its continuance, with distress and faintness at the pit of the stomach and diarrhoea, even when it has not assumed a severe and malignant character. The first observable effects are found in the digestive apparatus, particularly the stomach, in which food, drinks, and even wine, remain many hours unchanged. From this it may be conclusively inferred, that the stomach is weakened and disordered in its function, and another proof may be found in the white slimy tongue, a generally admitted evidence of gastric derangement. This, however, occurs in most epidemics, and the stomach participates in the diseases of so many other parts that the enquiry naturally arises, whether it is in this instance the seat of predisposition, or responds to some other organ with which it is sympathetically associated. The next symptom which becomes developed, and which at times makes its appearance simultaneously, is a milky or watery diarrhoea, often without any mark of pain, except distress at the stomach. What are we to infer from this milky appearance ? The small intestines are the parts where the food is received after being digested by the stomach, and taken up by the lacteals and carried into the circulation. We may conclude that the chyle, instead of 

31 



Spencer on Asiatic Cholera. 

lig carried into the blood vessels is discharged by the ininal outlet, giving to the evacuations a milky aspect. The [ undergoes changes likewise by mixing with the secres of the intestinal membranes, and with the exhalation eh dilutes and prepares it for the lacteals, and the serum be discharge mixed with the chyle, or appearing in the i of this watery diarrhoea, must come from the intestinal alents. The liver is the next organ which gives evidence lisorder. Pain in the right side, in the shoulder, and the other symptoms indicating inflammatory disease, are all wanting. A negative symptom alone, absence of bile in the evacuations, indicates an interrupted function of the liver, and there being no evidence of organic disease, we must believe that it results from torpor, obstructed duct, or that the materials from which the bile is manufactured, are cut off. Spasm of the gall ducts has been supposed by some to produce this result, but the absence of spasms sufficiently disproves this position. If not, we must suppose it often exists several days in this stage of predisposition. If it did exist, and the bile was continually secreted, the absorbents being always active, would carry the bile into the blood vessels, which would in the round of circulation, give a yellow tinge to the skin, a circumstance which does not occur. The source of this symptom admits of a ready explanation, from the established laws of physiology, in the sympathetic relations which exist between the several organs concerned in digestion. In health the liver always responds to the stomach, acting vigorously while digestion of the food is proceeding, preparing the bile to mix with the chyme in the small intestines. When the stomach is empty, the liver falls into a comparative state of quiescence, secreting but a moderate quantity. The function of the stomach in this disease, being nearly suspended, if the liver observed its habitual actions, the secretion of bile would cease. We may from all this infer that there is no mechanical obstruction to the discharge of bile, but merely a suspended function of the liver. How the 

32 



Spencer on Asiatic Cholera. 

cutting off of the materials for the manufacture of bile takes place in the progress of this disease, will be afterwards considered. Thus far we have found the evidence of little else, except disorder of all the viscera concerned in digestion, and the question recurs whether any of these give evidence of the epidemic predisposition. 

Bn health the avenue to the lacteals is guarded by the exents which pour out their fluids rapidly, washing out any irritating substance sent to them by the stomach. 

This is exemplified in the operation of cathartics, which by the irritation they produce, excite a discharge from the villi of the intestines, that are the seat of serous exhalation.* Large indigestible meals, or substances unacted upon by the stomach, have a like effect, and are often washed out by these discharges. Under ordinary circumstances, however, our food, even if imperfectly digested, is taken up by the lacteals. This is exemplified in dyspepsia, jaundice, and various other conditions of the system, in which no bowel discharges are excited, notwithstanding digestion is feeble, and no bile mixes with the chyme prepared by the stomach. During the epidemic, immense numbers were affected with diarrhoea, without any evident exciting cause, except their accustomed meals, and as chyme and water were generally the earliest fluids discharged, it is thought rational to infer, that the imperfectly digested food excites the intestinal exhalents, and is washed out. This is, of course, a slight irritant, and we have found the chyle ordinarily, under like circumstances, taken into the circulation. If this slight excitant produces such universal diarrhoea, whence does it arise ? The cause remaining equally intense, the part to be acted upon must be more susceptible to the action of stimuli, or this universal effect would not be produced. In speaking of the laws of epidemics, it was found that some organ or tissue becomes generally predisposed, and ready to respond to the action of slight stimulants or exciting causes. In this epidemic, we find the exhalents thus morbidly susceptible, even the slight change of 

* See Jackson's Principles of Medicine, p. 55. 

33 



SpCnccr oh Asiatic Cholera, 

the irritating qualities of the food from indigestion, producing diarrhoea. The exhalent tissue of the intestinal membrane must therefore be the seat of predisposition induced by the epidemic influence. Have we any other evidence of this part being the seat of morbid susceptibility ? During the prevalence of the epidemic, an apple, an orange, emotions of the mind,, slight exposures to cold, which are ordinarily borne with impunity, 

would often produce diarrhoea. The smallest doses of cathartic drugs, or even the mild laxatives, as a Seidlitz powder, or a dose of castor oil, would frequently produce profuse discharges from the bowels. The proof of this position does not rest upon my individual observation ; many others have noticed the same circumstance ; among whom I may mention the name of Dr. Samuel Jackson, who remarks,* "that before and at the period of the invasion of the disease, affections of the stomach and bowels were universally prevalent. A state of irritability existed in the alimentary canal, which rendered it liable to be disordered from slight causes, that at other times would scarcely have been felt. This condition continued to increase, and during the last weeks of July and beginning of August, there were few persons in the city (Philadelphia) who were not complaining of being unwell from feelings of this kind. It is hardly exaggeration to assert, that in this period from fifty to sixty thousand people experienced this species of light disorder." Dr. Walker, who was sent from St. Petersburgh to Moscow, by the British ambassador, says in his report, " that a peculiar state of the atmosphere was proved by almost every person in the city (Moscow) feeling during the time some inconvenience or other, which wanted only the exciting cause of catching cold, or some irregularity of diet, to bring on cholera." Dr. Payne remarks : " Theory and experience all give way to the overwhelming argument of a choleric atmosphere. The constipated dyspeptic abandons his bolus of soap and aloes, and condemns unbolted flour as a purgative, and even the shampooing of Halstead threat- 

* In a paper prepared for the American Journal of Medical Sciences, for Feb. JB3J, and which he obligingly allowed me to read in proof. 

34 





ens him with hyper-catharsis." In answer to a circular in- Sng information relative to the epidemic, Dr. Azariah B. pman of Manlius, N. Y. says : " I remarked early in the ng that a majority of cases of disease were attended with an unusual degree of gastro-intestinal irritation, and that small doses of purgative medicines, often produced hypercatharsis, and that diarrhoea was an annoying attendant on cases of disease, with which I had not been accustomed to see it complicated." In answer to a like enquiry, Dr. Thomas Miner of Middletown, Conn, remarks : " There is one important circumstance which I ought by no means to omit. From about the middle of August to about the middle of October, there was very generally prevailing a peculiar epidemic constitution or predisposition to disease, which was manifest by the state of the stomach. The fruits of the season, though generally good, and in their usual perfection and abundance, could be rarely eaten with any thing like their usual freedom, without producing a very unpleasant sensation in the stomach and bowels, and a tendency to diarrhaa. This was not imaginary, but so palpable that very few persons could indulge in fruit at all." It would thus appear, that even in those sections of the United States, which the severe grades of the epidemic scarcely visited, the same general predisposition was given to diarrhceal diseases. Dr. John M'Call of Utica, at an early period mentioned to me the belief, that many cases of the severe disease in that city, were excited by cathartic drugs ; and lam indebted to Dr. Peckham of the same place for the remark, that " artificial is equally hazardous with natural diarrhoea." Cathartics always act by exciting the intestinal exhalents. In health they produce little mischief. If, then, they are found during the prevalence of the epidemic to produce such violent effects, we might almost from this circumstance alone sufficiently prove the existence of the universal predisposition in the community, given by the general cause of this malady, to be in the intestinal exhalents. 

The other phenomena of this stage require but a passing 

35 





I ice.* The involuntary discharges which occasionally pen while the patient is about, may be accounted for from circumstance that scarcely any thing but water is disrged, and which excites no irritation. The sharpened feais indicate that, the usual source of nourishment being cut the absorbents begin to take up the cellular and waste :s of the body, and carry them to the circulation for its rishment. Scanty urine and dry skin can be accounted for he sympathetic relations existing between the intestines, i and kidneys, by which discharges from the one are often itituted for the other, and which will be farther noticed n we come to treat of the pathology of the second stage. 

fOf intemperance and filth as predisposing causes. — lected with this subject may now be noticed the operaof intemperance and filth, the history of this disease havproved their frequent agency in producing a disposition to attacks. Intemperance always weakens the digestive functions, as evinced by anorexia, heartburn, pain in the stomach, and frequent diarrhoea, to which this class of the community are subject. The liver sooner or later partakes of this derangement, as evinced by want of bile in the evacuations, and chronic enlargement of this organ. Associated with drunkenness, we always have its twin brother, filth, which acts upon the same organs, as shown by its effects upon the temperate, when exposed to its exhalations, by destroying the appetite, and often exciting nausea and diarrhoea. Here then we have two causes associated, acting upon the same individuals, and producing the like disposition to diarrhoea as the epidemic influence, and a concentration of causes makes them the ready victims. The intemperate are so subject to diarrhoea, that it scarcely invites their notice, till the attack brings them to the very verge of death. We can readily discover how the impure atmosphere of the town should predispose to this epidemic, independent of the operation of 

* Dizziness, deafness and aflictions of sight, which occasionally occur in the latter part of this stage and in the second, so generally occur in nil great disturbances of the economy, as to drmand no special notice. 

36 



Spencer on Asiatic Cholerd. 

the moral exciting causes hereafter to be noticed, of the communication of fear and terror, so readily disseminated in a dense population. We may now sum up in a few propositions the pathology of this stage. 

Rlecapitulation. — 1. The epidemic influence being thrown n the exhalent tissue of the small intestines, renders it highly susceptible to the action of irritants, so that the imperfectly digested food or mild laxatives often excite profuse evacuations, and there is thus produced a disposition to violent disease from the common exciting causes of diarrhoea. 

2. The stomach being weakened in its function, digestion is imperfectly performed, and at times almost suspended. 

3. The liver responding to the stomach from its habitual sympathetic relations with that organ in health, falls into a state of torpor, and bile is no longer secreted. 



CHAPTER IV. 

Of the pathology of the second stage. 

1. Of the origin of the intestinal discharges. — In com j mencing our researches into the nature of the second stage, the most prominent symptom presented is the immense increase of the intestinal discharges. Diarrhoea, which constitutes so prominent a part of every stage, but especially this, demands a critical examination in its relations as an immediate effect of the cause, and in its relations as a cause in producing many of the resulting phenomena of this epidemic. What is the origin of these immense discharges ? And how do they find their way into the inner surface of the intestines ? Some natural or artificial outlet must give exit to these fluids. Satisfactorily to answer these enquiries, however, is it necessary to recur to the anatomical structure, and the physiological offices of the intestinal membranes in health ? In the organ* izatioa of these membranes, notwithstanding they are denom* 

fi 

37 



Spencer on Asiatic Cholera- 

mated mucous, they are sero mucous,* combining the properties both of the serous and mucous tissues. In these membranes, then, are found all the elements that enter into the composition of the serous membranes, with the addition of the mucous tissue, which is beset with innumerable glandular bodies, named from their discoverers. f In the healthy condition of the membranes, these glands discharge a lubricating fluid, which protects their inner surface from the irritative action of the nutritive substances, sent to them from the stomach. Like all glandular bodies, these follicles perform a slow elaboration from the blood, which is interrupted in its progress by the complicated structure that always enters into the organization of the glandular tissues. These membranes, then, in addition to the glandular structure referred to, must have entering into their composition all the elements which make up what are called the serous membranes, to wit, capillary arteries, veins, absorbents, exhalents, nerves, and condensed cellular tissue. There open upon the inner surface of these membranes, the excretory ducts of the glandular bodies alluded to, and those of other glands, as the liver and pancreas. Now, from some of these sources we are to look for the intestinal discharges in the present epidemic. Il they come from the capillary arteries or veins, a rupture must give exit to them, and we should then expect that these fluids would be tinged with blood, a circumstance which at times happens when the evacuations look like the washings of beef. Opposed to this supposition of ruptured arteries or veins, is the fact, that the discharges are generally clear or rice-coloured, and it would be absurd to believe that an infinite number of small ruptures should be made for the exit of the watery to the exclusion of the red particles of blood. We are therefore to look to some of the natural openings of vessels upon this surface for the source. Few would be found to advocate the belief, that the liver or pancreas could be so changed from its healthy function as to give exit to these fluids through its 

" Bichat 011 the membranes. 

T Peyer and Crunncr. 

38 



Spencer on Asiatic Cholera. 

Iretory duct. In addition to these, there open the ducts n the minute glands of the mucous tissue, and from which »c fluids might flow, without the supposition of disorganion of any part — a circumstance proved not to happen m they die in collapse, by the whole record of dissections, bough no lesion of structure takes place, these little glanir bodies are often found exceedingly prominent on disions of those dying of this epidemic, and this has led ly to believe, that these were the source of the immense harges. The healthy functions of these glands being to secrete mucus, it would be necessary to suppose an entire change of action, to make them the source of the serous discharges. The parotid glands, the liver and the pancreas often have their natural secretions greatly increased, but the discharges from these glands always retain their distinctive characters. It is thought this may be said of all glands. A these little intestinal glands are subject to the general laws o this structure, it can hardly be believed that so entire a change can take place in their actions, (which are slowly and elaborately performed in health) as to give such rapid exit to serous fluids as must be required to have them the proximate seat of disease. The flocculcc and mucus often mixed with the discharges, giving them colour, probably come from the glandular structure of the intestines. If the, idea of the large discharges coming from this source be rejected, it may be enquired how the prominences of these glands can be accounted for in those who die of this disease. No pathological principle seems better established than that a rush of fluids is always determined to an irritated part. If there is a current ol fluids (hereafter to be noticed) to the intestines, these glands could hardly escape receiving an increased proportion, and they would become distended from the tortuous and complicated vascular structure entering into their composition. This explanation of the pathological condition of these glands receives further confirmation from the circumstance that they are found much more prominent when the patient dies in col- 

39 





lapse, than when he has suffered from reaction or fever.* In the latter case these glands have time to recover from their previous distention. Another source of these fluids might be from the absorbents which open by innumerable mouths upon 

tinner surface of the intestinal membranes, and here called teals. Many respectable physicians have believed this the ajin of these fluids, and this doctrine likewise requires examtion. In order to this, there must be a retrogade motion i ihe absorbents. The structural organization of these vessels offers an insuperable objection to this hypothesis in the present disease. There are throughout the whole extent of the absorbents to be found valves, which constantly interpose a barrier to the regurgitation of fluids. In addition to these, the chyle passes through the mesenteric glands, in which structure there is always interposed an obstruction to the rapid transit of fluids. But if both these impediments were overcome, what volume of fluids would the lacteals contain ? A quart or two at most. Allowing them, however, the capacity of a gallon, would this account for these immense discharges ? They are frequently a gallon every few minutes, until several are discharged — respectable physicians estimating the amount often lost in this epidemic, at from twenty to fifty pounds. When the lacteals become emptied, they must draw their |luids directly from the veins into which they empty. If this occurred, it would be absurd to suppose, that the mouths of these vessels would select the watery parts of the blood to the exclusion of the red globules. We have now examined every source but one, without finding any from which these large serous discharges can be derived. The only one remaining is the exhalent tissue of the intestines, and it is believed we may now draw the inference that the exhalents are the floodgates by which the vital fluids are thus rapidly drained from the body. If, then, these vessels give exit to the discharges, may we not infer that the exhalent tissue 

* Di\ Hnvi. 

40 





I (he bowels is the proximate seat of disease in the second tre^ as well as in the first, as already proved. In the exents, then, we have a natural outlet to these fluids, and of irse should expect no lesion of the membranes when the ient died in collapse — a fact most fully proved by the unisal testimony of the profession, who have made a record heir dissections, throughout the globe. It is believed that essential phenomena yet to be accounted for, can be traced hese discharges as a cause, and if so, the conclusion seems irresistible that we have correctly arrived at the proximate seat of disease. If, then, the proximate seat of disease is the same as in the first stage, when all will admit the disease is serous diarrhoea, shall we change the name and call it " cholera," because an indigestible meal or a debauch greatly increases these serous discharges, and vomiting supervenes ? In what has preceded, we have noticed only the serous evacuations, while the colour has not been accounted for. The first effects which w T ould naturally result from these discharges would be to wash out whatever might be in the alimentary canal at their commencement. At times these are yellow, or they look like dirty water, throughout the disease, and the discharges in these cases have a feculent smell. Dissections have shown about five cases in one hundred in which the colon was distended with feculent matter in those who have died of this disease, and this circumstance rationally accounts for such occasional appearance of the discharges. If part of the food remains upon the stomach, or the chyle remains unabsorbed, this gives colour to the evacuations, which sometimes resemble milk and water, or thin gruel. The follicular glands at times, on dissection have been found to exude a milky fluid, which may likewise give this or the rice-colour to the serous discharges. Rice-coloured evacuations are often observable in the chronic intestinal diseases of children. The red tinge seen at times in the latter stages of this disease, and in the intestinal contents on dissection, must result from the admixture of red globules of blood with the serum of the discharges. Colour would, therefore, appear as an accidental 

41 





circumstance, while the serum of the discharges is uniform, and in a large proportion of cases almost colourless.* When the pathological relations to other diarrhceal affections are traced, serous discharges will be found to constitute the source of danger in all. 

2. Of the immediate cause of these discharges. — If then the source of these fluids is what has been represented, yet it may be said that this does not explain the particular condition of the membranes, giving exit to them. Much contrariety exists among medical men in their views of the nature of all those conditions of the system denominated irritation, inflammation, congestion and sedation ; and until some definite ideas are affixed to each term, it is not intended to enter the controversial list to attempt to point out the particular condition, if to either of these, this malady belongs. It is sufficient, as is believed, to prove the position, that the exhalents give exit to these immense discharges. May not the actions oi these, as in hemorrhage, be variable, having their vitality morbidly exalted in some cases, and being rather passive mediums of the discharge in others ? The pathological principle, that whenever a part is irritated, a rush of fluids is directed towards it, has been handed down from the father of medicine, and is generally admitted. In the present disease, the epidemic influence rendering the exhalent tissues susceptible, and the exciting causes all having a direct tendency to irritate the intestinal membranes, we should expect a rush of fluids towards them. That this takes place is inferible from the rapidity of these discharges, which could hardly be supposed possible, unless a larger proportion of fluids was sent to these parts, than in health. This appears likewise deducible from the circumstance, that morbid changes have been much most frequently observed in the abdominal viscera, being often engorged with blood. This epidemic bears a more striking analogy to intestinal hemorrhage than any malady except the other varieties of diarrhceal diseases. Hemorrhage 

* Scott. 

42 





has been most satisfactorily proved to take place from the exhalents, when it is a primary disease,* and no modern writer but Gregory, it is thought, controverts this position. Dissections after the epidemic and after hemorrhage, show a striking resemblance, the structure of the membrane in both remaining entire. Indeed, the principal difference between these two appears to be, that in the epidemic a kind of secretory action only admits the watery and saline parts of the blood to pass, while in hemorrhage all its parts are discharged. Indeed, in the latter stage of the epidemic, the evacuations are often tinged with the red globules. The striking analogy in the effects resulting from hemorrhage will be pointed out, when we come to speak of the effects of these serous discharges upon the circulating system. 

3. Of the effects of the discharges upon the mass of circulating fluids. — Marked changes are observable in the chemical composition of the blood in this epidemic, and it presents a question of interesting import to determine, whether the phenomena of this disease result from such change in its pathological condition, or whether the alteration of the fluids results as a mere effect of the discharges. Chemical analyses in the first stage of the disease show no essential change in the composition of the fluids, while on the contrary in the collapse, there is an entire alteration in the relative proportions of its ordinary ingredients. That this change of the fluids produces some of the phenomena of this disease, and that the alterations which take place in the circulating mass, in the progress of this and other maladies, has been too much overlooked by many modern pathoiogists, is unquestionable, yet it is believed we should guard against the other extreme, of explaining every thing from changes in the blood, as too exclusive. 

It is obvious, that all sources of supply of the watery and saline parts of the blood are cut off, since the stomach and in- 

¦y Prof. Chapman in his Lectures in the University of Pennsylvania, and in t's General Anatomy 

43 



Spencer on Asiatic Cholera. 

