THE TRUE PATHOLOGICAL NATURE OF CHOLERA, AND AN INFALLIBLE METHOD OF TREATING IT, WITH AN INTRODUCTION, ADDITIONS, AND EMENDATIONS: IN A SERIES OF LETTERS. BY GEORGE STUART HAWTHORNE, M.D., iATE SENIOR PHYSICIAN OF THE BELFAST GENERAL HOSPITAL, &C, AND NOW OF LIVERPOOL. AUTHOR AND ORIGINAL DISCOVERER OF THE NEW MODE OF VENTILATING HOSPITALS, SHIPS, PRISONS, AND PUBLIC BUILDINGS, BY THE AGENCY OF HEAT, jfC&HI) OTHER WfIRKS. LONDON: SIMPKIN, MARSHALL, AND CO., STATIONERS -H ALL-CO I X t JOHN CHURCHILL, 46, PRINCES-STREET, LEICESTER-SIJUARK ; LIVERPOOL: SMITH, ROGEKSON, AND CO. 1848. iIVBRPOOL : PRINTED BY SMITH, ROGER3ON, AND CO., LORD-STREET. INTRODUCTION. Cholera has assumed a fearful pre-eminence among the judgments which have visited our globe. The eyes of all the world are directed towards it ; and that its visit is as certain as that of the King of Terrors himself all nations have taken for granted. This was the case during its former career : the same views are entertained of it now. It has been a fearful scourge to the world. Nothing short of a civil war could exceed the effects it has produced, whether in embarrassing the commerce, or in thinning the population of the countries over which it has passed. In whatever point of view we regard it, it is certainly a mysterious visitation of Divine Providence. As the sun riseth in the east, and shineth unto the west, so have been the origin and progress of this direful malady. Unchecked by country or climate, it has gone forth through the length and breadth of the land, leaving death and misery as the mementoes of its visit ; and, like the destroying angel, armed with the power of Omnipotence, it has invaded alike the palace of the king and the hut of the peasant, dealing forth indiscriminate slaughter, sparing neither rich nor poor, age nor sex, Former pestilences were generally limited to con- ğ tinents, islands, or districts ; but the limits of this fell destroyer appear to be nothing short of the boundaries of the globe. Regardless of climate, season, or circumstance, it has pursued the even tenor of its way, laughing to scorn the vigorous quarantine precautions which have been used to arrest its progress. Devastation and misery marked its desolating course. Consternation and despair led the vanguard of its approach to every land, and sudden havoc proclaimed its triumphal entry. It has accomplished mighty deeds of slaughter. In the course of its dread career it has swept with it many a useful life. Many a fair form of grace and beauty — the solace of a mother's heart — which, in the 4 morning, flourished in all the pride of youth and loveliness, in the evening fell before it, like the tender flower and the green herb before the mower's scythe, It has hewn down its thousands, and its tens of thousands, affording to the grave and to the worm a bountiful harvest. Wherever it has appeared it has left behind it melancholy proofs of its frightful character. It is worthy of remark, that this malady proved more extensively fatal, in Eastern countries, in proportion to the number of the inhabitants of the towns it attacked, than it did in the European and more temperate climates. The conclusion to which this leads us is, either that the exciting cause of the disease in the latter climates must have been, to a certain degree, modified by some counteracting contingent disturbing influence, or that the inhabitants of such colder and more temperate climates are, by constitution, less obnoxious to its influence. How the disease is propagated, and how it travels from country to country, and Jfrom city to city, is a subject on which there is a variety of opinions entertained by medical men. Some suppose that it at first originated from malaria, generated by the decomposition of animal or vegetable matter, or both, or from a something else, they know not what; and that it has since been propagated by contagion alone, and carried from place to place, by fomites that are known to imbibe and retain infection, and again to communicate it to those who may come within the sphere of its influence. Others attribute it to a certain specific poisonous vapour, forced from the bowels of the earth by some subterraneous commotion ; and argue, that its sudden devastations in particular places can be accounted for on no other principle. A third assign its cause to animalculae; and a fourth class of speculators believe it to arise from certain states of the atmosphere, produced by meteoric influence. ' The arguments on all sides are so ingenious, however, and the evidence in favour of the different theories adduced by each is so conflicting, that to enter into a discussion of the points at issue would require more space than can be allotted to it in a pamphlet of this description. I shall, for the present, therefore confine myself to 1 /%. j •Ĥ*' A some general observations on the history of the disease, since its commencement in India, in 1817. Wherever the disease has appeared, it has afforded at least probable proofs of its being contagious ; but it has unquestionably, at the same time, prevailed as an epidemic When we take a view of its history from its origin, we find it starting up in many places simultaneously, leaving intervening cities and towns, even on the banks of the same river, untouched. In tracing its progress in India, the first appearance we find of any thing like it, is in May and June, 1817, at Nuddea, on the western branch of the Delta of the Ganges. Tt next appears on the 11th July at Patna, many hundred miles up the same river, and within less than a hundred miles of where it receives the Goggrah. Early in August it manifests