B tines, which in health perform this important oflice, are ;v rapidly withdrawing these ingredients, and every thing en into them is washed out by the exhalents. The source 

I supply being thus destroyed, and the heart and blood ves-5 being a common reservoir from which all the discharges taken, we should rationally expect that the mass of cirating fluids would be deficient in those elements which er into the composition of the fluids evacuated — facts fully ved by chemical analysis, as stated in a preceding chapter. From this it may be reasonably inferred, that the changes observable in the chemical composition of the blood, are the effects of the discharges, which are of course the primary cause of the phenomena that eventually result from this pathological condition of the fluids. Is it not reasonable, then, to conclude that the changes in the relative proportions of the elements of the blood, would bear a ratio to the extent of the discharges ? Chemical analyses which have been made support the affirmative of this question ; and it appears the only reasonable mode of accounting for the differences in the composition of the blood in the early and advanced stages, to believe that these changes result at this period from the previous withdrawal of some of its elements. Depriving this fluid of its watery parts, would tend to render it thicker : thus presenting a mechanical obstruction to its circulation, and producing other phenomena, to be noticed in another place. The free oil, discovered in the blood by Dr. Gale,* does not appear to have been subjected to chemical tests, yet no doubt can be entertained of its being an animal oil. It probably comes from the cellular deposit into which oil enters as one of its proximate principles, brought into the general mass by the absorbents, which will be hereafter proved to be peculiarly active in this disease. But why remain unchanged in the blood ? The answer to this question may not be satisfactory, yet the following appears the most plausible exposition in our present state of knowledge. Vital changes in the solids or 

* Mentioned in Dr. Pavne's Letters on the Epidemic 

44 





fluids are entirely inexplicable upon mere chemical laws, yet these appear to influence some of the alterations in the animal economy. Chemical analysis of the blood has proved this fluid to be deprived of the alkaline ingredients which usually enter into its composition. These out of the body always combine with and change the sensible properties of oils ; and unless the principles of life which are in the collapse stage much enfeebled, subjecting the system to be influenced by physical laws, entirely change chemical affinities, the oil which the absorbents bring into the general mass might be expected to remain unchanged. 

4. Of the effects of the discharges on the heart and circulation — As yet we have only traced these serous discharges to the exhalent vessels as their source, but the effects upon the organs which are the fountain of these fluids, remain to be examined. Coming directly from the general mass of the circulating fluids, the most direct effect produced must be to lessen their volume, and thereby take off from the heart and blood vessels the stimulus of distention. What should be expected from this, but failure of the actions of the heart and arteries proportioned to the extent and rapidity of the evacuations? If this be the immediate consequence of unloading the blood vessels, can we wonder at the sudden sinking when the amount of fluids is often equal, nay more, in a few hours, than the estimated quantity of the whole volume of circulating mass in the heart and blood vessels ? What are the effects, for instance, of blood letting ? The pulse is found to grow feeble in proportion to the extent and rapidity of the discharge, and if carried too far the heart fails to beat, or pulsates feebly, respiration is slowly or convulsively performed, and if carried still farther, we have faintings, at times convulsions or spasms, coldness of the whole surface, &c. How different are these phenomena from the prominent symptoms of the epidemic ? The general explanation of the effects of bleeding is, that the symptoms result from the sudden manner in which the blood vessels are unloaded. But I may here be met by the objection, that the discharges being dififer- 

? 

45 





ent, like effects could not be expected. The saline parts of the blood are necessary to its due arterialization, as most amply proved by Dr. Stevens, and others ; and water, which constitutes ninety-nine hundreths of these discharges, is an important ingredient for preserving the life of all organized matter, whether vegetable or animal. All great discharges produce the same general train of symptoms. Profuse sweating always rapidly diminishes the force of the heart and arteries. The same may be said of profuse discharges of urine. Witness the extensive ravages produced by this cause in the diabetic patient. The effects of colliquative diarrhoeas in hectic, and indeed in all febrile diseases, are rapidly to impair the vigor of the circulation. The objection may here be raised, that the intestinal evacuations are at times altogether too small to account for the severe train of symptoms and death, which happen in this epidemic. Constitutional peculiarities always vary the effects of all evacuations. Dr. Marshall Hall, in his researches on the effects of the loss of blood, says : " it will be readily conceived that hypercatharsis and diarrhoea may induce the symptoms of exhaustion in adults as well as children. In some cases of great susceptibility to exhaustion, this event is very remarkable, and occurs when from the degree and measure of its cause, it could scarcely have been suspected." The force of this remark of Dr. Hall must strike every one, and a like observation holds as to bleeding, which cannot be borne by some individuals to any considerable extent, without the most alarming consequences. In numerous cases likewise of sudden death, without intestinal discharges, dissections have shown the bowels filled with serous fluids, in this respect similating concealed hemorrhages. During the prevalence of all great epidemics, cases of sudden death occur without the developement of the usual symptoms of the prevalent disease. Shall we on that account be denied the privilege of accounting for the generality of cases according to the established laws of living organism ? 

How does this epidemic differ from hypercatharsix produc- 

46 





Ed by elaterium or croton oil ? These, if taken in large doses, always induce profuse serous discharges. Medical men have for ages agreed, that they produce them by the irritation thej luce upon the exhalent tissue of the intestines, from whence fluids are discharged. It has been proved that the evacu>ns come from the same source in the epidemic. If so, a ilar effect should be expected. This is strikingly the case nust be obvious to every observing physician, and to enu:*ate the effects would only be to enumerate the prominent lptoms of the epidemic. There is an exception, however, tydragogue cathartics producing these severe effects. In jsical cases, for instance, gallons are discharged, by the ration of a brisk cathartic, and yet the patient is scarcely reduced in strength, and at times appears invigorated. What produces the marked difference of effects observable in these instances ? In dropsy, the effused fluids are thrown out of the general mass of circulating fluids into cavities. During the operation of the cathartic, the absorbents, by innumerable mouths, take up the effused fluids, a rapid transfer occurs through the medium of the blood vessels, and they are discharged from the intestinal exhalents. In this case, the heart and arteries are supplied from the dropsical fluids, as rapidly as serous discharges take place from the bowels. On the contrary, when there are no such sources of supply to the heart, its function rapidly fails from loss of the stimulus of distention. When speaking of the pathological analogy of the epidemic to hemorrhage, a comparison of effects was promised. In hemorrhage, when the evacuations of blood are rapid, a much less quantity is necessary to induce death, than when slowly withdrawn ; in which case almost the whole volume of the circulating mass is sometimes discharged before death ensues. This was strikingly the case in the epidemic, and both seem to admit the same exposition from the difference of times allowed for the blood vessels to contract upon their contents. In hemorrhage, we have sinking of the pulse, slow or convulsive breathing, syncope, occasionally convulsions, cold clammy sweats, corrugations of the 

47 





RLs, retention of muscular power, enabling the patient to in bed, thirst, dulness, but entire retention of the mental ers, marble coldness of the extremities, shrinking of the features. Spasms and vomiting are both, though not as frequently, present. Could a better description of symptoms, resulting from the epidemic be given, than those occurring in hemorrhage? If such a marked similarity is observable in the phenomena of these two diseases, is it not reasonable to infer, that they result from the same cause — the unloading of the blood vessels? 

5. Of the effect upon the respiratory and capillary functions — The function of the lungs unceasingly depends upon the volume and quantity of the circulating fluids sent to then by the heart. This dependence is indeed reciprocal, am whatever interrupts the healthy performance of respiration suddenly, arrests the function of the heart, as evinced by the effects of noxious vapors. The first enquiry that here pre sents itself is, how the lessening of the volume of circulating fluids, and consequent failure of the heart's function, inter rupts the due arterialization of the blood ? Every organ de pends for its function upon the due supply of its accustome( stimulus, and the blood being the natural stimulus of the lungs, if the general mass was lessened, and the heart ceased to perform its function vigorously, we should expect to find what Mr. Scott remarks often happens, " that in many cases terminating in death, respiration has gone on in its mechanical part, with little or no interruption, except that it becomes slower and slower, and in one instance was performed only seven times in a minute." This I have frequently observed in all diseases, and the frequency of respiration bears a striking proportion to the rapidity of the heart's movements, and the slow breathing in this disease can thus be readily traced to the effects of the discharges upon the functions of that organ. The changes which are gradually taking place in the relative proportions of the circulating mass appear likewise to have no inconsiderable share in producing the interruption of this function, water being an essential ingredient 

48 





Irepare it for ready transmission through the lungs and cairy circulation. Coldness of the surface, rapidly increasas this stage advances, is what should be naturally ex;ed to result from a failure of the respiratory functions, a want of the due quantity of blood sent by the heart to capillaries, as animal heat always depends upon the due brmance of the functions of circulation and respiration. 

I. Of the effects upon the secretions and excretions. — ence of bile constitutes a leading symptom in this, as well le first stage. The lessening of the general mass of fluids and the failure of circulation, would have a direct tendency to lessen the materials from which bile could be elaborated, but in thise pidemic we may find, in the organized structure of the intestines, a direct mode, by which the materials are cut off. The liver, unlike the other glands of the body, prepares the bile from the venous blood. From whence is this derived ? Through the medium of the vena portse, from the extreme branches of the mesenteric arteries, distributed to the intestines, and other abdominal viscera. The current of fluids is turned to the inner surface of the intestines in this disease, and this has a direct agency in interrupting the return of the fluids from which the bile is secreted. The abdominal portal vein being found empty on dissections, supports the above exposition of this symptom. Suppression of the urinary secretion may be readily accounted for by a reference to some of the established laws of animal life, both in health and disease, by which discharges from one part frequently operate as a substitute for those from another. Four important functions of the body are employed in excreting the effete or waste parts, to wit, those of the lungs, the bowels, the kidneys, and the skin. On the healthy balance and performance of these functions, health unceasingly depends. In the organised structure of the skin, the membranous air passages of the lungs, and membranes of the bowels, there is an entire similarity, with the exception that the scarf skin is extremely thin, or perhaps in some places wanting in the two latter, and in these organs we have three exhalent sur- 

49 



Spencer on Asiatic Cholera. 

les, perhaps nearly equal. In the kidneys, we have a acture different, but from these are likewise secreted aqu is and saline fluids. One of these discharges is often subuted for the other, both in health and disease. In health i may be exemplified by the effects produced from sudden exposure to cold. This gives a check to cutaneous excre tion, and the most common effect observable is a simple in crease of the urinary discharge, and no serious injury is done to the constitution. At another time, or iv another individual, a slight watery diarrhoea is induced, but soon subsiding leaves no morbid impression. Under other circumstances, a catarrhal affection is produced, which is generally unattended with much danger, the efforts of nature being able in a short time to throw off the disease. If, however, the discharge from either of these organs is diminished, and a corresponding increase does not happen in another, febrile or inflammatory disease generally results. On the contrary, when any cause increases the discharges from either of these organs, a corresponding diminution takes place from some oi the others. While the balance of these functions is thus preserved, no serious injury results ; but when these discharges become profuse, disease and rapid emaciation are the consequences. In disease the discharge from one of these organs may often be observed to operate as a substitute for the other. In intermittents, for instance, the solution of the paroxysm is almost always brought about by a free perspiration. Occasionally we observe that a discharge from the bowels, kidneys or lungs, brings about the like solution. The same may be observed in other fevers. In hectic, the diarrhoeal discharges frequently suspend the expectoration, and the colliquative sweats often alternate with the bowel discharges. "In ischuria renalis, the urine taken into the blood vessels is sometimes determined to pass off by the intestines." (Cullen.) 

From these laws of the four functions may be readily deduced the reason for the diminished or suspended secretion of urine, which finds its way by the intestinal outlet, leaving nothing from which the kidneys can perform their usual 

50 





elaboration, the blood having lost its aqueous and saline elements. Do we need any other cause than the large discharges to account for the diminished cutaneous or respiratory transpiration ? A farther evidence that the bowels in this disease become the outlet of the venal secretion, may be found in the urinous smell and saline taste of the discharges. Another proof is, that the blood at the commencement of the disease is found, upon chemical analysis, to contain the neutral salts usually discharged by the kidneys, while they are deficient, or entirely absent, in the latter stage ; and the intestinal evacuations are proved to contain the like saline ingredients. The appearances on dissection show a mere suspended function of the kidneys, which are uniformly found in a healthy condition, and the bladder contracted into a small compass. This last appearance has been thought by some to be a peculiar feature of this epidemic, but involuntary discharges of urine, which must empty the bladder, are among the common precursors of death ; and Morgagni mentions that this viscus is almost always found empty upon dissection. Having, as is thought, sufficiently proved, that the usual excretions from the other organs find an outlet at the bowels, it may be well to institute the enquiry how these discharges influence the disease. However absurd the prescription, urine constitutes a popular cathartic for the infantile age, and repeated experiments have proved, that a moderate quantity will operate upon the adult. 

It can hardly be possible that the neutral salts, contained in these evacuations, should not have the same effect upon the intestinal membranes, whether received through the medium of their exhalents or the stomach. If so, they must be both cause and effect in keeping up the disease, especially acting upon the predisposed tissue of this membrane, which on that account requires a much less dose of a cathartic to operate than in health. Would not these discharges, acting upon the highly susceptible bowels, like other cathartic mixtures, induce vomiting by the irritation they produce ? These discharges would appear to be a sufficient cause to account for 

51 





t stage running so soon and certainly to a fatal terminaunless arrested by remediate means. If, then, intemperance and filth act upon the same organs as the epidemic influence, and produce a like predisposition ; and, as is wel known, if the exciting causes, such as crude food, exposure to cold, cathartic drugs, or fear, are either sufficient in health to produce diarrhoea, and if the discharges themselves operate as an exciting cause in perpetuating the disease, do we neec the interposition of any mysterious agency to account for this stage ? 

7. Of the effects upon the absorbent system. — In speaking of the extent of the discharges, it was mentioned that from twenty to fifty pounds were occasionally lost in the progress of this disease, and the difference in the weight of individuals before and after the attacks, has proved this esti* mate within bounds. The estimated quantity of fluids usually circulating in the heart and blood vessels is from twentyeight to thirty pounds.* From this general mass the large discharges must be derived, and but for the continuance of a function, which has not yet been taken into the account, the system could not sustain this rapid loss of fluids for an hour. 

This leads me to the consideration of a symptom which has been looked upon and described as peculiar and characteristic of this disease, viz. extreme emaciation of features. What is the " horrible expression of countenance" so vividly described ? Is it not the " facies Hipocratica," the precursor of death in all diseases? The same emaciation that happens in typhus in a month, or that occurs in the hectic patient after a struggle with disease for years, sometimes takes place in the epidemic in a few hours. The bones of the face are almost laid bare, and there is often added to this a dusky brown appearance of countenance, which presented in the form of disease, and appearing as a mysterious stranger, no one not steeled to the impulses of humanity, can for the first time view without horror. But this dusky or 

* Homer. 

52 





purple appearance of the surface is always observable when from any cause the function of the lungs is interrupted, and imperfectly arterialized blood is sent to the surface, and admits a ready exposition in the present epidemic from the circumstance, that on dissection even the arteries are often found containing the same dark grumous blood as the veins. 

lationally to account for the rapid emaciation, recurrence t be had to some of the established laws of life in health disease. In the organization of our bodies, two sources ourishment are provided, the one through the medium of the stomach and bowels, the other the system itself. The cellular deposit is a reserve of nourishment, and the waste of one part frequently supplies the wants of another. The latter sources are wise provisions of Providence to en able this " fearfully and wonderfully made" machine to sustain life during the progress of disease, when the ap petite is destroyed, and almost every source of nourishmen is cut off through the medium of the stomach and intestines. The powers of life are almost wholly sustained by this means during the continuance of protracted fevers, anc many other maladies. In health all parts of the body are unceasingly undergoing changes of waste and renovation, so that it may be emphatically said that man is not the same ma terial being to-day, that he was yesterday. In the present epidemic we have found, that the organs, which, in health are constantly supplying the blood vessels with nourishment, are rapidly draining the heart of the vital fluids, instead o: furnishing their usual supply. While on the contrary, the absorbents, like ten thousand pumps, are conveying the fat and waste parts of the system into the blood vessels to sustain the sinking powers of life. 

8. Of the effects of the discharges upon the functions of animal life. — Hitherto we have only traced the effects of the large discharges, upon the functions of organic life. It is now proposed briefly to examine the changes observable in those organs by which man holds communication with surrounding objects. It is not, however, intended to trace these 

8 

53 





Icts through all the mysterious operations of the nervous em. Appreciable phenomena are all that it is intendto examine. All the functions of life seem constantly meed by, and dependent upon, the interposition of the rous system; yet too little is known of its operations to te them the foundation of pathological doctrines. In thus iking, we are not to undervalue the recent brilliant discovis in this department of medical science. On the contrasuch has been their progress as almost to lead to the in*ence of the hope that the knife of the anatomist, aided by the light of physiology, may yet demonstrate the connection of the operations of mind with the mysterious organization of the brain, and point us to " the thin partition, thought and sense divide." 

Dullness of intellect generally follows as an effect upon whatever weakens the general system. The heart and nervous system are reciprocally dependent upon each other for their respective functions, and whatever reduces the amount iarterialized blood sent to the brain would impair its func-1, and seem rationally/to account for the change from feat I apprehension in the patient to an entire indifference as (he result. 

If, however, there is one redeeming feature in an epidemic, which thus insidiously and suddenly summons man to his great account, it may be found in the circumstance that reason often preserves her empire to the last. The intellectual functions being seated in, and perhaps even depending upon the mysterious structure of the brain, this symptom conclusively demonstrates that the organization of this " wonderful compages" remains unimpaired. This is likewise fully proved by the record of dissections. 

Convulsive and spasmodic affections have so frequently attended the severe forms of the epidemic, as to be considered by many as essential parts of it, and to constitute a great source of danger. This belief has Jed physicians, to overlook the es- Cl parts of the disease, and also to the extensive employof opiates for the relief of these spasms ; but experience 

54 





I proved these remedies generally injurious. When, howr, these muscular affections are severe, and greatly harrass exhaust the enfeebled patient ; or when spasms affect the )irutory muscles, they may become sources of danger, and for remediate agents. Constitutional peculiarities appear ltly lo influence these symptoms, which are often producin irritable habits, by whatever makes a strong impression upon the nervous system, and they are concomitants of numerous oilier diseases. The convulsions in this epidemic soon subside, leaving the senses clear, precisely as happens when they result from hemorrhage, and it may be inferred that they arise from a like cause. Spasmodic affections occur in two opposite conditions of system, depending upon repletion or depletion of the vessels of the brain and nervous apparatus, a remark which has come to us from Hippocrates, and has been confirmed by universal observation. To the conclusion that spasms arise from depletion, it may however be objected that they sometimes ensue at an early period, and before the serous evacuations have become profuse. This is sufficiently explanable from constitutional idiosyncrasies, but an indirect depiction from indigestion or mild diarrhoea has generally been going on for hours or days, in the first stage, and before spasms supervene. That they generally result from depletion in this malady, is likewise inferible from the fact, that spasms and convulsions are uniformly observable in the last struggles of animals which die from sudden loss of blood ; it being rational to conclude that they might equally be caused from a loss of serous or sanguineous fluids from the heart and circulating apparatus. But, if spasms result from the effects of the large discharges, let us institute the enquiry, how spasms in their turn influence the circulating and respiratory functions. What physician, who has often bled his patients, has not at times seen the blood trickling slowly from the arm, and on directing his patient to move the muscles of the hand, observed the blood spurt several feet ? Who, that has exercised himself by running, but has felt his heart throbbing powerfully, and his breast heaving, respiration 

55 





keeping pace with the hurried circulation ? In this instance t muscles contracting upon all the small veins, ramifying nnumerable branches among; the fibres, lessen their cali, and hurry the blood back to the heart, stimulating it edoubled exertion, and the lungs to a corresponding action. The patient, in the epidemic, often lies in a half dosing posture, breathing very slowly. Respiration is much under our voluntary power. On the supervention of spasms, the patient is suddenly roused, and calls loudly upon the bystanders to use friction as a mode of relief for his sufferings. Can any one doubt that spasms, by hurrying the blood back to the heart from the minute veins, and by rousing the patient to voluntary exertions to breathe, contribute to aid two important functions, on which the pabulum of life unceasingly depends ? 