itself at Calcutta; and, on the 7th of the same month, we have it at Dacca, two hundred miles north-east of that city, lying between the eastern branch of the Delta and the Megna or Brahmapootra river; on the 15th at Nattore, still east of the Delta; on the 18th at Chupra, on the opposite side of the Ganges from Patna, and still nearer to its junction with the Goggrah. On the 19th it assumed all the malignity of its present character at Jessore in the Delta of the Ganges. We find it again in the same month at Gazepoor, on the banks of the Ganges, one hundred miles beyond its junction with the Goggrah. I need not detain the reader by particularizing any more of the places in which the disease appeared in the same month of August, 1817 ; but shall merely observe, that in the course of that month it broke out and raged with violence in ten different cities and towns in India, and some of these at a thousand miles distance. That the same combination of circumstances must have existed in all, is more than probable, as such a simultaneous attack of the disease, in so many places, and these at such a distance from each other, cannot, in my opinion, be satisfactorily accounted for on the principle of communicated contagion alone- This will appear more evident from what follows. On the 7th of November, the same year, the Cholera made great havoc in the Marquis of Hastings's army, encamped on the banks of the Scinde, above fifty miles from where it enters the Jumna, and many hun- 6 i dred miles west of Gazepoor. Now, the disease raged in Gazepoor in August, 1817 ; but we have no account of it in Benares until May, the following year, though within a hundred miles of the former city, lying on the same side of the Ganges, and nearly in a direct line between it and the Marquis of Hastings's camp. Had the malady been propagated by contagion alone, why did it not appear in Benares, before, it broke out in the camp of the Marquis of Hastings ? Almost all epidemic diseases, when once produced, become highly contagious. These prevail at certain seasons of the year, and under certain states of the atmosphere; but when the circumstances which have combined to produce them cease to operate, they, of course, disappear. What tends, however, to set all speculation on this disease at defiance is, that it seems to be uninfluenced either by season or circumstance. Cholera had always existed in Hindostan as a comparatively mild disease, affecting a few individuals at certain seasons of the year; but in the August of 1817 it broke out with unprecedented malignity and violence among the inhabitants of Jessore, a town situated a hundred miles north-east of Calcutta. It soon extended across Bengal, and then retired for some time to the western banks of the Ganges and Jumna. In Benares, such was its malignity, that in two months fifteen thousand persons perished. Hence it gradually extended north and west to Lucknow, Delhi, Agra, &c. In the army under the Marquis of Hastings, consisting of eleven thousand five hundred troops and eighty thousand followers, it destroyed ten thousand persons in ten days. At this time the thermometer ranged from 90 to 100 degrees; the air was moist and suffocating, and the atmosphere a dead calm. The Cholera now directed its course along the Deccan, advancing, in many instances, at the rate of fifteen or eighteen miles a day. After ravaging many districts, and taking the direction of the coast, it arrived in Bombay in August, 1818, having crossed to the western coast of the Indian peninsula in twelve months after its appearance at Calcutta. Through the country of its birth it had the same characteristic which it still retains, having a measured rate of progression, with irregular halts, and a course sometimes direct and sometimes devious. 7 i While the interior of Hindostan was thus suffering, the pestilence had spread along the sea coast to Malabar and Coromandel, reaching Madras on the Bth of October. Here it developed a new and alarming feature — its capability of being transported by sea ; for it broke out in Candi, the capital of Ceylon, in December, 1818, with even greater violence than it did on the continent. By the 15th of September, 1819, Mauritius was infected, and, in the same month, the adjacent Isle of Bourbon. During the last six months of the same year, the epidemic had invaded the Tndo-Chinese peninsula, Siam receiving more than its proportional share of misfortune. In Bankoe alone, forty thousand individuals perished. By the end of April, it was announced in Java; in 1821, Cochin China and Tonquin were invaded; and in December of that year it entered China at Canton. Pekin received the enemy in 1821 ; and during that and the next year the mortality was so enormous that the poor were interred at the expense of the Government. Returning to Bombay, we must trace its route towards Europe. In July, 1822, through the intercourse between Bombay and Muscat in Arabia, the disease was conveyed to the latter, where it destroyed sixty thousand person — many expired in ten minutes after the first attack. Hence it spread to many parts of the Persian Gulf — Bahrien, Bushier, and Bassora, at the last of which places fourteen thousand persons died in afortnight. From the Persian Gulf, the Cholera extended inland in two directions, following the line of commercial intercourse. On the one hand, it ascended the Euphrates, traversing Mesopotamia into Syria, and the Tigris from Bassora to Bagdad. On the other side of the river, it made its way into Persia. In Shiraz, the population of which was forty thousand, there died sixteen thousand in the first few days. Ispahan