Vomiting was found, in our classification, an occasional, not a constant symptom, and only occurs in this stage of the malady. It is an exceedingly common symptom in all intestinal diseases. Whatever irritates the intestinal tube, generally produces it, and the higher the irritation is applied, the more certainly is vomiting induced. In colic, the spasmodic pains seem to cause it. In enteritis, when situated high up, the irritation is such as uniformly to produce this symptom. Give a drastic cathartic, its operation often brings on vomiting. Peritoneal inflammation and dysentery frequently present it as one of their phenomena. If a person lets a billet of wood fall upon his toe, or receives a blow upon his head, he often vomits. Is vomiting an essential symptom in such cases ? And is it strange that crude food, fear or cathartic drugs, acting upon the highly susceptible intestinal membrane, and either of which in health is often sufficient to produce this symptom, should cause vomiting in this epidemic ? Is it an essential phenomena, or the result of the irritants thus applied to the bowels ? When a dose of emetic tartar is given, the stomach generally rejects it, but if not, it frequently produces severe intestinal discharges, and even death. A 

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large dose of arsenic is sometimes vomited, and the patient thus preserved uninjured. Can any one doubt that vomiting is a salutary operation of the system, when these drugs are taken ? This brings me to the consideration of the effects of the operation of vomiting upon the intestinal discharges in the present epidemic. But it may be said that this phenomenon should have been considered while speaking of the derangements of the viscera of organic life, the stomach being one of these. In the first stage, we found disturbance in the functions of the stomach, and gave to it a full share of consideration. Is vomiting deranged function ? The muscular system is principally engaged in this operation, and it certainly appears proper to consider it in this place. When large serous discharges take place from the stomach, it is obvious they must in a great measure be brought to that organ by an inverted motion of the bowels, and have come from their exhalents. In this case, the mere action of vomiting which is induced by the serous discharges unloading the blood vessels, cannot constitute a source of danger. It can hardly have escaped the observation of any physician that nausea and ineffectual retchings always greatly depress the powers of life, while active vomiting often rouses enfeebled action, as may be exemplified by a reference to its effects, while a person is bleeding. If vomiting supervenes, it almost always exempts the patient from swooning, and when this occurs, he is always suddenly roused by the supervention of vomiting. In the operation of vomiting the stomach and muscles surrounding the abdominal viscera, are all thrown into powerful action. We generally have at the commencement of vomiting lie epidemic, an uncommon agitation in the bowels, rebling the swashings of water in an agitated barrel. This indicates that the bowels are thrown into spasmodic action, and that the stomach, as in colic, is secondarily drawn into the operation of vomiting. 

Diarrhccal discharges having been proved to come from the intestinal exhalents, it is now proposed to trace the opera- 

57 





r of vomiting in arresting these, by the immediate medianoperation of the contractions and their effects upon the 

other functions of life. 

We have already alluded to the pathological fact, that in hemorrhage the discharges come from the exhalents, and analogy would lead us to the belief, that the same circumstances 

found useful in bleedings, would act a salutary part in arresting diarrhoea. In hemorrhage, nothing is found more useful than muscular contraction of the part from which such discharge takes place. This may be exemplified by a reference to uterine hemorrhage ; and to the utility of emetics in bleedings from the stomach and bowels, to be more fully noticed in the treatment. Compression is one of our most efficient means of arresting hemorrhage. In the disease under consideration, the muscular contractions of the bowels would make direct compression upon the minute vessels, ramifying upon their surface. Concurring with this, the contractions of all the muscles surrounding, must strongly compress the abdominal viscera, and must, of course, produce the same mechanical effect upon the intestinal exhalents, as in hemorrhage, and directly tend to arrest their discharges. Having traced the effects of vomiting "upon the arterial circulation in the bowels, let us turn our attention to its effects upon the venous. Compression has always been deemed one of our most efficient agents in promoting venous absorption. We have already alluded to the effects of muscular contractions in hurrying the blood from the minute ramifications of the veins in their interstices. These intestinal contractions, and the compression from vomiting, must rapidly hurry the blood in the intestinal veins. Where do these go? To the liver ; and the direct effect of this would be to rouse the action of an organ whose function has been from the first dawnings of the disease, suspended. Active emesis sometimes restores the secretion of bile, and the concurrent testimony of the whole profession proves the patient safe, when this secretion returns. (See cases 3 and 4. Appendix.) 

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It is generally the case when an emetic is exhibited in other diseases, that no bile is ejected until the patient has vomited several times. May we not conclude that the action of vomiting, in such cases, hurries the blood from the intestines, and thus promoting the biliary secretion, this fluid comes at last to be discharged ? It may be said that compression of the gallbladder will account for this discharge, but it is at times altogether too profuse to admit of such an explanation. In jaundice and other diseases, with deficient biliary secretion, all experience proves emesis one of the most efficient agents for its restoration. Upon the function of respiration, vomiting cannot be an inert agent. The diaphragm and abdominal muscles which are so actively employed in vomiting, constitute an important part of the muscular apparatus for breathing, and their spasmodic contractions must rouse the patient and hurry respiration. Upon the heart and circulation, i cannot be a passive agent. The contractions of such an assemblage of muscles, and the compression of all the abdominal viscera must, from all these sources, hurry back the blooc to the heart, distending and rousing this organ, enabling it t( give a centrifugal direction to the fluids, which being thus vigorously directed to the lungs and extreme parts, promote warmth, and induce free diaphoresis. If the suppression of cutaneous perspiration acts a prominent part in exciting the epidemic, it would be absurd to believe that its restoration would not have a direct effect in arresting the intestinal discharges. If the above exposition of the pathology of vomiting shoult be rejected, universal observation has at least established the intimate relation of cause and effect between vomiting anr sweating, and from this alone might be deduced the utility o free emesis in restoring the lost balance of cutaneous and intestinal exhalation in the present epidemic. If then, emacition, spasms and vomiting, in this stage of universal commotion, perform these salutary operations, instead of being alarmed, should we not welcome their appearance as lending their aid in restoring the lost balance of the functions, and in repelling the invasions ol'ti foe that lias in the first period of the 

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remic insidiously made his approaches almost (o the citaoflife. 

X Recapitulation. — From a review of what has been adiced on the nature of the second stage, its essential pathol' may be summed up in a few propositions. 

I. The disease essentially consists in this stage, in a deterlation of fluids to the inner surface of the small intesss, diverting the respiratory, perspiratory and urinous disrges, with their neutral salts, from their usual channels; discharging them through the intestinal cxhalents, rapidmptying the blood vessels of their contents, and changing relative proportions of the remnant of circulating fluids. 

I. That the failure of the functions of the heart, lungs, llary circulation, and various secretions, results from didepletion, depriving those organs of their accustomed ulus. 

3. The absorbent system is rapidly taking up the adipose and waste parts of the body, to supply the failing resources of the heart, and thus results the rapid emaciation. 

4. The spasms of the voluntary muscles, and those drawn into contractions in the -act of vomiting, by compressing the intestinal exhalents, tend to arrest the discharges ; and by aiding the return of the venous circulation, stimulate the heart to redoubled exertion, giving a centrifugal direction to the circulation, thereby making a metastasis of the exhalation from the inner surface of the bowels to the skin. 

5. That a striking analogy exists between this disease and hemorrhage, differing only in its effects upon the constitution, from the circumstance of its changing the relative proportions of the ingredients of the blood. 

CHAPTER V. 

OF THE PATHOLOGY OF THE THIRD STAGE. 

(a) Collapse constitutes the leading feature in the latter stage of all diseases. The character of this is varied accord- 

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Ito the nature of the disease from which it results, being in c diseases sudden, in others gradual. In all cases, it is luced by the prostration of the vital energies — and two sral causes induce it. One is disorganization of some ortant organ on whose function life depends; and the oth-5 debility, from whatever lessens the volume of circulatfluids. The latter may take place gradually or suddenly* m what has been said on the nature of the second stage, it jvious that the collapse here must result from direct deple. This stage appears to be the last resource of the system, istore the lost balance of the functions, and the discharges c from the failure of the circulation, precisely as in the ipse in hemorrhage* 

¦hbility, not disease, must, therefore, be the leading charristic of this stage. The blood vessels not being able to contract down upon their contents as rapidly as they are emptied, fainting, and all the usual symptoms of collapse, from hemorrhage, present themselves. Some shades of difference are observable, but the leading phenomena are the same. The dusky brown appearance of the surface is more remarkable in the epidemic than in hemorrhage, and is what should be expected from changes taking place in the relative proportions of the ingredients of the blood ; the neutral salts having been most satisfactorily proved by Dr. Stevens, essential to its due arterialization. More of the colouring matter of the blood remaining in the epidemic than in hemorrhage, and this fluid not undergoing the usual change in the lungs, is of course sent back to the surface of a darker colour, giving this tinge to the skin. 

Ehe skin is frequently morbidly sensible. — This circume appears to result from the extreme coldness of surface, and resembles the same phenomenon arising from exposure to a cold atmosphere, or the other means of lessening the animal temperature. 

Convulsive breathing, by no means confined to this disease, undoubtedly results, at times, from spasm cf the respiratory 

0 

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licles. It is, however, an exceedingly common symptom sphyxiated conditions of the system, and in this disease deprivation of the blood of its ordinary aqueous and saline edients, prevents its undergoing the usual changes in the 

I^old tongue and cold breath, being common symptoms, in cases of collapse, demand no special notice ; obviously reing from failure of the capillary circulation of the tongue lungs. 

Intense thirst is more remarkable in this disease than alt any other. An instinctive desire for drinks, always res from whatever deprives the blood of its fluid ingredients. 

The internal heat, of which the patient complains in this stage, has led to the belief, that there was internal inflamma tion, and the remedies employed in that disease have been put in requisition in this stage. From the known effects however, of depleting remedies in inflammation, its continu ance would seem impossible in this stage. Our sensations o heat are always relative, depending upon the degree to which a part had been previously subjected. The cold tongue, cole breath, and hot injections coming away cold, go conclusively to prove that the internal parts participate in the same gener al failure of the capillary circulation as the surface, a condition incompatible with the continuance of inflammation. — This sensation of internal heat must, therefore, be referred to deranged sensation of the patient. 

The moist tongue, its vessels being entirely uninjected, and the same condition of the lips, all disprove the continuance of inflammatory disease. To these evidences may be added the appearances on dissection, which exhibit no lesions in any degree, when the patient suddenly dies in collapse. It is thought fairly inferible, from all that has preceded, that death, under these circumstances, results from depletion, and iliat the solid organism of the body remains entire, requiring nothing but Klating fluids to keep up the functions of life. If this be c should naturally infer, that animation may be for a 

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Ie suspended, and the vitality of the blood vessels remain, by contracting down upon their contents, might subsently set the machinery of life in motion, and the patient be s resuscitated. Facts sustain this conclusion. In answer t circular, inviting information on this subject, Professor ter, of Baltimore, says : " I saw no case of apparent death i collapse, followed by convalescence, though I have learnfrom high medical authority, that two cases, apparently 1 from collapse, were resuscitated. They are now in good ith. I have seen them both within the last week." Dr. res Palmer, of Cayuga, remarks : " that two had recovered from apparent death, one of whom was actually laid out upon the board, and the coffin preparing." Dr. Lyman Cla- Kf Salina, remarks: ' ; I saw a child, three years old, in h, at two hours from the attack, respiration and pulsation ceased ; the child was laid by, and a shroud prepared. Some hours after, the child was perceived to move, and recovered so as to call its mother by name. It died, however, about fourteen hours from the attack." Alderman Barnes and Mr. Gore, of New-York, mentioned two cases of the kind within their knowledge, one of whom, a woman, was apparently dead from an hour to an hour and a half, and subsequently recovered. The other case was a man, who was apparentlydead for a longer period, afterwards revived, but subsequently died of consecutive fever. Alderman Coxe, of the same place, mentioned to me that there were some cases in the Bellevue alms house, that were apparently dead for several hours, and afterwards recovered. 

In the Cholera reports of Hospital Physicians, New- York,* Dr. Codwise remarks : " about 5 o'clock I thought my patient dead ; it was after an attempt to raise her head, that she might swallow some chicken tea" ; " she lay sometime breathless, pulseless and motionless." She recovered. 

The vitality of the absorbents continuing after apparent death, may likewise contribute to the resuscitation of the pa- 

• Page 171. 

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tient, by supplying the blood vessels with aqueous and saline ingredients. Dr. Isaac Hays, in an able lecture "on the Pathology of Cholera,"* remarks : " The functions, it is known, do not all cease together : the organs die in succession. The function of absorption is among the last to die ; it often continues hours after the external phenomena of life have ceased. In one specimen of blood, taken from a cholera subject, some time after death, M. Lassaigne found nearly the same quantity of serum that is contained in healthy blood. Mr. Prater says, that sometimes in cholera, the circulation begins after respiration has ceased, the person being apparently dead." Should not such attempts at reaction, or those in which warmth returns, or strong muscular movements are observed, after apparent death, be aided by the same means of resuscitation, as when it happens from drowning, or sudden hemorrhage ? 

(b) Reaction in this disease does not materially differ from that which takes place when the system rallies from sudden collapse, resulting from any other cause ; and when irregular actions of the various organs occur, from having been in a state of previous inactivity, it should not be regarded in the light of confirmed disease. It presents considerable variety in the phenomena, demanding in this place no remarks upon their pathology. From what precedes, may be briefly deduced the pathology of collapse. 

1. That it consists in direct debility and failure of the functions of life, caused by the sudden loss of the stimulus of distention of the heart and blood vessels, which do not rear dily contract down upon their contents. 

I The qualities of the blood are changed, from the previdischage of some of its elements, while the others are ined. 

(c) Pathology of the fourth stage. — The fourth stage con^ sists essentially in fever of a low type, to which is often added local disease. Considering this a distinct form of disease, 

• Read before the Philadelphia Medical Soeiohr. Cholera Gazette, 21st Nov. W9, page 242. 

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and the pathology of fever, being foreign from my present subject, it will not be here considered ; although the remedies thought best adapted to this period, will in their proper place be noticed. 

CHAPTER VI. 

Pr THE PATHOLOGICAL RELATIONS AND COMPLICATION OF DIAKRHCEA SEROSA, WITH OTHER DISEASES. 

1. Of its relations to other forms of diarrhcca. — It must be evident, from what was said upon the origin of the serous discharges in the epidemic, (see chap. IV. 1) that all discharges coming from the intestinal tube, must be composed of hemorrhagic, serous, or mucous injesta or feculent matter, or a compound of these, and which would of course vary the appearance of the evacuations. It is here proposed to examine the several varieties of diarrhoea, with a view to determine what constitutes the source of danger in each. 

(a) "Diarrhoea Biliosa" — " Focces loose, copious, and particularly yellow." — (Good's Nosology.) In this variety, there is evidently an increased secretion of bile, the natural cathartic of the system. If this were discharged into the intestines, in too large quantity, what should we expect ? The specific action of cathartic drugs being to act upon the intestinal exhalents, would excite serous discharges, which woulc wash out the bile from the bowels, in the form of copious yellow stools. Suppose, however, this proceeded so far as to endanger the system, from the extent of the discharges, what would happen ? The rapid drain of fluids into the inner surface of the bowels, by cutting off the return of blood to the liver, through the portal veins, would suspend the secretion of bile, and the discharges would at last come to be devoid of this fluid. Observation proves this to be the general termination of bilious diarrhoeas. It must, therefore, be concluded, 

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B: if any danger results, the serous and saline matters disrged, must constitute its source. 

Ib) " Diarrhoea mucosa. — The discharges consisting of, or taining a copious discharge of mucous." — (Good.) This n of diarrhoea evidently consists of a compound of serous mucous discharges, and as mucous is secreted from glands eh always perform a slow elaboration from the blood, it st be evident that any pressing danger in this variety must lit from the serous part of the discharge. 

(c) " Diarrhaa Caliaca — discharge of a milky humor, like chyle." — (Cullen's Nosology. ) Of this variety we have already spoken, while treating of the epidemic, where it was found that the serum, with which the chylous fluid was mixed, constituted the principal source of danger. 

R(d) " Diarrhoea Lienteria — the food, without any materia ange, quickly discharged." — (Cullen.) No immediate danger can attend this form, unless serous discharges are excited. 

( c) "D. Hepatirrhma — discharge of a bloody matter, like serum, without pain." — (Cullen.) This must evidently be a serous discharge, in which a few of the red globules of the blood pass off with the serum, as often happens in the epidemic, and the source of danger the same. 

(f) " Diarrhoea Fusa — (D. Crapulosa of Cullen?) faeces of common quantity, but immoderately loose and copious, (stercoracea.)" — (Good.) It must be evident that this is the mere washing out of the contents of the bowels, by the intestinal exhalents. These constitute all the varieties in Cullen's and Good's Systems of Nosology ; and it must be obvious that serous discharges are the only source of danger in all. A set of nosological names for these varieties of diarrhoea, pointing to the serous part of the discharges, as the important circumstance, and to the various colours, &c. as accidental coincidences, would appear to be a desideratum. The analogy of hypercatharsis to the epidemic, has already been traced, and the train of symptoms resulting found similar. It now remains to trace the pathological relations of the epidemic to 

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¦lera morbus, a disease with which it has been unfortun \y confounded. 

Ig) Cholera, as defined from Cullen, (see page 219) cons essentially in its first onset, of vomiting and purging, ex(l by bilious matter, from which the name of the disease erived. This is essentially a disease of warm weather warm climates, which either by producing a change in mass of circulating fluids, or operating upon the function le liver itself, produce a change in the properties of the atic secretion, and induce an augmentation of its usual ntity. Now, what are the usual properties of bile ? Cathartic. If the quantities of this become acrid, what should be expected ? The same as from the operation of any irritating cathartic drug, which always produces catharsis, and often emesis. If the bile is not very acrid, it excites bilious diarrhoea, but if vomiting happens, the disease is at once christened with the name of " cholera." In this disease, is vomiting an essential symptom, or does it result from irritation of the intestines, by the sympathetic relations existing between them and the stomach, as in other diseases of the bowels ? Let us examine the progress of this disease, and see whether it becomes hazardous, from the same cause as the other intestinal diseases already noticed. If the disease advances to a fatal stage, we have large watery stools, which lose their bilious tinge, and as the consequence, if the case prove fatal, cramps, low voice, profuse sweating, &c. as in the epidemic, or in any disease attended with hemorrhagic or other large discharges. Here, then, appears to be a train of symptoms, showing an intimate pathological relation to the epidemic in the latter stages. These large serous discharges, in the latter period of common cholera morbus, must evidently come from the intestinal exhale nts, and death must be produced in the same manner as in any of the diarrhceal discharges, whether natural or artificial. Vomiting generally ceases in the latter periods of common cholera, and the serous discharges Ktitute the only source of danger. This disease, then, s an entire analogy to hypercatharsis from active drugs, 

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Ehe name " cholera," is most unfortunate, since it has ne so much associated with our ideas of vomiting and morbid bile, as the source of mischief, that the serous diarrhcca excited is overlooked, and thus becomes the insidious outlet of life. Common cholera morbus should be considered as bearing the same pathological relations to bilious diarrhoea, as the severe forms of the epidemic to the diarrhoea serosa, which is always a much more dangerous disease than the bilious. It must be evident, from what precedes, that the source of danger in all these intestinal diseases, is the same, whether resulting from morbid bile, cathartic drugs, irritating food, or the epidemic influence ; no hazard attending either, except from the serous and saline discharges. And hence it is, that the term cholera, in medicine, is most unfortunate,, since it is merely applied to the aggravated forms of these complaints. 

(h) The operation of emetic tartar^ when it produces little vomiting, is generally that of a severe cathartic, and it can scarcely have escaped the observation of the experienced physician, that the train of symptoms resulting from the operation of this drug, often simulate in a striking manner the epidemic. Where death is the consequence, may we not believe it principally results from this drain from the intestinal exhalents ? 

2. Of the complications of serous diarrhoea, with othef diseases. — (a) Dysentery, although an inflammatory disease of the mucous tissue of the large intestines, is believed to be often complicated with serous discharges, which add greatly to the hazard of the malady. This complication becomes a matter of practical importance, requiring the resulting indications to be placed upon a rational basis. During the prevalence of dysentery, as an epidemic, I have observed cases of a suddenly severe character, in which large watery evacuations supervened, vomiting was a frequent concomitant, and as the disease advanced, the tormina and tenesmus ceased, and the patient sunk rapidly into collapse and death. A case of this description, made a strong impression upon my mind in 1830. 

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A young lady, aged 15, of strong constitution, was taken with severe symptoms of dysentery ; soreness of the abdomen, mucous and bloody stools, severe tormina and high fever ushering in the complaint. The exhibition of a dose of castor oil, seemed to be the exciting cause of a sudden change — large watery stools and vomiting supervened, the mucous and sanguineous dejections, and the tormina ceased, rapid sinking o] the pulse, marble coldness of the surface, profuse sweating, and corrugated hands came on, soon terminating in death. On witnessing the entire similarity of symptoms in the fatal cases of the late epidemic, it recalled this and other similar cases to my recollection, and I am satisfied that it must have been no uncommon complication, notwithstanding my attention was never before directed to the circumstance. Dr. Hodge, who has witnessed the prevailing epidemic in India, in a lecture, on the disease to the Philadelphia medical society, mentioned that he had often known the serous discharges to supervene upon dysentery, when this disease would cease. In one instance, he remarked, that the dysentery returned as the patient recovered. In these cases, the rapid evacuations^ from the exhalents, by reducing the system below the grade of inflammatory action, account for the subsidence of the dysenteric symptoms. A striking similarity is observable in these two diseases, in relation to the biliary secretion, which is absent in both ; and its return is among the most favorable symptoms in each. During the prevalence of the epidemic last summer, several cases occurred, complicated with severe dysenteric symptoms. Six cases of this description came under my care, and five under the care of a professional friend. These all readily yielded to the remedies hereafter recommended for the epidemic. 

(b) Influenza has generally preceded the invasions of the present epidemic, and presents an interesting association with the history of this malady. The epidemic predisposition in the influenza, appears to be thrown upon the mucous membrane of the lungs, which entirely resembles, in its organization, the structure of the intestinal membrane. 

10 

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(c) Intermittent and remittent fevers, are often complicated with diarrhoea, which is a cause of sudden death at the close of the paroxysm. Having for several years past, practised in a fenny country, I speak from careful observation, when I declare that this complication has constituted almost the entire outlet of life in this variety of febrile diseases. So suddenly, at times, has death been produced, that I have known the patient walk about in the morning, and found him in fatal collapse at night. My attention was early directed to this complication, yet I have the painful recollection of several sudden deaths from this cause, and my pupils can bear testimony to the earnestness with which I have directed their attention to this point. Although not mentioned generally by writers as a symptom in the malignant forms of intermittents and remittents, I strongly suspect many of the cases may have been complicated with diarrhoea, which contributed to their fatal character. The train of symptoms in these cases, entirely simulate those of the epidemic in collapse. 

(d) Measles, and other eruptive diseases, are often complicated with diarrhcea, which, when severe, always adds to the hazard of such cases. It is believed that this complication is one of the most frequent causes of retrocession of the eruption of measles, which is always attended with imminent danger. 

(c) Typhoid fevers are frequently combined with watery discharges from the bowels, and so hazardous are they considered, that one writer* on this disease remarks : " I have never lost a patient whose bowels continued constipated through the whole course of the disease, and have never known a fatal case of typhus unattended by diarrhoea." Professors Chapman and Jackson of the University of Pennsylvania, invite the attention of their pupils in the most urgent manner to serous diarrhcea, as a source of danger in febrile diseases. 

It becomes a matter of the deepest moment to the interests of humanity, that a more efficient means of curing this complication, than that too often pursued, should be developed. 

* Dr, Nathan Snitlii 

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Under the usual modes of treatment, by checking the diarrhoea with opiates, absorbents, and astringents, perhaps fol lowed by cathartics, the truce is often illusory, as it has been when the first stage of the epidemic has been thus treated the serous discharges bursting forth with redoubled force When the diarrhoea is thus checked in typhus, and the skin ¦ains dry, hemorrhage from the nose, or fatal coma often ;rvenes. Whether the remedies hereafter recommended in the epidemic for making a metastasis of the exhalation from the bowels to the skin, can be generally extended to typhus in its advanced stages, observation must determine. In one case, under the care of a neighboring practitioner, where the disease had continued between twenty and thirty days, watery diarrhoea had bpcome a pressing symptom. In consultation, an emetic, combined with sudorifics, was employed, the biliary secretion soon returned, and the patient recovered. Much respectable testimony might be cited in favor of the employment of emetics in the advanced stage of typhus, and I have in a few instances derived decided advantage from their use* Great care should always be exercised, carefully to distinguish bilious diarrhoea, which is the presage of recovery, from watery discharges, which are an unfavorable omen in typhus. I cannot close this branch of my subject without warning the medical student against the employment of active cathartics, for the cure of such cases. 

It would appear from all that has been said on the pathology and complications of diarrhoea serosa, that little danger need be apprehended in intestinal diseases, attended with discharges, except these come from the mucous glands or exhalents of the bowels. When the mucous tissue is the seat of disease, the alarm is at once given by the severe tormina present. In case of hemorrhagic discharges, the colour immediately arrests the notice of the patient. On the contrary, serous discharges being frequently unattended with colour or Kare often overlooked even in the first stage of the ep*, which, from the universal apprehension it has pro- 

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duced, it would be supposed, ought promptly to invite attention to its attacks. The danger, however, does not appear to be confined to the epidemic's terrific career, but the same disease entwining itself with a host of other maladies, becomes the sly destroyer of human existence. 

CHAPTER V;I. 

OF THE NAME AND DIAGNOSIS OF THE EPIDEMIC. 

The successful practice of medicine depends upon the early and correct diagnosis of disease. If disease advances toward a fatal termination, great difficulty is frequently experienced in determining its precise seat or nature, which can alone guide us to a rational mode of treatment. In the pre sent epidemic the early dawnings of the complaint have been too much overlooked, and when it has advanced to the very yerge of death, the term " cholera" is applied to it. This name might have answered very well, if it had been applied to al the periods of the malady. Its derivation would appear, however, to show its improper application to a disease in which no bile is present, and in which every physician hails the return of this secretion as the certain presage of recovery, ' f When the disease first broke out in Sunderland, the reports contained three classes of affections, diarrhoea, mild cholera, and malignant cholera, the cases of diarrhoea being four or five times more numerous than those of cholera." (Winslow.) Can any one point out the distinguishing symptoms of these three diseases ? If not, then should they be regarded as one. The same manner of reporting obtained in other places where the epidemic first broke out, and after its continuance, the milder cases came to find a place in the " cholera reports." This had a most favorable effect upon the public mind, and it is believed shows most conclusively that there is no line of demarcation between " diarrhoea," " mild cholera," and " malig- 

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nant cholera," but that they are only different degrees of the same disease. It has been proved that the proximate seat of disease in all is the same, and it is hence much more proper to call it by the same name throughout. What name should be selected, one that will call attention to its essential nature in every stage, or a name applicable to none ? Serous diarrhoea is the first stage certainly, and it may be well to enquire when the disease should be called cholera. Shall the appearance o vomiting be the point ? This symptom is so often absent, that diarrheca should hold the precedence in numerous cases throughout. Indeed vomiting is wanting so often, and especially in the stage which should invite attention from certainty of cure, that it is exceedingly improper to name the disease from the presence of this symptom. Spasms are still more frequently absent, and the concurrent testimony of the profession goes to prove that the patient is much safer when these symptoms are present than absent, conclusively showing them accidental parts of the disease. The epidemic generally goes on for several hours or days, when crude food, or other exciting causes, bring on the severe symptoms. Does this change the nature or degree of the disease ? If degree only, the name should not change. But it may be said, that vomiting and purging sometimes come on at the same time. They indeed do, but the patient in this case is comparatively safe. These cases are, however, unfrequent, and it would be obviously much more proper to name a disease from the the nature and phenomena generally present, than to take the symptoms of rare cases for that purpose. Indeed the serous discharges are here the only sources of danger. Physicians have for ages believed that serous diarrhoea consisted essentially in an exhalation from the bowels. It has been proved that the same seat of disease exists in the epidemic. This is an old name, coming to us from remote ages, and applies to a prominent symptom, and expresses the true nature of the disease. Shall it be exchanged for any of the numerous modern appellations of the epidemic ? The same error of designating diarrhoea by the name " cholera^ when vomiting su- 

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I fens, has come down to us from ancient times. If mede is ever to take its place among the certain sciences, it ecessary to get rid of some of the vagaries of the ancients, affix a more definite idea to the terms employed. 

|!o vaguely has the term cholera been used by ancient, as 1 as modern physicians, that it would be most fortunate t could be excluded from all nosological arrangements of disease, as it is from that of Dr. Young. There is an equal propriety in calling the collapse of fever, or any other disease cholera, as to apply the term exclusively to this stage of the epidemic. And if (he occurrence of vomiting is to be the period to call it cholera, then may a number of intestinal diseases receive the application with equal propriety. It is thought the epidemic would never have been regarded as an aggravated form of cholera, but for vomiting appearing as one of the occasional symptoms ; yet this phenomenon is a frequent concomitant of all forms of diarrhoea, and generally appears ill the latter stage of the chronic disease of the infantile age. All diseases become much aggravated by becoming epidemic, and we should under such circumstances expect to find an augmentation of all the occasional symptoms. 

Some respectable physicians have regarded the epidemic as a malignant form of fever, but the essential characteristics of typhoid fevers are wanting in the three first stages. In what is called the consecutive fever, this is undoubtedly of the typhoid type, but this is a mere accidental sequel of the disease. The moist tongue, which is pale at its edges, the uninjected condition of the lips, and the general coldness of skin in the epidemic, with the absence of coma and muscular debility, sufficiently distinguish it from typhus. 

Common cholera morbus is the only disease with which it has been confounded to any considerable extent, and the distinguishing characteristics of the two complaints, require to be carefully traced. 

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The epidemic almost universally commences with diarrhoea, of several hours or days' continuance. The commencing diarrhoea of the epidemic is devoid of bile. Water is the principal discharge in the early period of the epidemic. If bilious discharges come on in the epidemic, the patient is considered safe. The epidemic as well as the common diarrhoea is a disease of all climates and all seasons. Vomiting is by no means a uniform symptom of the epidemic. The epidemic is always greatly aggravated by changes of weather from warm to cold. In the epidemic, the hepatic function is suspended from the first dawnings of the disease. 

Cholera morbus is scarcely ever preceded by diarrhoea. If diarrhoea precedes cholera morbus, it is generally bilious. Bilious matter is the principal discharge of cholera in its early stage. If the bilious discharges cease in common cholera and watery stools come on, there is great danger. Cholera morbus is peculiarly a disease of hot weather, and warm climates. In common cholera vomiting is a. uniform symptom, when absent called bilious diarrhoea. Cholera morbus is increased by hot sultry weather supervening upon cool. In common cholera, the liver is actively excited and the acrid bilious matter secreted becomes the exciting cause of the disease. 

But, there are many striking resemblances between the two diseases in the advanced stages, as lias been noticed under its proper head. The insidious manner in which the epidemic advances, undermining the constitution for a longer or shorter period, in the first stage, giving notice of its attack by scarce a pain, until it conies suddenly through some exciting cause to assume the appearance of common cholera, will explain the reason for the error that has been transmitted successively from one physician to another, since the first appearance of the disease in the east, a mistake which could only be Kcted, by the accumulated observation of the whole pro- 

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If the name cholera is retained to designate the epidemic, hould be the name applied in the first stage of the disease, I should be used as a synonymous term with diarrhoea and treated accordingly. Considered in this light, ere is the frightful character of this epidemic ? It only beles dangerous from overlooking the first stage, which is entirely under the control of remedies. What is it that has rendered hydrocephalus no longer one of the opprobria of medicine ? It is an attention to the symptoms in the early stage of the disease, before the water collects in the brain, at which period, " dropsy in the head," like " cholera" in the present epidemic, is synonymous with death. The conclusion that the universal diarrhoeas constitute a part of the same general epidemic, is sustained by the concurrent testimony of the medica profession, with many of whom I have correspended throughout the union, all which goes to prove that these discharges, with few exceptions, have been of the same character as those which preceded the severe forms of the disease. From the same source, and the public journals, it would appear that the mortality from all diseases has been far less than in ordinary seasons. It hence follows, that these diarrhoeas, according to a long observed law of epidemic maladies, have tended to chase off other diseases. Notwithstanding, then, this epidemic has fallen upon some localities, with the impetuous rush of the tornado, may it not, like the rains of heaven, be regarded as a general blessing ? 

CHAPTER VIII. 

OF THE NON-CONTAGIOUS CHARACTER OF THE DISEASE* 

Few people would apprehend the slightest danger from common diarrhoea being communicated by contagion, but during the prevalence of this disease, even medical opinion has been divided, and it may therefore be deemed expedient 

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briefly to notice some of the evidences of its being merely epidemic. Diseases, by becoming epidemic, do not change their essential characters, although greatly aggravated during their continuance in this form. If we regard the universal diarrhoea as a part of the epidemic, this should be equally contagious as at the more advanced periods. Now, the prevalent diarrhoea simultaneously attacked the inhabitants at immense distances from each other, and the almost entire population of whole towns and villages were affected with this mild form of the disease. Contagious complaints generally attack in small scouting parties, while epidemics, like immense armies, spread simultaneously over immeasurable tracts of country. The progress of this epidemic has been regarded as exceedingly mysterious, from the circumstance of its seemingly contravening the established law of these dire diseases. Considered, however, in the light in which I have tiewed it, the mystery vanishes, since the universal diarrhoea conforms to, instead of contravening this law. The severe grades were generally confined to those places in which there was a dense population ; and a concentration of all the common exciting causes of diarrhoea, sufficiently accounts for the different degrees of severity* Its following the great thoroughfares has likewise been adduced in favor of its being contagious ; but these rarely pass through regions of country, thinly inhabited ; on the contrary, through dense populations, which, of course, sufficiently explains the severe disease following this track. The rapid spread and fatality in prisons and alms-houses, have likewise been adduced as an evidence of its contagious character. But purely contagious diseases, have never been known to disseminate themselves thus rapidly, and in such establishments we generally have broken down constitutions, and a huddling together of many individual — always a fruitful source of diarrhoea, which is indeed readily propagated by sympathy and panic. The fatality in some of these places has, in some instances, been in a great measure attributable to the inmates concealing the fact 

11 

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lieir having diarrhoea, for fear of being sent to the cholerd )ital. This circumstance happened at the Walnut-street on, Philadelphia, as stated to me by Dr. G. W. Norris, likewise at Bellevue alms-house, New-York, mentioned by Alderman Coxe. Is it rational to believe, that diarrhoea has its essential character changed, by becoming epidemic, and is thus rapidly disseminated by contagion ? Again, contagious diseases have some general determinate period at ¦which they attack after exposure, and the disease once established will almost universally go through its several stages, observing regular times for each. If this epidemic is contagious, it contravenes both these laws, since the rigid observation of the profession would have determined the time required after exposure, if there had been any regularity, and all experience proves that there was no determinate period for its duration, different cases continuing from an hour or two, to a fortnight. Contagious diseases rarely recur, while this epidemic would often return on the slightest application of the ordinary exciting causes. This disease could generally be cut short when attacked with appropriate remedies, entirely differing in this respect from contagious complaints, which proceed under any treatment. Contagious diseases do not require the influence of exciting causes to develope them. The severe form of this disease rarely, if ever, attacked any one without some obvious exciting cause. If mild diarrhoea is not contagious, will an indigestible meal, exposure to cold, or fear, convert it into an infectious disease ? Physicians in their anxiety to develope the nature of this malady, have been engaged day after day in dissecting those who have died, and notwithstanding they have wounded themselves during those investigations, have entirely escaped its attacks. The country has been as a whole, much healthier during the present season than usual, a circumstance probably resulting from a known law of epidemics, which chase off other diseases. If the universal diarrhoeas are not to be considered a part of the •pidemic, it will be impossible to account for the general 

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exemption upon this principle ; the severe grades having been altogether too circumscribed to account for this effect. Fevers have been almost chased from the country. This would appear to be the result of some general pervading cause. Epidemic typhus is generally preceded by the same symptoms of indigestion, which mark the first stage of the disease under consideration. May not the general diarrhoea, by preventing the improperly digested food from entering the blood vessels, account for this exemption from fevers ? And may not the same general cause produce all epidemics, which assume different characteristics according to the particular organ or tissue, which becomes the seat of predisposition ? Inferior animals are generally exempt from the contagious diseases to which the human family are liable, while, on the contrary, they are subject to be affected by epidemics, as has been strikingly exemplified during and preceding the appearance of this diarrhoea. From the close analogy which this disease bears to intestinal hemorrhage, the proximate seat being the same, and the effects on the constitution alike, we should infer that their general characters would be similar. No one entertains a belief in the contagious character of hemorrhage. 

It may be said that whole families being attacked would indicate its spread by contagion. To this it may be answered, that all are of course subjected to the same atmospheric cause, which we have shown, gives a predisposition to be acted upon by slight exciting causes, to which they are generally alike exposed. Not only so, the panic has in many places been such as to drive every neighbor from the family, leaving those only who remain well to perform all the duties of humanity to their friends. In this way they are all worn down by excessive fatigue, and want of regular meals. If to these exciting causes we add grief, fear, and despair of remedy, in case of attack, it sufficiently explains such occurrences without the adventitious aid of contagion. It may likewise be remarked, that those who went among the dis- 

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lid were no more subject to the attacks, than those who en\y avoided exposure. Indeed, several cases occurred unmy observation, among those who sedulously avoided Ir sick neighbors, becoming the ready victims of the disi, while not a single instance of death occurred among c who fearlessly and faithfully performed their duty, tchers lay down, and even slept on the same bed with the , without contracting the disease. The same thing is tioned by Broussais, and others, where the experiment been tried, and even inoculation has not been found to uce the disease. 

Physicians and nurses have been no more subject to attack than others. The evidence of the disease not being contagious must rest, of course, principally upon negative evidence, which may be abundantly found in its whole history, During, for instance, the English campaigns in India, two regiments being for a time stationed at different places, would be brought together, and daily and unceasingly intermingle, and yet the soldiers of one regiment would almost all have the disease, while those of the other would almost all escape,* Could this have happened, if contagion had any agency in its propagation ? It would appear much more rational to conclude that some atmospheric causes existed where one had been previously stationed, and which was absent where the other had been located. It may be said that the disease being mainly confined to large towns and dense populations, mr dicates its spread by contagion. But the mild form of the epidemic has been almost as general in the country as in the city. This difference appears perfectly explainable from the difference in the concentration of the causes. In the cities great preparations were made for the reception of the epidemic ; old sewers were often opened, to the exhalations of which, the population were exposed. If we have the general epidemic predisposition, and the concurrence of a cause sufficient alone to produce the disease, contagion would certainly be unnecessary to its production. We not only have poxi 

• Bombay Report. 

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ious exhalations in large towns, but a general concentration of all the exciting causes. Napoleon used to remark, " that a man could dodge a single ball, but could not dodge twenty,'' and frequently ordered a platoon, or park of artillery, to fire on a given point, The fatality generally told the effect. In cities, we have the epidemic influence, intemperance, filth, poverty, indigestible meals, changes from heat to cold, cathartic drugs, and " cholera reports," producing a sympathetic terror of the population, either of which is alone sufficient to induce the disease, and at times even death. If so many fatal causes are concentrated in one place, do we need the adventitious aid of contagion, to account for its spread or mortality? 

CHAPTER IX. 

OF THE TREATMENT OF THE FIRST STAGE. 

In the treatment of the early period of the epidemic, the subject presents itself under two general heads — preventive and curative. Among the means of avoiding the disease, may be classed those under the control of each individual, and others belonging specially to the supervision of the public authorities. 

1. Of the individual means of avoiding the disease. — (a) Pure air constitutes, at all times, an essential ingredient for the preservation of individual health, but during the prevalence of the epidemic, its importance is greatly enhanced, from the circumstance, that an impure atmosphere, resulting from filth, produces a similar effect upon the organs of the body, as that induced by the general cause of the epidemic. Every individual has it, therefore, in his power, by a proper regard to personal cleanliness, to guard against attacks of the disease. 

( b ) The food should consist of such articles as are easy of digestion, and all irregularities as to time and quantity should 

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be avoided. The functions of the stomach being much weakened in almost every individual, during the continuance of the epidemic, it is important that the quantity of food should be conformed to the powers of the stomach. A person had much better eat too little than too much, because all that is not well digested, does injury, and often excites the disease. The diet, therefore, should not only be nourishing but moderate. Great changes of diet, however, should not be made, those accustomed to high living being; liable to have the dis- CJ CD O ease excited by too suddenly withdrawing the accustomed stimulus of the stomach. Crude food, or a large meal, is in health a very frequent exciting cause of diarrhoea, and its effects must be greatly increased by the susceptibility produced upon the intestinal membranes by the epidemic influence. It should, therefore, be expected that profuse serous discharges would be the immediate effect of large indigestible meals, as proved by the history of the disease, and hence they should be cautiously avoided. 

(c) Drinks require to be equally subjected to proper regulation, otherwise no rules of diet can be in the least available. As intemperance in drinking is one of the most common excitants of the epidemic, it can therefore hardly be expected that the temperate will bear the use of ardent spirits with impunity. Notwithstanding the high authority by which brandy has been recommended as a preventive of the attacks of this disease, I am fully satisfied, that ardent spirits are not only unnecessary, but injurious to those previously unaccustomed to their use. To those, however, habituated to its daily employment, it may be proper to say, that a sudden suspension of the habit during the epidemic, might expose them to hazard, but great moderation should be exercised, since the slightest excess is liable to bring on the severe grades of the malady. Malt liquors, in moderate quantity, from the carbonic acid they contain, afford a grateful stimulus to the stomach, and aid the process of digestion. Port or Madeira wine may be advan- Bously employed for the like purpose, when the function le stomach is weakened from previous disease, or when. 