escaped. This was thought to be owing to the caravans being prohibited from entering that city — a very doubtful supposition. During several successive years, the malady invaded new countries, or reappeared in those it had recently scourged. Mosul, Beri, Aentab, and Aleppo were infected, and also Diarbekr and Antioch. It had then reached the Mediterranean on the one side, and also on the other side it had 8 arrived at the borders of the Caspian. Finally, in September, 1823, it appeared in the Russian city of Astrachan, at the mouth of the Volga. In 1830, it revived in Persia with violence, and crossing the Russian frontiers, entered Teflis, the population of which it diminished from thirty thousand to eight thousand. While it continued to devastate India, China, Persia, and Syria, Europeans looked on as mere spectators, no doubt congratulating themselves on the impregnable barrier which their temperate climate opposed to its approach. But, as if at once to put to silence all human calculation on the subject, it passed over into the frozen regions of Russia in two directions. In penetrating the heart of the Russian empire, it pursued the course of the Volga. Between the Cossacks of the Don and Moscow, several districts were ravaged in succession. In that city, the appearance of the destroyer was announced on the 28th of September, having travelled from Astrachan, above nine hundred miles, in less than three months. By the 18th of November, 5507 cases were returned, and the deaths amounted to 2908 — more than the one-half. In January, 1831, the malady had subsided in Moscow, but had appeared to a limited extent among the troops marching to the reduction of Poland. The portion of the globe it had then ravaged included 70 degrees of latitude and 100 of longitude. The ravages it has since committed in Poland, and over different parts of the continent of Europe, (particularly at Paris,) and in America, are fresh in the recollection of all. With what effect it visited our own shores, the memorials of the destruction that marked its desolating course will long bear testimony. Cholera, in this country, assumed the character of an epidemic. In Sunderland, it prevailed with great malignity for some weeks before it appeared at Gateshead, though lying at a very short distance, and between which places the thoroughfare must have been very great. All at once, however, it started up at the latter place with its characteristic virulence, furnishing the report with seventeen cases on the first day. During the time that it raged in Musselburgh, several 9 persons came from that place to Edinburgh affected with the disease ; but we have no authenticated account of its having extended farther than the individuals themselves, until the epidemic afterwards visited that city. In the town of Belfast, during the winter of 1 832, several sporadic cases occurred, which assumed all the peculiar characters of the spasmodic Cholera, and two or three of these cases in its most malignant form ; yet none of those appeared to be contagious, In a number of instances, during the spring of that year and beginning of summer, the disease was imported from Glasgow and elsewhere ; but the fact was, that it seemed to extend itself on these occasions no farther than the persons importing it, or the families to which they belonged. The horrible epidemic at length came over the town like a shower, filling streets and lanes, in almost every quarter, with wailings and lamentations. The attacks, on the night of the 12th, and on the morning of the 13th of June, were simultaneous, and widely scattered over the town, without any apparent communication. In illustrating the awful visitation, on that occasion, I could not employ more appropriate language than that used by Mr. Jamieson, in his graphic description of the sudden attack of the epidemic on the camp of the Marquis of Hastings : — " The disease, as it were, in an instant burst forth with irresistible violence in every direction. Unsubjected to the laws of contact, and proximity of situation, which had been observed to mark and retard the course of other pestilences, it surpassed the plague in the width of its range, and outstripped the most fatal diseases hitherto known in the destructive rapidity of its progress." The phenomena, in my mind, could not be at all explained on the principle of communicated contagion alone. The mere cases reported were not so striking as the great numbers who were all at once seized with premonitory symptoms, and who were cured without ever being reported. On this part of the subject I would merely add, that the disease not having as yet made its attack on Lisburn, as an epidemic, though only seven miles distant from Belfast, is a circumstance for which I confess myself altogether unable to account. ~ 10 After all that has been written on the subject, and all the talent and ability that have been employed in its investigation, the mode of its travelling from place to place is still involved in absolute obscurity. It may, therefore, be very appropriately designated, "the pestilence that walketh in darkness." For above a year after the Cholera disappeared from this country, it raged with considerable severity over different parts of the Continent of Europe, particularly over the Italian States. During the succeeding ten years, it continued yearly to disport itself in its destructive gambols over the East, the original theatre of its dread career. Above a year ago it again directed its steps in a north-westerly direction, menacing Europe, and tracking, as nearly as may be, exactly the same course which it pursued on the former occasion, confirming