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lit oppression is produced by the effects of the epidemic innce. Under such circumstances, wine produces a tem»ry aid to digestion, especially if a meal remains long uniged upon the stomach. 

ti) Warm clothing is important to guard against the vicisles of weather, and all changes from heat to cold, should romptly met by an increase of this article. This direcis exceedingly important, since the whole history of the ise proves that exposure to cold, or rain storms, or sudden changes from heat to cold, have greatly aggravated the attacks — circumstances to be expected, since a sudden check of perspiration would produce a rush of fluids to the internal parts, and the predisposed membranes of the intestines would invite disease to those organs. Flannel next to the skin, is indispensable to the health of those who are much subjected to the vicissitudes of weather during the cool seasons. Beds should be abundantly supplied with clothing, since the cool night air is exceedingly liable to excite the epidemic. All unnecessary exposures to currents of air, or night or morning damps, should be guarded against or sedulously avoided. 

(c) All exertions of body and mind require, during the prevalence of the epidemic, to be subjected to careful regulation, avoiding every exertion which excites or fatigues either. Fear is a common exciting cause of diarrhoea in health. Who but has observed, that any strong emotion of mind, will often suspend the appetite for food, and that a meal previously received, lies like a weight upon the stomach, producing great oppression ? A person sitting down to a meal, on hearing some unpleasant intelligence, has his appetite suddenly suspended. Fear often produces vomiting and diarrhoea in the duellist, and that it frequently produces a like ellect upon the soldier, suddenly summoned to an engagement, or the person frightened at the appearance of a thunder-storm, or laboring under alarm from any cause, is a fact of universal notoriety. The attacks of this epidemic have been most frequent during the night. Impressions are always more vivid during our sleeping than waking hours. During sleep, the voluntary 

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I rations of mind are suspended. Fear keeps man half ike ; imagination, an involuntary operation of mind, prets to the timorous person, who has labored under previous •rhoea, the belief that he has the " cholera." Dreams are ays realities, and he is roused by the extreme symptoms, he hour of nigbt, when " the clock sounds the knell of his departed years." The connection between fear and diarrhoea, as cause and effect, is established by universal observation, and the effects of this passion, in health, entirely simulate the first stage of the epidemic, being characterized by distress at the pit of the stomach, and a diarrhoea almost free from pain. If, then, this passion excites the same disease in health, can we wonder at its fatal effects during the epidemic constitution of the atmosphere ? One of the best preventives must, therefore, be a serene and tranquil mind, bent upon meeting, unmoved, every emergency. The hours of exercise and repose should be carefully observed 1 , and no business should prevent their methodical regulation. This direction should not, however, be supposed to interfere with the extension of the most full and ample provisions for the relief and comfort of the sick. 

2. Of the public means of preventing the epidemic. — The observation and experience of every section of the globe, appear abundantly to prove that the epidemic cannot be excluded from a country by quarantine laws — a circumstance to be expected, if the views presented of the nature of the disease be correct. But it is not thence intended to convey the idea that quarantine regulations are of no utility, since much may be done by the public authorities to prevent and mitigate the sufferings produced by severe epidemics. It may, therefore, be proper in this place to offer some suggestions, not only to the medical profession, but to those who are the guardians of the public health, in relation to the best means of lessening the terrors and fatality of this disease, should it continue to devastate our country. 

(a) Nothing contributes more efficiently to individual or public health, than cleanliness, since its converse engenders a 

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Spencer on Asiatic Cholera. 

local or general contaminated atmosphere ; always a frightful source of disease, but especially so of the present affection, even unaided by its epidemic predisposition. Too much can not, therefore, be done by judicious means to avoid an impure atmosphere in a dense population- It is believed, however, that a great error has obtained in some places in the means employed for securing the cleanliness of a town in preparing for the expected visit of the present epidemic. The opening and exposing of old sewers and other depositories of filth, especially during the hot season, is a circumstance which has probably added to, instead of dissipating, the contaminated condition of the atmosphere. Dr. Winslow, in his " essay ou cholera," refers to some interesting cases which occurred in 1815 or 1816, in the neighborhood of London, at a school near Clapham. He remarks, " that it came out without any suspicion of the kind having been awakened before the circumstance was related to Mr. Angus, that a drain that had been choked for many years, had been discovered behind the house and partially opened. Directions were given to cleanse it, and during that operation the scholars gathered repeatedly about the opening, from which issued a most offensive effluvium, and assisted the men in their labors." A complaint simultaneously broke out among the scholars, who were nearly all affected with symptoms of more or less severity, and so entirely resembling those as to leave no reasonable doubt of its being the same disease — the epidemic. This circumstance would strongly indicate the propriety of cleansing drains and removing other sources of mischief of this description, in large towns, in the cold season, and when no general predisposition to this class of diseases pervades the atmosphere. 

(b) Great care should be exercised by boards of health, to avoid the crowding together of ill-fed, poor, or intemperate persons, during the prevalence or apprehended invasion of the disease. With this view, some efficient measures might be properly adopted to prevent the crowding together 

12 

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of many emigrants on board of boats. These vehicles likewise should be subjected to repeated cleansings. 

I'c) When the disease breaks out in a crowded, ill-ventil-1 filthy tenement, or in the vicinity of stagnant waters, no* c should be lost in removing the inmates to a more airy ition. This has, in repeated instances, appeared effectu' to check the extension of the disease. 

(d) From the known effects of sympathy and fear, in ex•citing and aggravating this disease, too many sick persons should not be crowded into the same apartment. 

(c) In the employment of nurses, great care should be exercised not to select those who from intemperate hahits, or timorous dispositions, are naturally predisposed to attacks of this disease. 

(f) In country places it is frequently a matter of exceeding difficulty to procure necessary attendants upon the sick. Under such circumstances, there would be an obvious propriety in having several persons employed at the public expense, ready at a moment's warning, to afford the rites of humanity to the sick. No considerations of public economy should interpose a barrier in a matter of such vital importance. 

(g) " I might also add, that considering how powerful an exciting cause intemperance appears to be, whilst it is at all times the dictate of sound public policy, to use every effort to stop its progress and to control its influence, it is especially so during the prevalence of this disease. It should be remembered, that intemperance not only increases the number of victims of the disease, but in this very way also increases the general alarm, and thus aggravates not only the predisposing but exciting causes."* 

(h) No pains should be spared during the prevalence of the epidemic, to see that those who are unable to provide for themselves, should be supplied with sufficient food and clothing. This is no less the dictate of humanity than of sound policy ; since those who eventually contribute for this pur- 

• See " report on cholera," made to Got. Throop, by Lewis C. Betk, M. D. 

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le, are indirectly benefited by the lessening of the gen- I mortality, which excites universal panic, always a fruitsource of the disease. 

Ii) " Cholera preventives" have been among the common :iting causes of this disease, and the mischief of which they r e been productive is incalculable. Not to allude to the lI tendency, under all circumstances, of allowing ignorant tenders to the healing art, to distribute with entire impunijvery poisonous drug, I can not forbear alluding, on this asion, to the immeasurable mortality resulting from this rce during the prevalence of the present epidemic. The mischief occasioned by these pretended preventives, has been mainly produced by the general distribution of stimulants, but especially cathartic drugs. What ! a dose of physic do injury ? Under ordinary conditions of the atmosphere, or during the prevalence of almost any other epidemic, a simple dose of cathartic medicine could rarely be productive of injurious consequences. But such is the susceptible condition of the bowels, during the prevalence of this disease, that one tenth part of a common dose has often produced the severest grades of the complaint. I speak advisedly on this subject, having witnessed the fatal effects of cathartics in several instances, where they had been given as preventives. Indeed, in every place where the disease has prevailed, the public press has teemed with reiterated warnings against people having recourse to this class of drugs, without the advice of a skilful physician. Perhaps no subject more deserves the attention of legislatures and boards of health, than this, and should the epidemic recur, as it is very probable it may, the interests of humanity would be greatly advanced by an ordinance prohibiting the vending of such medicines, except under proper restrictions. 

(k) During the prevalence of all epidemics, fear, and the depressing passions, are injurious, but they are prominently so in this, from their known tendency, even in health, to produce diarrhoea. It is, therefore, a matter of the deepest mo,~ 

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lit to preserve tranquility in the public mind. During itary campaigns, every soldier is instructed in the method arresting bleeding from wounds, and some military comlders have for this purpose humanely furnished every solr • with a field tourniquet (a stick and handkerchief) prejs to an engagement. At the approach of the epidemic, ; believed that boards of health might subserve the interests humanity by distributing a few sanatory precautions to ry inhabitant, to put him upon his guard, and inspire him only with hope, but a confidence, that with proper care attention he can escape the dangerous stage of this disease. With this view, in addition to repeated enquiries into their wants and health, something like the following simple rules might very properly be put into the hands of every family, thereby constituting them the centinels of their own life and health. 

First. To keep their persons, houses and premises cleanly. 

Second. To live upon light nourishing diet, as salted meats, eggs, milk, farinaceous vegetables, such as preparations ol ¦wheat, rye, potatoes, rice, oat meal, partaking of moderate meals. 

Third. To avoid the use of much fresh meats, especially veal, or hard salted meats, such as ham. 

Fourth. To lay aside all crude vegetables, such as cucumbers, green corn, plums, peaches, &c. 

Fifth. To wear warm clothing in the cold season, to put flannel next the skin, to avoid sudden exposure to cold or damp air, and during the night to take care that the bed clothing be such as to prevent the increasing cold from giving a sudden check to perspiration. 

Sixth, Bilious diarrhoea, characterized by yellow stools, should not excite apprehensions, as it generally shows an exemption from the epidemic. If, however, it becomes profuse, and the evacuations are watery, it may terminate in the severe disease. 

Kventh. The symptoms which first appear, are distress 'aintness at the stomach, and milky or watery discharges 

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irom the bowels, often devoid of smell, and unaccompanied with pain. 

Eighth. These symptoms, although moderate, demand attention, being liable from slight causes, to run into the severe grade of the malady. 

Ninth. All domestic medicines should in general be avoided, but in case of a sudden severe attack of diarrhcea, and no physician is at hand, the following precautions maybe taken. 

Tenth. Provide laudanum of common strength, and to an adult give 20 or 30 drops every half hour, till the complaint abates, or until three or four doses are taken, at the same time covering warm in bed, and taking warm chicken, crust or corn tea. It should be, however, borne in mind, that laudanum is generally injurious in this disease, and that it should not be used unless its effects are promptly counteracted by the skilful physician. 

Eleventh. If vomiting supervene, it should be promoted by warm drinks, as chicken tea; and laudanum should not be taken unless the purging becomes profuse and watery, when >t may be given as directed above. 

Twelfth. Vomiting should not be considered a necessary or dangerous symptom of the epidemic, but that large watery stools, although no pain be present, are attended with imminent hazard, and call for prompt attention. 

Thirteenth. Cathartic medicines produce an artificial, equally hazardous with natural, diarrhoea ; even in small doses they are liable to excite the epidemic, and unless advised by a physician, should be shunned as the hyena or the rattle snake. 

Fourteenth. The disease is in general perfectly cureable in its early stage, and danger results only from a disregard of proper precaution. However delicate the subject, or painful (the reflections to which it leads, duty impels me to invite public attention to the impropriety of the practice of suddenly burying those who fall victims to this disease. In prosecuting my enquiries into the nature of this disease, I came to the irresistible conclusion, that death in many instances, was pro- 

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I:ed precisely as from bleeding ; that the solid parts of the \y remain entirely uninjured, and that a patient might rein a considerable time in a swooning condition, apparently 

Id, and yet subsequently become resuscitated. From the current testimony of some of the most respectable mem-5 of the medical profession, it appears that several cases 

have occurred in which patients have for some hours been apparently dead, and yet have subsequently recovered. From the sudden manner in which persons have been hurried to the grave, during the terrors awakened by the ravages of this destroyer, the opinion cannot be resisted, that many have been buried alive. Humanity shudders at the thought. This part of my subject I feel unwilling to close, without imploring not only the medical profession, and tho functionaries who are the guardians of the public health, but every philanthropic individual, to aid in turning the broad current of public senti^ ment against the marked inhumanity of such sudden interments. 

3. Of the remedies for the first stage. — In no disease can our remedies be employed with much prospect of success, if delayed till the last struggles of life. This remark emphatically applies to the present epidemic, from its sudden termination in collapse, if its insidious dawnings are overlooked, and we wait for vomiting and spasms to point us to the invasions of the foe. In the first stage, even the unaided efforts of nature are sufficient, many times, to perform the cure, and such is the certainty of remedies in this stage, that by due care, on the part of physicians and the community, the disease may generally be controlled. The indications of treatment are — Ist. To allay the susceptibility of the intestines and stop the tendency of the cutaneous and urinous fluids towards them, by acting upon the skin and kidneys. 

2d. To restore the weakened functions of the stomach and liver. When the patient suffers from slight oppression at the stomach, accompanied by a furred slimy tongue, relief may be obtained by a blue pill, or a few grains of calomel at night, followed in the morning by a moderate dose of rhubarb. 

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and cream of tartar, or magnesia and rhubarb, and subsequently by some bitter drink. If slight diarrhoea be present, the mercurial should be combined with sulphate of morphia I Dover's powder, and with the pediluvium and warm drinks )romote perspiration. To these may be added mucilages mild diuretics, or the spirits of nitre, to allay the irritable dition of the bowels, and determine to the kidneys. Sublent exposure to cold should be cautiously avoided, and patient should not be too suddenly allowed to rise from bed, and thus expose himself to the return of the disease, ose of castor oil and laudanum at night, followed by warm ents, will frequently afford relief. The distress of stomis sometimes accompanied with costiveness, which may be obviated by small doses of soap pills, or by castor oil, during every stage of the disease. 

yf opening medicines are employed, they should be of the dest character. Active cathartics always expose the patient to the hazard of the same disease, and should be carefully shunned. Notwithstanding many patients might get well under their administration, yet it would seem equally as rational to expose an inflamed limb to repeated motion, to afford relief, as to administer a remedy whose specific action is to augment the general predisposition by exciting intestinal exhalation, which constitutes the essential nature of this epidemic. So fully am I satisfied of the propriety of this position from repeated observation, that I should be wanting in duty if I omitted to express my entire conviction, that cathartic drugs should be excluded from our remedial means. In the mild cases of recent origin, the remedies above detailed may be sufficient to secure an exemption from the severe grades of the disease, but when the diarrhoea has been protracted, or is becoming severe, there is no security short of a combination of emetic and sudorific remedies. It is not wished to underrate too much the use of opiates, astringents, or the other remedies often employed for this purpose, but the patient i» exceedingly apt to relapse, when the disease is checked in this manner, especially if it be followed by cathar- 

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lie drugs. Opiates tend to interrupt the urinary secretion, which, even at this early period, is often much lessened. Emetics are at all times among our most efficient means of rousing the weakened functions of both the stomach and liver, which constitutes an important part of the indications in this stage of the disease. Not only so, but they are among our most prompt means of acting upon the exhalent tissue of the surface. When the diarrhoea is moderate, ipecac or eupatorium, or both combined, may properly be employed, confining the patient in bed, and administering warm drinks to promote perspiration. If the diarrhoea be severe, vomiting and sweating should both be free, and promptly procured. This maybe produced by a combination of emetic tartar and ipecac, provided a dose sufficient to act promptly, is used. Nothing is more improper than half doses of emetics, especially if tartarised antimony is employed, from its known tendency, in small and repeated doses, to run off by the bowels, and in this disease thus augmenting the very discharge it is intended to relieve. This occasional effect of emetic tartar renders it somewhat objectionable, and it is believed that the sulphate o zinc and ipecac, as recommended by Dr. M'Naughton, may be safely and advantageously substituted in most cases, where the diarrhoea has been of considerable standing. Sulphate of zinc 5 grs., combined with 20 or 30 grs. of ipecac, may be given in a wine glass of warm water, and if not vomitec in 8 or 10 minutes may be repeated, or 20 grs. of ipecac alone may be repeated every few minutes till full vomiting is produced. The eupatorium, from its emetic, diaphoretic and tonic properties, is admirably adapted to the cure of this disease, and a strong infusion of this article or chamomile may be very advantageously administered to promote the operation of the emetics. 

After the operation of the emetic, the tone of the stomach may be restored by the use of some vegetable bitter, as quassia, columbo or gentian, with the occasional use of wine. The above remedies, with the preventive cautions detailed, constitute the sum of the means necessary to cure this stage of the epidemic, and their efficient application may in a great measure disarm it of its tenors. 

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CHAPTER X. 

OF THE TREATMENT OF THE SECOND STAGE. 

Bhe leading indications which follow from the pathological r taken of this stage of the disease, are obviously, 

1. To arrest the intestinal discharges. 

2. To make a transfer or metastasis of the serous discharges from the exhalents of the bowels to those of the external surface. 

3. To restore the lost balance and healthy performance of the various excretory and secretory functions. 

4. To support the powers of the system, and combat incidental symptoms. 

The first three indications may in a large proportion of cases be simultaneously fulfilled by a combination of active emetics and sudorifics. To these the disease yields with great promptitude, provided a dose sufficient to act efficiently is employed. Nothing can, however, be more improper than the exhibition of half doses of emetics in this stage, since every thing depends upon making a prompt and decided impression upon the disease. If the operation of emetics is prompt and active, all the energies of the system seem to be aroused — the face resumes its wonted flush, a free warm perspiration starts from every pore, and the patient is comparatively safe. (Case 2.) On the contrary, ineffectual retchings at considerable intervals, attended with a kind of passive vomiting, whether produced by emetic drugs, or coming on as symptoms of the disease, always tend to prostrate the powers of the patient. In the choice of emetics, therefore, it should be an object to employ those which act promptly, anc the stage of the malady should always influence our selection. In the early part of this stage, I have employed a combination of emetic tartar and ipecac, and it has rarely disappointed my expectations. (Case 5.) In the more advanced period, or where the preceding diarrhoea has been of long standing, the emetic tartar should be exchanged for the sulphate of zinc, as recommended in the first stage. 

13 

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I This, from its astringent properties, is by no means so lie to run off by the bowels as the tartarised antimony, ich must always be injurious when it acts in this manner. c white vitriol, from its rapid action upon the stomach, in ay instances, suddenly suspends the large serous discharg as if by a grasp of the whole abdominal viscera. (Case 9. len a large indigestible meal has been the exciting cause of the disease, it is at all times an object, while it remains, to dislodge it from the stomach, but this organ, as well as the bowels, soon become washed out by the serous fluids. Un»such circumstances it should be, therefore, borne in mind, the operation of the emetic is not so much to dislodge bid matter, as to give a centrifugal direction to the fluids, for the purpose of equalizing their circulation, and especially to act upon the skin. Their operation, should, therefore, be promoted by copious drafts of eupatorium tea, or chamomile tea, and the vomiting should be continued till the patient sweats profusely. It is likewise, at times, necessary to aid their operation by irritation of the fauces. During the vomitings the patient's surface should by no means be exposed to the air, as this would obviously check the perspiration. The patient should, therefore, be well covered with bed clothes, allowing no part, save the face, to be exposed. In some instances vomiting and purging were both suddenly arrested, on giving an emetic, and considerable difficulty was afterwards experienced in procuring full emesis. This rarely happened unless the disease had advanced so far that the vomiting and purging seemed rather passive than active, and the constitutional energies had become much prostrated. Indeed, such is at times the condition of the stomach, that after the exhibition of the emetic, it seems almost to defy our efforts. Believing this difficulty resulted from debility of this organ, diffusible stimulants have been given under such circumstances, and promptly brought on vomiting. Wine, aether, carbonate of ammonia or camphor have been preferred, accord- Kthe age or habits of the patient. In old people, a glass it wine repeated every few minutes has produced the 

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Spencer on Asiatic Cholera. 

best effects, while in younger persons or children, the more diffusible stimulants should be preferred. (Cases 1 and 7.) If stimulants are used under such circumstances, and free sweating is induced, little apprehension needs be entertained of exciting the consecutive fever. After the vomiting has been continued until free diaphoresis is produced, the quantity of diluents may be lessened, and a few drops of camphorated spirits, mingled with a wine glass full of hot sweetened water may be administered every 20 or 30 minutes for three or four hours to promote the sweating. After free vomiting the camphor is exceedingly grateful to the stomach, which is often tranquilized by the first dose. If nausea continues, a weak solution of carb. of soda, or of gum arabic, or an effervescing draught may be employed. In the early part of this stage, the sweating should be copious ; but if the stage of collapse approaches before the emetic is administered, it would be obviously as injurious too much to unload the blood vessels by the skin as bowels. In this condition of the system, the sweating regimen should be gradually withdrawn as soon as an obvious check is given to the intestinal discharges, carefully avoiding, however, for some hours, the slightest exposure to cold, which will reproduce the disease. After the continuance of the camphor and hot water for some three or four hours, the patient's surface should be wiped with hot chalk, and flannel, under the bed clothes, and these should be carefully lightened. The patient may then take for ten or twelve hours the camphor and hot water, and a half tea spoonful of spirits of nitre in water, every two hours, and at the same time continue the mucilaginous and alkaline drinks. 

In a large proportion of cases the above detailed remedies have been found to give an effectual check to the disease, the secretion of urine soon returning, and evacuations from the bowels tinged with bile, would announce a return of the healthy functions, both of the liver and intestines. In a few instances, after the patient had vomited actively for some time, bile would be mixed with the evacuations from the stomach. 

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(Cases 3 and 4.) One great advantage from this treatment is the almost certain exemption from consecutive fever This is so uniformly the case, that I am induced to believe that a vast proportion of the fevers which have followed this epidemic, have been the effect of the opiates, astringents aru stimulants, which have been so freely administered by many physicians for its cure. So fully am I satisfied of this from repeated observation, that although I shall recommend them under certain circumstances, yet I wish to have it fully un derstood, that they should be regarded as among our resources rather than remedies. Notwithstanding the great confidence reposed in the remedies above detailed, we shall not be fortun ate in all cases, and constitutional peculiarities, or some un expected circumstances may prevent our exhibiting emetics or procuring free emesis and diaphoresis, or the intestina discharges may still continue to threaten the destruction o the patient. An expedient for checking these, but which have not employed, was put in practice by my friend ant former pupil, Dr. Benjamin Palmer of Smithfield. It was the application of ligatures to the extremities. These a times promptly stopped the discharges. The analogy of thi epidemic to hemorrhage, in which this expedient has been found useful, would indicate the propriety of this remedy When the serous discharges are profuse, might not the dash ing of cold water upon the abdomen be useful ? When our other resources fail, a choice of dangers is presented, the hazard of the sudden and terrible collapse, from the profuse evacuations, or of consecutive fever, from the employment o opiates or astringents. I think the latter the lesser hazard, if our remedies are skilfully applied. A full dose of laudanum, combined with spirits of nitre, will at times tranquilize the stomach and bowels. Under such circumstances, pills of opium § gr. and sugar of lead 2 grs., may also be given every twenty or thirty minutes. An enema, of starch half a gill, and from 20 drops to a tea spoonful of laudanum, mny be at once administered. Should this not stay the bow- 

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els, a solution of twenty grains of saccharum saturni, may bo mixed with the starch and laudanum, and thrown up the bowels. (Cases 8 and 10.) Should the injections he suddenly discharged, pressing firmly with a cloth upon the rectum, or introducing a plug of beeswax, or a piece of oiled cloth, may be useful in retaining them. Some medical practitioners give the preference to combinations of opium £ or gr., with a grain or two of calomel, under these circumstances. This combination should undoubtedly be preferred, when sufficient promptly to stay the disease, being less liable to produce fever ; but from a careful trial of both combinations, the lead and opium have been found more prompt in arresting the discharges, than the opium and calomel. But when the disease is stayed by any of these means, it should be borne in mind, that we have only obtained a truce, and that we have now to guard against a commotion of the blood vessels. The brain is the organ most liable to suffer, when the disease is thus checked, and fever is to be guarded against by promptly acting upon the skin and urinary organs, and exciting the healthy functions of the liver and intestines. With a view to the attainment of these objects, a powder of calomel, gr. 3 to 1, ipecac, gr. £, pulv. camphor, grs. 3, cream tartar, grs. 5, may be administered every two or three hours, alternating with half or a tea spoonful of spirits of nitre, in water. Warm diluents, as barley water, gum arabic water, crust or balm teas, or an occasional glass of hot water, combined with a few drops of camphorated spirits, as before directed, maybe employed to determine to the surface. If these means should not succeed, and a hot skin and coma supervene, recourse should be promptly had to the remedies recommended under the head of consecutive fever. After the continuance of the above remedies for some twelve or twenty-four hours, if the healthy motions of the bowels are not restored, some mild laxatives as calomel and rhubarb, or rhei and magnesia, calomel and castor oil, or the oil alone, should be administered. Kmetimes happens that great irritability of the stomach nues after the intestinal evacuations cease, rendering it 

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difficult to administer any remedies. When there is tenderness of the epigastrium, scarifying and cupping or leeches to 

It region are indicated. The mustard cataplasm, or wha )ften better, a large blister, should be applied over the stom i. An effervescing mixture, a little essence of pepper it, or cinnamon, crust or corn tea, or weak lemonade, or cc of ice, will often allay this symptom. When other re sources fail, a negative remedy will be found very effectual giving the stomach nothing to do. (Case 6.) Restrictin the patient to a tea spoonful of some mild drink, every hal hour, will often succeed, when all medicines fail to quie this organ. If spasms of the respiratory muscles supervene producing convulsive breathing, or if spasms of the limb become so severe as greatly to harrass or exhaust the patient the extract or tincture of cicuta or hyosciamus, as employee by the Russian physicians, is indicated, and is less liable than opium to check urinary secretion. Of the utility of blooc letting, I cannot speak from experience, although an abund ance of respectable testimony may be found in its favor, es pecially among the writers of the eastern continent. In this country, though it has some highly respectable advocates, this remedy does not seem to have been very extensively employee or approved by physicians, notwithstanding the general prepossession in its favor in the treatment of many other diseases. 

If the pathological views of the disease presented be correct, bleeding may find an appropriate place among our remediate means, but its indiscriminate use must be exceedingly hazardous. The operation of this remedy in the epidemiC) must be very similar to its action in hemorrhage, and if employed before the action of the heart and arteries is prostrated by the severe discharges, I can discover no good reason why it is not equally t«»fe to unload the blood vessels by the lancet, as to have them thus rapidly emptied by a continuance of the large serous evacuations. It is thought that by bleeding the patient from a large orifice, until faintness is induced, the discharges may be thus stayed, and by directing our remedies to the restoration of the various secretions, the. patient may be cured. 

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Some medical practitioners have very successfully treated the disease in this manner, but it must be obvious that the remedy is applicable only to the early part of this stage, when the pulse remains vigorous ; a period which often passes before professional aid is called. If the pulse has, however, failed, and the system is rapidly approaching the collapse, or this actually exists, no good reason can be discovered for using blood letting in this disease, any more than in any other malady, when the vital energies have been prostrated By direct depletion. If we found a man nearly or quite pulseless, from natural hemorrhage, or from the division of an artery, we should hardly be considered rational, if we undertook to bleed him to rouse the system. Now, it is thought equally proper in this case, as in the collapse of the epidemic, when, as frequently happens in rather slow cases, the patient has already lost a quantity of fluids, equal in volume to the estimated amount of blood ordinarily circulating in the heart and blood vessels. Those cases which occasionally occur in this epidemic, and which often happen at the onset of febrile diseases, in which extreme coldness results, from an oppression of the sanguiferous system, resulting from a congestion of the fluids in the internal organs, unattended with evacuations, are often benefited by bleeding. But this collapse should be carefully distinguished from that resulting from large evacuations, the principles of treatment being widely different. 

On the use of cathartic medicines, the conviction can not properly be withheld, that these have been too extensively and indiscriminately employed in the treatment of this and the collapse stage. Calomel has been frequently prescribed with a view to its specific action upon the liver. This organ being secondarily drawn into the disease, and the serous discharges, while they continue, having a direct tendency to cut off the supply of fluids to the liver, and to wash out whatever might be carried into the intestines, but little expectation can be indulged, that sufficient can be absorbed in this stage to influence the biliary secretion. Given in minute doses, however, it sometimes acts beneficially in allaying irritability of 

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the stomach, and exciting a healthy, peristaltic motion of the bowels. Although calomel appears to act principally upon the mucous tissue of the bowels, and is on that account less objectionable than most cathartic drugs, which act upon the exhalents, yet notwithstanding the high authority in favor of large doses of this article, it can hardly be conceived that any of this class of medicines can be used to any extent without adding a new exciting cause to those powerful intestinal discharges. That many patients might get well, when it is used, is not denied ; but it does not hence follow that they recover in consequence of the employment of such remedies. Of the modus operandi of emetics in this disease, little need be said in this place, after the exposition of the pathology of natural vomiting, in the remarks upon the nature of the second stage. Although strenuously recommended by Dr. Yates and others, such were the prejudices I had imbibed against the employment of emetics in this disease, that I did not venture upon their use, until I had, in the midst of the epidemic, completed an analytical examination of all the symptoms of the disease, and come to the conclusion that vomiting should be regarded as a salutary effort of the system. They were then prescribed with the fullest confidence of success, and in no instance, where vigorous vomiting and free diaphoresis were induced, was there a failure of promptly arresting the disease, and an exemption from consecutive fever was uniform. The same result followed the like treatment, under the administration of several professional friends, who have obligingly furnished me statements on this subject. For the suggestion of the idea of confining the patient to bed, and entirely excluding the external air from ihe surface, I was indebted to a communication from Dr. William Taylor of Manlius, previously to either of us having witnessed the disease. By adopting this suggestion, I had only to aid the use of emetics and sudorifics to make a prompt impression upon the skin. It is believed that this method of combining these remediate agents, may be advantageously extended to many other diseases. Dr. Charles T. Jackson, in his observations on chole- 

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ra in Vienna,* when speaking of the utility of emetics, remarks, that " at length one of the physicians of the military hospital, reflecting on his practice in the plague, resolved to try the means he had often found successful in that disease, in cholera. This treatment consisted in the administration of emetic doses of ipecacuanha in the beginning of the cold stage. This medicine was given in doses often grains every ten minutes, until vomiting was produced — warm water and irritation of the fauces were also used to bring on this artificial vomiting as soon as possible. 

The effects of this apparently paradoxical treatment were surprising, and its success exceeded even the most sanguine anticipations of the physicians who first thought of this remedy. 

Eighteen individuals in the cold and blue stage of cholera, were treated by the means above noticed ; two died in the cold stage, and two or three sunk in the typhoid stage. The success of this experiment drew the attention of all the physicians of Vienna to the use of ipecacuanha, and the mortals ty of cholera began rapidly to diminish. The changes effected by this treatment are as follows : The first effects of artificial vomiting were marked by a determination of blood to the surface. After a short time, the patient sank, as if exhausted by his efforts to vomit. The complexion of the skin now changed, the fuliginous tint of the face gave way to a feverish flush — the sunken appearance of the eyes, and the black rim about them, gradually disappeared. The whole surface became excited, as in inflammatory diseases, and was burning hot. The patient now frequently complained ol pains in the stomach and bowels, and there was often pain, augmented by pressure at the epigastrium. The feverish heat soon gave way to a copious perspiration. The secretion o urine took place, and usually in abundance. This was regarded as critical, and certainly was one of the most favorable symptoms. We could not help expressing our astonish¦t at the results we had seen by this mode of treatment sudden changes effected by the ipecacuanha were indee< 

* Medical Magazine, Boston. Oct. 1«32. H 

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remarkable. The patients were affected so suddenly by it, 

that " it seemed to be a sort of enchantment." 

(Phis statement of the utility of emetics at Vienna, fully responds with the result of their employment under my ervation. Emetics of ipecacuanha, were likewise given h much benefit, in some of the French hospitals, and even Hippocrates used emetics in diarrhoea serosa, with a view to act upon the exhalents of the skin. The analogy of this disease to hemorrhage, the discharges in both coming from the same vessels, would lead to the belief that emetics might be equally serviceable in both diseases. Professor Chapman, of the University of Pennsylvania, and other writers of great respectability, recommend the employment of emetics in bleedings from the stomach and bowels, and speak of their great utility under the most desperate circumstances. It is a matter of general observation among the medical profession, that if the patient, in the early part of the epidemic, could have free diaphoresis induced, he might be considered secure. If even that part of the pathological views in relation to the mechanical operation of vomiting, in arresting the serous discharges, should be rejected, the universal effect of emetics in their action upon the cutaneous exhalents, would point to their use as proper means of diverting the current of fluids from the bowels. Have we any other remedies by which we can start the sweat from every pore with like promptitude or certainty ? If.the disease is checked in this stage, and the healthy functions of all the various organs re-established, the same means for restoring the strength of the patient are indicated, as recommended under the treatment of the first stage. 

CHAPTER XI. 

OF THE TREATMENT OF THE COLLAPSE 

This stage of the disease has, by many, been emphatically believed to constitute " cholera," and regarded in this light, 

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it may be considered almost beyond the reach of medicine. But its fatality, even in this stage, has undoubtedly been increased by the evil genius of empiricism, having been too frequently allowed to usurp the throne of reason and preside over its treatment. The terror and wonder excited by the rapid approach and onset of " the pestilence walking in darkness," have deprived many of the profession of their philosophy, and led them to overlook the almost entire similarity in the train of symptoms presented in this stage, and that which threatens death in a host of other maladies. These remarks are by no means of general application, and the records of medical science bear testimony to the deep interest and skill with which the profession have prosecuted their researches into the nature and treatment of the epidemic. The great discrepancy, however, in the various methods of cure proposed by the different writers on the disease, renders it exceedingly difficult for one who has never before witnessed it, to conduct the remedies upon those rational principles which flow from a knowledge of the pathology of other complaints, and govern their treatment. If, however, this stage of the disease is produced by the large discharges, the obvious indications are, when these have ceased, 

1. To restore to the heart and blood vessels the stimulus of distention, by supplying them with the fluids, and neutral salts, of which they have been deprived. 

2. To sustain the sinking powers of life, and combat accidental symptoms. 

(a) Water is the principal ingredient of which the blood has been deprived, and this fluid being essential to the performance of all the functions of life, it becomes a matter of the highest importance to restore this to the blood vessels. The instinctive call of the patient, while utterance remains, points to it as the most grateful, as it is the most useful, remedy we can employ. It should be generally given warm, unless it too much increases the serous discharges from the intestines or skin. The grateful taste of cold water, however, 

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I even ice water, may at times be properly indulged, especiyif a passive vomiting or purging continues. They are 

Bn the most efficient remedies we possess for allaying those iptoms. While such extreme coldness of the internal and external parts exists, warmth properly graduated, is, however, decidedly indicated. Rice water, chicken tea, toast, or gum arabic water, being mildly nourishing, constitute proper drinks. With a view to the restoration of the neutral salts, of which the blood has been deprived, these may be combined with the drinks, if the stomach will retain them. The formula of Dr. Stevens, consisting of muriate of soda 1 scruple, carb. of soda | a dr. and chlorate of potass grs. 7, dissolved in a tumbler of water, and repeated every half hour or hour, appears well calculated to accomplish this object. Or, the prescription of Dr. Harris of Philadelphia,* consisting of sup. carb. of soda dr. 1, mur. of soda scrup. 1, chlor. of potass grs. 8, water oz. 4,, may be employed, and is said to have been found highly useful. A simple solution of common salt, or combined with the other neutral salts, with starch, as the vehicle, may be used as an enema, which should be drawn off with a tube, and repeated at like intervals. Should they tend to run off, they should be retained by the means recommended in the second stage. If, however, these neutral salts are found to keep up or augment the serous discharges from the bowels, they are obviously contra-indicated, and aqueous fluids alone, or slightly impregnated with nitric acid, as advised by Mr. Annesly, or combined with camphorated spirits, should be used. Even these ought likewise to be employed according to the effect they produce, requring at times to be sparingly used, or their employment suspended, as in the second stage, when the stomach and bowels need to be tranquilized. A heavy covering of bed clothes, which fatigue the patient, and induce profuse sweating, is obviously improper. Coldness of the surface is one mean of supplying the heart with fluids, and while vitality continues, the skin being less essential to life 

» Mentioned by Professor Revire of Jetfenon Collego, in hi* lectures 

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than the function of the internal organs, should not be too much heated. Professor Jackson mentioned that he had apparently derived great advantage from external frictions with ice, and Mr. Ainsvvorth of Berlin, speaks of the utility of cold effusions in this stage. I have seen this used but in one instance, and then with no apparent advantage. It appears rational to conclude that this remedy would be indicated only in those cases of collapse suddenly induced by the discharges, when they had not been very profuse ; and that it would be injurious when the system had more gradually succumbed to immense discharges. This remedy was likewise employed in some of the French hospitals, with apparent advantage. (See case 12.) But here proper bounds must be observed, and coldness of the surface should by no means be suffered to proceed too far. Occasional frictions with hot flannel and chalk, or the flesh brush, or some stimulating embrocation, as the ammoniated oil, or this mixed with tincture of cantharides or capsicum, are obviously proper to rouse the action of the skin, but great care should be exercised not to carry this to the extent of too much fatiguing the patient, or the feeble glimmerings of the vital spark will be thus extinguished. Too much may be done in this stage. The patient should not be suffered to dose too long. When the respiration is slowly, and with difficulty performed, voluntary exertion often aids this function. But on the contrary, if quiet sleep locks the senses of the patient, this should not be too soon interrupted, since, during that state, the recuperative powers of the system are at all times most vigorously displayed. 

Venous injections constitute another source for fulfilling the first indication, but their utility does not seem as yet to be placed upon a certain foundation. This method of administering remedies had been alternately practised and abandoned by medical men, long before the appearance of the present epidemic. High expectations were at first raised by the wonderful effects displayed from the use of this remedy ; patients, apparently in the last moments of life, being so far resuscitated, that they were able at once to 

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present the appearance of a being possessing the vigorous exercise of all the functions of animated existence. (See case 11.) Such expectations have, however, been but toa often raised to be suddenly disappointed, patients soon sinking irrecoverably into the grave. Perhaps the too rapid manner in which these have been thrown into the veins, may be one reason for this sudden failure, the enfeebled energies of 

I heart being overwhelmed by the inordinate and high exition they produce, or the balance of the circulation may destroyed, from the fluids becoming detained in the disded veins, by the use of these stimulants. This would gest the propriety of the very slow introduction of fluids, [ their suspension as soon as the system begins to rally. It may likewise be suggested, that as these injections must act in a great measure by the stimulus of distention, water* Bixed with neutral salts, might be safer, and answer the ose of rousing the action of the heart. I cannot speak,, jver, from experience on this point, having never seen the cucU of venous injections, unless they contained neutral salts. Great care should be exercised when venous injections are used, to avoid the introduction of air into the veins.* In detailing our means for fulfilling the second indication, perhaps one of the most difficult problems in the practice of medicine needs to be solved — the appropriate exhibition of stimulants. No question is more perplexing to the young practitioner of medicine, than to learn when his depleting remedies require to be exchanged for those calculated to sustain or rouse the vital energies ; and even those who have the lights of observation and experience as a guide, are often obliged to feel on this subject a painful uncertainty. In the disease under consideration, it may be emphatically said, that " in avoiding Scylla, we are often driven upon Charybdis." By resorting to the too free use of stimulants, there is danger of suddenly suspending the action of the heart, or 

* On the use of this remed)', however, I most fully concur with the opinion expressed by Dr. Greenhow, that " the recoveries which have taken place, ought more properly to be considered as having occurred in spite, than in consequence of 

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Eueiiig consecutive fever, which is indeed by some consid " more hazardous than the collapse." Entirely to with them, is frequently to see the patient rapidly and irrecov erably sink. Much diversity of opinion obtains among mcd ical men upon this difficult point. Some strenuously insis on the use of active stimulants, while others as earnestly con tend for their entire exclusion from our remediate means It is believed that the middle course will be found neares right. An important axiom in medicine needs to be kept in view in regulating the quantity of stimulants in this stage, to wit : " that it requires much less doses of medicine to cure debility than disease."* 

This may be exemplified by a reference to typhus fever when in the advanced stage immense doses of wine and stimulants are required to sustain the diseased and enfeeblet functions of life ; but when the fever is suspended, the quan tity of stimulants may be very promptly lessened, withou endangering the patient. 

I' the view taken of the nature of this disease be cor, we have in this stage debility, not disease, to contenc I—hence1 — hence the moderate use of stimulants would be the obvious indication. Perhaps the best general rule that can be laid down is, the less stimulants we use the better, provided sufficient arc employed, to sustain life. But the difficulty ol conforming to this rule must be obvious. Camphor and carb. ammonia are among the most valuable stimulants, as these are not so liable to produce consecutive fever, as some others often employed. The exhibition of camphorated spirits in small and repeated doses, in a wine glass full of warm water, as proposed by Hahnemann, is proper and generally grateful to the stomach. Camphor does not excite a very powerful action of the heart. 

It is however, believed, that the warm water is in this prescription more decidedly useful than the camphor, by supplying the blood vessels with this important agent. Small doses of carbonate of ammonia, dissolved in a solution of gum arabic, 

• Uu*h. 

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lirnated with the doses of camphor, by a change of stims, may be advantageously employed. The capsicum has fiy respectable advocates, both as an internal and external ledy, but I cannot speak from personal observation of its cts. A combination, however, of quinine and piperine, he proportion of a grain or two of the former, to £ gr. of latter, by keeping up the tone of the enfeebled stomach, been at times advantageously employed, given at intersof half an hour or an hour. Wine or brandy are stimlts to which it may be necessary to resort, should the ;rs disappoint our expectations. Port or Madeira wine r be added to the drinks, but administered with the entta, they often answer every purpose. From a spoonful to a wine glass added to the starch, or with the saline injections, may be thrown into the intestines hot, and repeated every hour or two, should the symptoms require it. These injections should be drawn off by a tube, previous to each repetition. Brandy has been employed for like purposes, and although it is believed not in general so useful as wine, it should by no means be overlooked among our resources in this disease.* On commencing the use of stimulants in the collapse, I observed at times a sudden increase of the energy of the pulse,, with increasing warmth ; but these effects, like those from venous injections, were frequently of short duration, and the patient sunk more suddenly than could have been expected without their employment. This led me to the following reflections on the modus operandi of stimulants, which is submitted only for what it is worth. The heart is believed by physiologists to be the principal organ of the circulation of the blood, although a division of opinion exists as to the agency that the arteries and veins have in the performance of this function, some supposing they are merely elastic tubes, in which the blood is circulated, by the force of the heart alone, others believing that they possess muscular 

* See Dr. Kirk, on (he use of this remedy. 

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powers, by which they aid this function. It is, however, admitted that the coats of the veins are much weaker than those of the arteries, and that their elastic or contractile power, (which ever they possess) is also much less. In the disease under consideration, the immense discharges greatly lessen the volume of circulating fluids. In proportion as the living powers are diminished, the functions of the system become more and more under the influence of physical laws. The heart and blood vessels constitute the most perfect hydraulic machinery in nature, balanced in health by the incomprehen sible principle of life. Let us now suppose the balancing principle greatly lessened, and the fluids to be diminished in volume, as evidently happens. At the same time allow a great increase of the principal motive power, by augmenting the energies of the heart by stimulants, what should we ex pect ? Would not the fluids be driven into and retained in the weakest parts of the tubes conveying them ? If they would, the arteries being the stronger tubes, would become empty, and the veins being much the weaker parts of the circulating machinery, would become readily distended, thus detain the blood, and thereby cut off the supply of this fluid to the heart. If the supply of blood to the heart be thus indirectly interrupted by stimulants, we can very rationally account for the sudden suspension of its action from their employment, and hence deduce an important practical precept in the use of stimulants. If stimulants are administered, they should, therefore, be commenced moderately, and their effects should be carefully watched. When commenced, if the pulse is found suddenly to return to the wrist, after it has for a time ceased to beat, or becomes greatly augmented in frequency or force, and the respiration becomes oppressed, the stimulants are certainly doing injury. On the contrary, if the pulse becomes slower, or remains nearly stationary in frequency, gradually increasing in strength, and if at the same time the profuse sweating, which attends this stage, gradually abates and the corrugation of hands subsides, a perseverance in stim- 

15 

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ulants is indicated. Patients should be carefully admonished in this stage not to make use of much voluntary exertion or rise into an erect posture, (a power they sometimes retain) since swooning or sudden death are occasionally produced by 

such exertions. 

On the use of emetics, when complete collapse has super- 

vened, I cannot speak from personal observation, although I can bear testimony to their great utility when the powers of the system appeared closely to approximate to this stage. Apprehensions have been entertained that the system would not bear the shock of this remedy, but these prejudices maybe ill founded. Mustard and muriate of soda have been strongly recommended, and even the use of other emetics has been advocated.* In cases when the collapse has been suddenly induced by the severe discharges, they must be obviously more proper than when the system has slowly yielded to more extensive, but less rapid, evacuations. 

Opiates have been employed by some, and perhaps demand a notice of their uses and abuses in this stage of the disease. Laudanum, and other forms of opium, have been much used since the days of Sydenham, for the cure of common cholera morbus, which disease has been considered by most of the profession as constituting, in an aggravated form, the present epidemic. This has led to their very extensive employment as the principal remedies in this disease, but experience has certainly proved their general use injurious. A strong tendency is manifested at an early period for the fluids that generally find an outlet at the kidneys to pass off by the bowels, as is evinced by the scanty urine, and difficulty of making water. Perhaps no medicine so suddenly suspends the urinary function as opium, and hence its great utility in manycases of diabetes. An intimate connection appears to exist between the functions of the kidneys and brain, it being generally remarked, that a suppression of urine for three or four days produces a termination in fatal coma. In the present disease, this tendency to suppressed urine must be often aug- 

•-See an Essay by C. C. Yate*. M. D. 

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lented by the use of opiates, and the frequent return of the arrhoea, when suppressed by this medicine, indicates that eir effects upon the bowels are lost much sooner than upon the kidneys. It is believed that the use of opiates has been (principal cause of the entire suppression of urine, which followed the collapse of this disease, and the tendency to I affections of the head, in the consecutive fever, may raally be referred to this interruption of the urinary discharge. I am the more inclined to this belief, from the entire exemption from fever of those treated with emetics and sudorifics in the second stage, and the prompt return of the urinous secretion in such cases, and the almost certain train of febrile and comatose symptoms which followed the extensive use of opiates and other stimulants. In protracted cases of ischuria, we almost always have a train of symptoms resembling the comatose condition of typhus. May we not conclude that comatose affections are often connected with deranged urinary secretion ? The fact is well established that the action of opiates upon the skin, greatly diminish the danger of their producing comatose symptoms, and it is believed their employment in the present epidemic would have been rendered much safer if pains had been taken uniformly to invite their action upon the cutaneous exhalents. Their use may likewise be rendered much safer by combining or following them with spirits of nitre, and other medicines which promote urinary secretions. When the evidences of reaction begin to display themselves by the gradual restoration of the vigour of the pulse, by respiration becoming more full and free, by the gradual return of warmth and dimunition of the profuse sweating and corrugation of hands, it becomes highly important so to conduct this period as to prevent the establishment of consecutive fever. The blood vessels have now so far contracted down upon their contents as no longer to have their functions interrupted from want of the stimulus of distention, but the whole capillary system of the body has been in the lowest state of life compatible with the continuance of vitality, and nro liable to become irregular in their 

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actions, presenting coldness of one part, while heat may be developed in another. In this condition warmth should be applied to the colder parts, while if the heat of any other part becomes inordinate, it should be moderated by exposure to cool air or ablutions. Perhaps nothing is more important than the entire suspension of stimulants, as soon as life can be sustained without them, such is the propensity of all the organs of the body to be roused to inordinate or irregular actions, after their functions have for a time been almost suspended. It would seem equally rational to apply and continue heat and stimulants to the surface of a frozen limb, to restore its healthy actions, as by the active employment of the same means to rouse and preserve the healthy balance of all the functions of life, after they have been in the lowest state of existence. In the collapse, following great hemorrhages, few physicians would, at the present day, persevere in the use of stimulants after the system presented the evidence of returning animation, and the marked similarity of the condition of the system, in the two cases, has been already noticed. In this stage, some narcotic, as extract of hop or hyoscyamus, or a few drops of laudanum, combined with spirits of nitre, may be given to allay the great irritability of the nervous system, which sometimes exist. These, followed by warm diluents, so as to keep up a moderate action of the cutaneous exhalents, will tend to guard against the return of the intestinal disease, as well as the developement of fever, but require to be carefully graduated to the condition and powers of the system. Mild diuretics should be administered, and half grain doses of calomel every two hours, may be properly given to restore the healthy peristaltic motions of the bowels, and act upon the biliary organs. Should the reaction become too high, threatening to terminate in fever, no time should be lost in administering a more active laxative, such as a few grains of calomel combined with rhubarb or castor oil. The highly susceptible condition of the intestinal membrane, should, however, be borne in mind, and caution be observed not to carry the remedies to the extent of reproducing the original disease. 

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So multifarious have been the remedies prescribed, or published as specifics in this disease, that to examine each in detail would of itself require an extended volume. I have, therefore, confined myself principally to the consideration of those, which, in my view, have the highest claim to confidence. 

CHAPTER XII. 

OF THE TREATMENT OF CONSECUTIVE FEVER. 

¦i all febrile diseases, there are two great sources of outlet fe — disorganization and debility. The first probably constitutes the largest proportion : a numerous class of organs on which life unceasingly depends, being all liable, in the progress of fever, to be attacked with inflammation, which may destroy their texture. Debility becomes the outlet of life, by the gradual exhaustion of the vital energies, or by being induced by sudden hemorrhage or discharges from some of the excretory organs of the body. In the fever under consideration, it must be borne in mind that we have one of a low type, and both debility and disease to combat ; and hence it becomes a matter of the highest moment to preserve, as far as possible, the vital fluids, and at the same time promptly relieve the threatened destruction of any important organ. The pathology of fever being foreign from our present subject, it may be allowable to state that the indications of treatment should be drawn from our observance of those operations of nature, by which is produced a natural cure of fever. These are free perspiration, hemorrhage, diarrhoea, and copious discharges from the kidneys or lungs. This fever is to be treated upon general principles ; but from the natural means by which a solution of fever is so frequently procured, may be deduced the following indications . 

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I. By an imitation of nature, in her hemorrhagic efforts to p the actions of the heart and arteries within those bounds ich guard against excessive reaction and disorganization, he same time observing those limits which will prevent ger from debility. 

2. To act upon the four excretory functions, and restore their healthy performance. 3. To sustain the powers of the system and combat untoward symptoms. For fulfilling the first indication, blood letting, both general and local, is the most efficient remedy, and is more under our prompt and immediate control than any other. But in its use much discrimination is required to keep within the range of the indication as laid down. The blood vessels having, by this time, accommodated themselves to their remaining contents, less apprehensions need be indulged of inducing debility, than would at first view be entertained. This remedy should gen erally be restricted to those cases giving evidence of loca disease of some important organ. In such cases, bleeding may be hazardous, but to omit it is inevitable death. No general rules can of course be laid down for graduating the quantity which should, with the other means, be carried to the extent of promptly relieving the local disease. Although in such cases the system cannot sustain large and repeatec bleedings, it may readily recover from the temporary collapse of pretty free ones, when the local disease first begins. Local blood letting is obviously more important in this fever than it is when inflammatory disease attacks those in previous good health. In the cases attended with excessive febrile reaction, without local disease, bleeding, if employed at all, should be moderate, confiding principally in other remedies. Position, when there is local disease of the head or lungs, becomes, in this disease, highly important, and the half sitting posture should be directed. To fulfil the second indication, the paramount object should be to act upon the skin, since by inducing Kiration, we more promptly equalize the distribution of rculafmg fluids, than by any other means. In the fever 

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ler consideration, there is often a great determination to portion of the body, while there seems to be lessened vas ir action in another. The cold effusion and emetics stain le head of our means for promptly acting upon the skin, ii ebrile diseases. Properly combined and aided by the use arm diluents, they are among our most efficient means o sting febrile diseases, or of putting them in a safe train. Bu they cannot be used in all conditions of the system, and like every thing else, must be employed or omitted according to existing circumstances. When the skin is hot and dry, an< there exists no serious inflammatory affection of the thoracic or abdominal viscera, the cold effusion may be unhesitatingly employed. In this fever the constitutional energies being en feebled by previous disease, care should be taken to ensure reaction. With this view, the extremities should be smartly rubbed with hot flannel previous to the application, and the patient should be subsequently put into hot flannel sheets The previous exhibition of some diffusible stimulant, as ether, camphor, or warm sangaree, is likewise proper. A pail o cold water should be poured over the whole body of the patient, from a height of some three or four feet, and he shoulc then be wiped dry with warm flannel. A few grains of ipecac may now be administered, followed by some warm diluents to promote emesis and diaphoresis — (see cases 13 anc 14.) Should the stomach not be readily acted upon by the Ipecac, its operation may be promoted by the use of eupatorium, chamomile or diffusible stimulants, as recommended in the treatment of the second stage. If the powers of the system are deemed insufficient to withstand the shock of the cold, the tepid affusion may be substituted. The presence o: local disease of the head, constitutes no objection to the use of the cold affusion, on the contrary, we are possessed oi few remedies of more utility in its inflammatory diseases. These complaints being frequently attended with cool surface, an exception to the general rule of requiring a hot skin for the use of the cold affusion, may here be found. (Case 16.) Notwithstanding the ample testimony of medical wri- 

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ters in favor of this potent remedy, in febrile diseases, it is quite too rarely and timorously employed by the generality of medical practitioners. Should the means above detailec fail to relieve the fever, or should local disease of the head or lungs exist, we may simultaneously act upon the four excretory functions of the body by a powder composed of calomel cream tartar and emetic tartar. Emetic tart, and ipecac are generally allowed to exert a specific action upon the skin and lungs ; calomel exerts a specific influence upon the actions of the intestines and liver, and we possess few articles more Ive in promoting the urinary secretion than cream tartar, jcially in a febrile condition of the system. The urinary etion being generally suspended in this fever, it becomes atter of paramount importance to restore it, or fatal coma too frequently supervenes. By combining these three articles, we have one of the most active anti-inflammatory combinations. A powder of calomel, lor 2 grains emetic tartar, £ gr. cream tartar, Bor 1 0 grs. may be given every 2or 3 hours, at the same time spts. nitre and mucilages are employed. (Case 15.) When the powers of the system are much enfeebled, the emetic tartar should be exchanged for the ipecac, and camphor may often be advantageously added to the powder. When there is severe affection of the head, the calomel may be increased to 5 or 6 grains in each powder, without the danger of inducing too much catharsis, (Case 16) and with manifest benefit to the patient. If these should not prove sufficiently laxative, some aperient may be administered, as rhubarb or castor oil. If in the progress of the fever, large discharges from any organ should take place, they should be promptly arrested, and care must be exercised not to carry our depleting remedies too far. Stimulants and tonics must necessarily be resorted to, if the constitutional powers become too much enfeebled, and should by no means be too long delayed, if convinced that their effects should determine the propriety of their continuance. When they produce, in- Bof moderating delirium ; when they augment, instead ssening, the frequency of the pulse ; when the skin be- 

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Kes hotter and dryer, instead of becoming soft and perspir, and the respiration becomes hurried and difficult, by * use, attended with pain or oppression at the precordia, they should be laid aside. When opposite effects are produc- » a perseverance in them is indicated. In the treatment of febrile affection, however, nothing peculiar is demanded, apt a proper adaptation of the remedies to the varying litions of the system, as indicated by the developing symps. Indeed, this constitutes the great secret of all diseases, attempt has been made to place our remediate means in all the stages of the epidemic, upon the same basis, with what success, is respectfully submitted to the decision of this enlightened society. 

Gentlemen of the Society — 

Allow me to turn for a moment, from the contemplation of a disease which has spread such general devastation, to some individual instances of mortality, deeply affecting the interests of the medical profession. Since the last meeting of this society, two of its aged and distinguished members and former presidents,* have yielded to the obliterating hand of time. Although this is not the place to pronounce their eulogy, I may be indulged in taking a rapid glance at the principal incidents in the lives of those who have sustained so elevated a position, not only among the profession to which' they belonged, but in the public estimation. The high place they held in the affections of their medical brethren, was evinced by their election for many years in succession, to the Presidency of the Medical Societies of the counties where they respectively resided, and of the State Medical Society. During our revolutionary struggle, both participated in the perilous and glorious scenes of that eventful period. The place of army surgeon was at this time rilled by Dr. Rodgers, who, although young, was ably prepared for the discharge of its responsible duties, by the ample opportunities he had enjoyed at the Uni- 

* Joseph White, M. D. of Cherry-Valley, and John R. B. Rodgers, M. D. of New-York. 

16 

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Isity of Edinburgh, where he received the honors of that inguished medical school. He at first settled in Philadela, but afterwards removed to New- York, where the public y appreciated his merits, and he was called for several rs in succession to discharge the duties of health officer of : flourishing city. He was for many years a professor in medical department of Columbia College, was subsequentppointed to a similar post in the College of Physicians and geons, and in the discharge of these, as indeed of all the lie trusts committed to his care, exhibited the fullest proofs , he had industriously improved the extensive advantages lad enjoyed for collecting medical intelligence. 

¦ L t the close of the revolution, Dr. White located at Cherryley, then a frontier settlement. Of him it may be emphatically said, that he was the artificer of his own fortune. The estimation in which he was held by his countrymen, was at an early period evinced by his elevation to several public offices ; among which may be mentioned, his election to the assembly and the senate, where he fearlessly and satisfactorily performed all his duties, and aided the passage of those acts, which have so largely contributed to advance the interests of medical science, and elevate the character of our profession throughout the state. But his strength and usefulness lay in his profession, to which he devoted the active energies of his mind. In the infancy of our country, he did not enjoy the advantages of a medical education now presented to the student in our flourishing universities, but he supplied this defect by a persevering industry in the pursuit of knowledge, during the whole period of his life. Fixing upon usefulness and eminence in his profession, he attained an elevated rank, rarely equalled in any country. 

For several years he filled the. chair of surgery in the Western Medical College of the state of New York, where he displayed to his pupils the fruits of the rich store with which his deep research, accurate observation, and ample experience in this department of the healing art, had furnished him. He filled the place of President of this institution until the period 

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of his decease. In the elevated character of these distinguished men, attained by their indefatigable perseverance in the pursuit of medical science, may be found abundant cause to stimulate us to emulate their illustrious example, and to deplore the dispensation of that Providence which has deprived the profession of two of its brightest ornaments. 



APPENDIX. 

Case 1. — M. F. JEt. 68. Between August 24 and Sept. 1 , had several attacks of serous diarrhoea, checked by opiates, confinement, warm drinks, followed by laxatives of calomel, combined with rhubarb, or this and magnesia. Strength greatly reduced. 

¦ept. 12. — Taken the night previous with profuse serous harges, from the bowels. His strength rapidly failing, and no physician being near the family, laudanum was taken, which checked the disease. 

6, A. M. Found his pulse feeble, between 80 and 90 in a minute, skin cold, white slimy fur on the tongue. An emetic of ipecac and tart, antimony was administered. This failing to operate, 5 grs. sulph. zinc and large doses of ipecacuanha, strong eupatorium tea, and irritation of the fauces were all employed, but no vomiting. A glass of port wine was now given every sor 6 minutes. Vomiting occurred after the 3d glass, and the patient sweated moderately. This was promoted by hot sweetened water, combined with camphorated spirits, every few minutes for three hours. To be wiped dry. Powders of camphor, cream tartar and ipecac, a half tea spoonful of spirits of nitre and the camphor and hot water each every three hours afterwards. 

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7, p. m. Skin soft, pulse moderate, no return of disease. Gr. I calomel, added to each powder. Bilious stools soon returned, and port wine and bitter tea completed the cure. 

Ease 2 S. H. iEt. 65. Habitual drinker, taken with ilky diarrhoea, at 3 o'clock. 

ILugust 28. 6, A. M. Has had several profuse discharges n the bowels, retching and vomiting, tongue furred, but le pain, complains of weakness, pulse compressible. Gave r. laud., and an enema of starch and laud, combined ii kino. Chalk mixture, laudanum, and kino were givevery 2 or 3 hours, warm drinks, dry heat, mucilages, enemas, to be repeated pro re nata. 

I.ug. 29, BA. M. Very feeble, profuse serous dischargpeculiar wail of voice, so common in low cases, pulse very feeble, extremities cold. Gave an emetic of ipecac, followed by strong eupatorium tea, vomited 5 or 6 times, and sweated profusely. Covered warm in bed, and took a •wine glass of hot sweetened water and camphorated spirits every half hour, for three hours ;; — to be wiped dry with hot chalk and flannel. 

11, A. m. Took calomel, gr. 1, ipecac, gr. f, crem. tart. gr. 8, camphor, grs. 3, every 2 hours, till 4 were taken, mucilaginous drinks. Then gave a dose of rhubarb and magnesia, which operated in 6 hours, being the first movement of the bowels since the emetic. Dark bilious stools. Columbo tea completed the cure. 

Case 3. — J. I. L. JEt. 55. Attacked about the same time with similar symptoms, as the preceding case. Similar remedies. 6, p. m. diarrhoea checked. Continue medicines. 

Aug. 29, 9a. M. Symptoms much worse, diarrhoea, sickness at stomach, retchings, cold extremities, sunken eyes. Emetic tartar, grs. 3, ipecac, grs. 30, one third every %b minutes till vomiting, and then strong eupatorium tea. After vomiting about ten times, bilious matter was ejected, and patient perspired freely. Followed by same treatment, »nd 

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result as in preceding case. The attack and obstinacy of the continuance of this, and the preceding case, were more severe than several which I treated in the usual method, with opiates, calomel and opium, confinement, warm drinks, laxatives, dry heat, but which terminated fatally.* 

EASE 4 Mrs. U. Mt. about 50. August 29. 9, . Taken some 12 hours before with milky discharges from the bowels, soon becoming serous and profuse ; had vomited several times, pulse feeble, extremities becoming B. A full emetic of em. tart, and ipecac, with strong itorium tea. Vomited severely, and profuse sweating soon came on. After vomiting some 8 or 10 times, bile was ejected. Intestinal discharges at once ceased. Gave diuretics and diaphoretics. 

Aug. 30. Has had bilious stools. Soon recovered 

¦ase 5. — I. S, iEt. 48. August 25, attacked with us diarrhoea, at times profuse, repeatedly checked with opiates, followed by laxatives, returning every few hours with increased violence. 

August 29. After a return of diarrhoea, devoid of bile, for several hours, taken with severe vomiting of rice-coloured fluid, pulse accelerated and feeble ; countenance emaciated; on rising in bed complained of entire deafness ; great alteration of voice. An emetic of tart. ant. and ipecac, followed by strong eupatorium tea, till he vomited and sweated profusely. Hot water and camphorated spirits frequently repeated for 3 hours, and then to be wiped dry. The intestinal discharges were promptly arrested. After 3 hours, gave small doses of Dover's powder and camphor, mucilages and spirits of nitre as a drink. 

August 30. Bilious stools. Recovered from this time. 

Case 6 Mrs. H, Mt. 42. September 10, a. m. Has had diarrhoea 3 or 4 days, at first milky, afterwards almost colourless. Has greatly increased for several hours, and she has vomited several times. Dejectious very clear, and of a 

• Thi», Caie 14, and the preceding case, were obligingly furnished by ¦ professional friend, Dr. Stillman Spooner, of Wampiville. 

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urinous smell. Although the evacuations have been profuse, there is scarce a pain in any organ. Pulse feeble, surface moist and cold, countenance emaciated, hands slightly corrugated ; voice plaintive. Gave full emetic of em. tart, and ipecac, followed by large draughts of eupatorium tea. Vomiting and sweating free ; diarrhoea at once suspended. Gave a wine glass of hot water, with a few drops of camphorated spirits, every half hour for 3 hours, then wiped with hot chalk and flannel. Then to give a powder of camph. 3 grs., crem. tart. gr. 8, ipecac, gr. |, a tea Bmful of spts. nitre, and the camphor and hot water each y three hours. Elm and gum arabic teas for drink. 

R, P. M. Pulse more full and soft, skin moist, no diloea or vomiting. Return of urinary secretion, which had been suspended 24 hours. Had 2or 3 bilious stools during the night. 

September 11. Took some breakfast, and with it a small piece of cheese. Serous discharges from the bowels soon followed by vomiting. Being very feeble at 10, a. M., a professional neighbor ordered an enema of laud. 60 drops and a spoonful of saturated solution acetate of lead. This stayed the disease for an hour or two, when vomiting became a troublesome symptom, every thing taken suddenly being rejected. Large epispastic to epigastrium. Powder o camph. gr. 2, cal. § gr. every two hours, in a small powder of loaf sugar. Gum arabic water, a tea spoonful every half hour. Every thing else forbidden. 

7, P. M. Vomiting had ceased after the above prescription. A little crem. tart, and ipecac, added to the powders, and these continued every two hours, alternated with 20 drops spts. nitre ; mucilages. 

September 12. 9, a. m. Has had no stools. Ordered 24 grs. rhei. and 10 grs. carb. magnesia, combined with ginger, half to be given at intervals of 3 hours. Operated 5 times, dark bilious stools. Calomel left out of powders. These, and spirits of nitre, continued every four hours each after 

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Spencm on Asiatic ChoUra. 

¦ cathartic. Columbo tea every 6 hours, with a moderallowance of wine. Cured. 

lUase 7 — G. Mt. 1| year. September 8. 1, P. M. d previously labored under diarrhoea for several weeks, ich had been several times checked ; but the treatment > unknown. Has had profuse rice-coloured serous disxges from the bowels for 8 or 10 hours, vomiting for 2 3. Pulse feeble ; countenance exceedingly emaciated, 1 eyes sunk deep in the sockets, cold extremities. Emetf sulph. zinc, grs. 3, ipecac, grs. 5 ; to be divided in[ doses, and given every 5 minutes. The vomiting and ging ceased immediately. Nearly a half ounce of ipewas given in divided doses, ether and carb. ammonia c severally combined with these, but vomiting could not induced under half an hour. Strong eupatorium tea then given till full vomiting and sweating were induced. j advanced stage of the disease rendered it necessary to tiously avoid the too long continuance of the free perspiration, but the skin remained moist for 24 hours. A moderate allowance of wine whey, mucilages and spirits of nitre for drinks. 

September 9. 8. A. M. No return of diarrhoea. A powder of calomel, gr. J, camph. and crem. tart, a a gr. 1, ipecac \ ; give every 6 hours for 48 hours, and continue spirits of nitre and gum arabic. 

¦eptember 11. Tea of aromatic powder. No return of rhoea. 

Case 8. — Mrs. B. Mt. 34. Of feeble nervous constitution, habituated to the use of opium. 

September 10. 12, A. M. Has had diarrhoea 2or 3 days ; at first bilious, then serous, and very profuse for some time, and has vomited several times a rice-coloured fluid, pulse feeble, faintness in erect posture, cramps of abdominal muscles, skin dry. Medical attendant gave emet. tartar grs. 3, ipecac, grs. 30; one third every 15 minutes, to be followed by eupatorium tea. Vomited 6 or 8 times. 

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but did not sweat freely. Spirits of nitre, hot water and camph. frequently given. 

9, a. m. First saw her. Symptoms better, but moderate diarrhoea continues. Enema of sacchar satur. grs. 20, laud. 60 drops ; pills of sac* sat. grs. 2, opium gr. |, to be repeated in an hour, unless diarrhoea ceases. Promptly checked. Powders of camph. and crem. tart, a a grs. 3, cal. and ipecac a a A gr., half tea spoonful spts. nitre and camphor julep, each once in eight hours. Mucilages. 

September 11. 9, a. M. Stomach and bowels quiet. Rhei, grs. 24, mag. calc, grs. 6, one half at intervals of 3 hours. Operated favorably. Columbo tea and mucilages. 

Case 9. — T. M. Ex. 43. Of intemperate habits, and broken down constitution. 

September 12. Taken, with common cholera morbus, which readily yielded to ordinary treatment. 

September 14. Ate a meal of mutton, and exposed himself to cold air. Taken in the night with diarrhoea, at first tinged with bile, but soon becoming serous and profuse. 

September 15. 12, M. Has been vomiting near 3 hours, profuse discharges of serous fluids from stomach and bowels, pulse very feeble, intense thirst, moist slimy tongue, some gripings, cold clammy sweat, cold extremities, severe spasms of the extremities, emaciated countenance, voice plaintive. Sulph. zinc, grs. 6, ipecac, grs, 35, in warm water, one third every ten minutes, to be followed by warm eupatorium tea. Vomited promptly, free warm perspiration ensued, and diarrhoea at once ceased. Glass of hot sweetened water and camphorated spirits every 20 or 30 minutes, for 2 hours, then to be wiped with hot chalk and flannel under the bed clothes, and these lightened. 

3, p. M. All the symptoms favorable. Pow. camph. grs. 3, crem. tart. grs. 8, ipecac, gr. A, 30 drops spirits nitre dul. and the hot water and camph. to be given at the following hours : 

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Spencer on Asiatic Cholera. 

Powder, at 12, 3, 6, 9, o'clock. 

Spirits nitre, at 1, 4, 7, 10, do. Camph. and water, at 2, 5, 8, 11, do. 

September 16. 0, a. m. Urine had been voided. Moderate return of diarrhoea. Sac. sat. grs. 20; laud, guttae, 20, in thin starch, which promptly checked the diarrhoea. Cal. and ipecac, a a gr. £, camph. and crem. tart, each grs. 2, and spirits nit. &c. as yesterday. Gum arabic as drink. 

September 17. Bilious stools. Continue spts. nit. and gum arabic ; omit powders. Columbo tea and port wine. 

Case 10 September 15. R. F. 70. A farmer. Taken with milky diarrhoea, which soon became serous, attended with some griping pains in the afternoon. 

September 16. 1, A. M. Taken with vomiting. 

3, p. m. Medical attendant found him with the following symptoms j Profuse watery discharges from bowels, vomiting had ceased, voice a whisper, pulse almost imperceptible extremities cold, skin of hands corrugated, cold tongue breath giving a cold sensation to the hand, countenanc emaciated, no urine had been voided for 24 hours, scarcely any pain. An emetic of tart, antimony, grs. 6, ipecac 20 grs., followed by strong eupatorium tea, and hot camphor julep, but these did not produce free perspiration. 

10, A. m. I first saw him. Diarrhoea continues moderately. Dusky brown appearance of skin, low wail of voice, cold extremities, pulse feeble, about 90 in a minute, but variable, respiration slow, has voided no urine. Enema of sac. sat. grs. 20, laud, guttae 60, in thin starch ; hot frictions. Powders of camphor, 5 grs., crem. tart. grs. 8, ipecac, gr. £, spirits of nitre, dulc. 1 tea spoonful, and a wine glass of hot sweetened water, with spts. camph., each every 3 hours, alternately ; mucilages. Port wine, if patient sinks too low, but little taken ; hot frictions. 

8, p. m. Intestinal evacuations ceased, moderate perspiration, pulse more full and soft ; continue same prescription. 

17 

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September 17. 9, a. m. Has had several bilious stools, and a return of urinary discharge. Continue spirits nitre, and mucilages as drinks ; chicken tea and rice as food. Golumbo tea and port wine. Slowly recovered. 

Case 11. — H. L. Mt. 65. Very intemperate habits. 

August 15. 11, a. m. Taken with profuse diarrhoea, while laboring in the field. 

4, p. M. Severe vomiting and purging of rice-colourec fluids, with floccuke, pulse feeble, and 120 in a minute ; severe spasms of the abdominal muscles and extremities ; intense thirst ; burning sensation in the epigastrium. Laudanum and ether repeatedly given ; hot bottles, frictions, calomel and opium, enemas of starch, and laud, frequently repeated. 

6, p. m. Vomiting and purging continue ; cold perspiration, corrugated hands, pulseless wrist. On getting up, swooning, followed by convulsions, which soon subsided. Cold affusion, stimulants, opiates, &c. 

8, P. M. Complete collapse, voice a whisper, marble cold ness, pulseless, slow breathing, and every appearance of im mediate dissolution. Venous injections. Carb. soda, s. 4 muriate of soda, oz. IJ, and the white of 6 eggs diffused in 10 lbs. warm water, strained. 8 lbs. were injected into the bas ilic vein, pulse became perceptible, spoke distinctly, able to rise in bed, warmth returned. Continued better, except occasional vomiting and purging, until 

9J, p. M. Began rapidly to sink*, and soon pulseless. Remaining 2 lbs. saline fluids injected with no less apparent benefit, but of shorter duration. Return of vomiting and purging. Laud, ether, stimulants, frictions, &c. of no avail. 

12 o'clock. Died soon after this hour. 

Case 11. — H. W. Mt. about 38. Of very intemperate habits. 

August 1 8. Had labored under diarrhoea for 2or 3 days. The above case (11) having terminated fatally in his house, a justice of Ihe peace, with the best intentions, recommended 

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number, were most of them closed with them. [Three of his children had suddenly died with the severe vomiting and purging of serous fluids, notwithstanding the most persevering use of calomel and opium pills, laudanum, injections, stimulants, hot bottles, frictions, &c] Vomiting and profuse serous discharges from the bowels, spasms, in which the muscles rose into hard balls, profuse cold sweat, cold extremities, emaciated countenance, low wail of voice progressively came on, the pulse rapidly sinking. During this time he took calomel and opium, starch and laud. ; enemas, ether, and other stimulants were employed as collapse threatened, and doses of piperine, \ gr., and quin. 2 grs., every half hour, and evacuations became less frequent ; dry heat and frictions, Sic. 

Towards evening a preacher, who has great faith in what are called steam doctors, and hot drops, returning from a neighboring city with a certain cure for cholera, sent in, as he was passing, some of his medicines, which the patient was willing to take, having witnessed the fatality of the other cases. He took one dose of hot medicines, which were soon vomited, but not liking the taste resolved to take no more medicines of any description ; stripped off the heavy covering of bed clothes, and hot bottles removed. 

8, P. M. Several medical gentlemen called to see the progress. Patient cold over the whole surface, clammy sweat, corrugated hands, great emaciation of countenance, and a dusky brown appearance, low wail of voice, pulse scarcely perceptible, and at times entirely receding, occasional spasm?, discharges from the bowels almost suspended. Bad prognosis, unanimously. The patient during the night took moderate draughts of cold water, and occasionally a little brandy, lay nearly naked, and did as he pleased. 

August 1 9. Convalescing, in spite of the prescriptions of justice, regular physicians, or preacher. 

Case 13.— M. J. iEt. 17. Has had repeated attacks of serous diarrhoea, which had been checked with camphor and opium pills, laudanum, &c. followed by warm drinks, laxatives, &c. 

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August 29. Found his skin hot and dry, pain in his head, redness of eyes, pulse 1 20, and sharp, restlessness, thirst, white tongue, red at the edges. The febrile symptoms had continued several hours. Cold affusion, followed by an emetic and warm drinks, which vomited and sweat him freely. Usual febrifuge medicines. 

August 30. All the febrile symptoms subsided, pulse about 70, soft. All the secretions and excretions returned. Had no return of intestinal or febrile disease. 

Case 14.— Mrs. B. JEt. 70. Had suffered two or three attacks of severe serous diarrhoea which had been checked by opiates, followed by calomel, rhei, &c. under the prescription of a neighboring physician. 

September 19. 12, M. Having suffered from severe discharges from the bowels, and becoming alarmed, she took as a domestic prescription, laudanum, which immediately checked the complaint. 

10, P. m. Found her with slight perspiration, pulse strong, bounding and full, was very stupid, slight delirium. The skin soon became hot and dry. 

September 20. 12 a. m. Cold affusion, followed by an emetic of ipecac, and warm drinks, to be covered warm in bed, to be followed by hot camphor julep every half hour for three hours. Vomited and sweat freely. Laxative of cal. and rhei. 

12 in. Fever subsided. Laxative had produced bilious stools. Drinks of gum arabic, soda and spirits of nitre. Bitter tea. 

Case 15. — N. F. JEt. 4. For a week he had repeated attacks of serous diarrhoea, alternating with costiveness. 

September 5. Taken with profuse serous diarrhoea for which the family gave him 25 drops of laudanum, and this not checking the disease, it was soon repeated. The diarrhoea was suddenly checked, and the urinary secretion almost suspended, Patient lay in a torpid state without medical aid, till 

September 7. 8, a. m. Had vomited several times during the day, and had several watery discharges from the bowels 

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the night before, more since, pulse full and quick, skin covered with clammy sweat, thirst urgent, white fur of tongue. Tepid affusion, followed by an emetic of ipecac, and warm drinks, which produced free perspiration. Followed with laxative of rhei and crem. tartar. A solution of emetic tartar once in 2 hours. 

September 8. 8, a. m. Has been restless, pain in the head, eyes suffused, pulse quick and hard, skin hot and dry, respiration quick, bowels loose. Bled Bor 10 oz. nearly to fainting. Powds. cal. gr. £, crem. tart. gr. 4, em. tart. gr. £, spirits of nitre 25 drops, and the solution of emetic tart, to be each given every 3 hours alternately. Epispas. to back of neck, and cold to the head, and to be elevated. 

September 9. 9, a. m. Pain in the head severe, great intolerance of light, knitting of eye brows, mind irritable and wandering, complains of great increase of pain on shaking the head, universal soreness of the body, pulse quick, sharp and hard, skin hot and dry. Cold affusion. As soon as reaction was fully established, bled 8 oz. Ipecac, grs. 15, was given in divided doses, followed by warm drinks ; moderate emesis, and free perspiration followed. Same prescription as yesterday. Much relieved for some hours, but at 6, evening, pulse still quick, and somewhat variable, pain in head continues, sensibility to light, rather comatose, and exceedingly cautious about moving. Bled 6 oz. Epispastic nearly whole length of spine. 

September 10. 9, a. m. No motion of bowels for 12 hours, symptoms a little relieved. Cal. 5 grs. were added to each powder, till 3 were given, followed by castor oil. Emetic tartar solution to be omitted. 

7, evening. Symptoms better. Cathartic had operated favorably. Powders once in 3 hours, alternated with spirits of nitre and acetate of soda as drinks. 

September 11. Much better, left the 'calomel, the powders at longer intervals. 

12 and 13. Convalescing. Light diet and mild drinks. 

¦use 16. C. L. Mt. 6 years. September 29. Tawith severe diarrhoea of milk and water colour. 

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11, evening. Nausea, some vomiting, profuse discharges from the bowels, strength rapidly failing, pulse quick anc sharp, respiration hurried, whitish fur of tongue, skin dry The medical attendant directed tart. ant. grs. 2, ipecac, grs 25, to be given in 3 doses at intervals, to be put in warm bed and to drink freely of warm drinks, and afterwards camphorat ed spirits, and hot water, every 15 minutes. Vomited severa times, but no perspiration. The continued profuse became alarming, and the mother gave her a few drops o laudanum. 

September 30. 3, a. m. Some vomiting, profuse serous discharges from the bowels, pulse quick, and somewhat sharp skin dry, strength rapidly failing. Enema of a few drops o laud., and solution of sac. sat. This not checking the discharg es, was soon repeated. This checked the discharges. Mv cilages and spts. nitre as drinks. 

10, a. m. No motion of bowels, or discharge of urine pulse rather quick, skin dry, slight determination to the head Powders of cream tartar 3 grs., ipecac gr. £, every two hours with 15 drops spts. nit. in the intervals. Gum water as common drink. 

9, p. m. Pulse full, quick and strong, comatose, rousec with difficulty, respiration laborious, no intestinal or urinary discharges, skin dry and hot. Bled 10 oz. Put in warn bath 15 minutes. Roused up, became more sensible, complained much of the light. \ oz. 01. ricini, to be repeated in half an hour; large epispasticto nape of neck. Powders crem tart. 4 grs., ipecac, gr. |, every two hours, alternately with spirits of nitre. 

October 1. 8, a. m. Bowels moved but once, pulse quick, less comatose, no discharge of urine, headache severe, intolerance of light, conjunctiva red. Discharge from nose, skin dry, not softened by warm bath. Bled 10 oz. and scarified and cupped the temple, with immediate relief to head. Cal. grs. 15, rhei 10 grs., one half at interval of 1 hour as cath. Epis- 

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ncer on Asiatic Lholera. 

to each powder, and repeated every 2 hours, to be suspended if they operated too much. Crem. tart, as drink. 

October 2. 8, a. m. Pulse variable, from 114 to 120 soft and full, eyes sensible to light, head ache, 3 evacuation from bowels, of green bilious appearance. Cal. grs. 5, crem tart. grs. 6, em. tart. gr. £, every 3 hours, and 30 drops spts nit. in intervals. Scarified and cupped temple, with grea relief to the head. 

8, p. m. Pulse quick and hard, 120, skin rather cool, but dry ; eyes very sensible to light, comatose. Cold affusion, followed by 15 grs. ipecac, which produced vomiting, and some perspiration for the first time. 

10, p. m. Pulse from 110 to 115, soft, very little pain in the head, skin softer and moist. Continued the powders, <$>c. in less doses, same intervals. 

October 3. Head much relieved, lively expression of countenance, eyes less sensible to light, copious discharge of urine in the night, and discharge from bowels like coffee grounds, skin soft and moist. Recovered slowly from this time. 

ERRATA. 

Page 10, line 4 from bottom, for " all of," read of all. 

13, line 4 from bottom, strike out (;) after " hot," and insert a comma after cold. 

14, line 13, for " sometimes," read sometime. 

20, Note, for Prof. Thomson of " Edinburgh," read Glasgow. 28, line 5 from bottom, for "influenza," read injiutnee.. 31, line 4, for " last be," read best be. 

32, line 17, for " spasms," read pains in the hepatic region. 37, line 4 from the bottom, for " is it," read it it. 

51, line 5, for "renal," read renal. 

65, line 13, for " mucous ingesta," read mucus, mgesta. 67, line 12, for " quantities," read qualities. 

84, line 19, for " supposed," read suffered. 100, line 5 from bottom, for " aid," read add. 104, Note, for " Revene," read Revere. 

104, line 16, for " sup. carb. sod. scrup. 1," read dr. 1 ; and for " mv- 

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