the supposition that the destructive element which produces the disease must be forced from fissures in the earth, caused by some subterraneous heaving commotion; — the fissures from which that element escaped on the former occasion are giving it forth again, from which circumstance we may infer that the progress of the disease over its original track will be more rapid now than it was on the former occasion. Accordingly we find that, as, when the Cholera retired from Russia on its former course, it next revived in Persia, so its movements on the present occasion have been somewhat similar; but mark the difference. On the former occasion, after leaving the Russian city of Astrachan, it, as it were, disappeared from the world altogether for nearly seven years, when it again started up in Persia, and, taking Russia in its course, it made a more rapid sweep over all Europe and America ; whereas, when, on the present visitation, it retired from Russia, we find it again to start up in Syria, in the city of Aleppo, where it was raging at the last report we have of it, but at an interval, from its leaving Russia, of only a few months, contrasted with the seven years on the former occasion. In its present progress in our direction, it has, as formerly, reappeared in Russia. At Moscow there were twenty-five cases and twelve deaths between the Bth of April and the 12th of May; at Nishni-Novogorod twenty-two cases II and twelve deaths between the 17th and 24th of April; at Alexandroff, between April Bth and May Ist, there were fifty-one cases and twelve deaths. Some idea of the degree of the malignancy of the disease, as manifested in its present course, may be formed, when it is stated that the last official accounts from Russia showed, that in that country there had been no fewer than three hundred thousand persons attacked, of whom one hundred thousand persons had perished, and that the proportion of persons attacked to the population was nearly as great as on the former visitation. It is also stated that its progress was in all respects similar to the former visitation, when it abated on the occurrence of the frost, and reappeared in the spring and proceeded onwards. The last accounts from Constantinople state that Cholera increases daily in that city, and also in the surrounding villages, and that all precautions are unavailing. Tt has also broken out in Galatz, furnishing the reports with twenty cases a day. And still later accounts from Vienna announce it as having manifested itself in the Danubian provinces. From all this we may infer, that its approach to our own shores may be more rapid than we anticipate; and it requires no arguments to prove that we cannot be too soon, or too well, prepared for its onslaught. The report of the London Sanatory Commissioners, and the general — I should rather say, the universal — acquiescence in the opinions expressed in that report, with regard to the alleged incurability of Cholera, prove, if any proof were still necessary, that what has been called the malignant Cholera never was understood, or judiciously treated, in any part of the world. The fact is, that all the malignant cases proved fatal, and the cases reported as recoveries were so mild as scarcely to deserve the name of Cholera, unless merely those cases favoured by peculiarity of constitution, such as I have described in the following letters, which cases would recover by the healing power of nature, without the aid of medicine. The result of my own experience proved this. From accurate observation, I found that the malignant cases bore, as nearly as may be, exactly the same proportion to the comparatively mild cases which the number of deaths bore to the recoveries, 12 as recorded in the statistical reports of that disease, published over all parts of Europe and America. From this it follows, that — as is acknowledged by all eminent writers on the disease — the means generally adopted proved inefficient to grapple with the malignant and really dangerous form of the malady. Under these circumstances, I felt it to be my duty to explain to the public the true pathological nature of the malady, and to describe the proper mode of treating it in a series of letters through the columns of the Liverpool Mercury. That these letters have carried conviction to the minds both of the medical profession and of the general reader I have ample proofs, in the general and extensive desire expressed, both by the medical profession and by the public generally, that I should publish them in a less perishable form than in a newspaper. With this so-generally expressed wish I now hasten to comply, particularly as it is uncertain how soon that frightful disease may invade the country ; and the sooner the public be made acquainted with the true nature and character of the disease, and with the proper method of treating it, so that they may be properly instructed and prepared to defend themselves from its influence when it may make its attack, the better. 13 LETTER I. To the EDITORS of the LIVERPOOL MERCURY. Gentlemen, — My attention has been directed to a report of the London Commissioners appointed to inquire whether any and what special means may be requisite for the improvement of the health of the metropolis, &c. With regard to that report, I would observe, that it appears, for the most part, to be founded on the soundest principles. To a part of it, however, I must take exception, namely, to that in which the Commissioners state that they " think Cholera is incurable by medicine /" " that no measures of alleviation can materially avail against a malady which almost sets at defiance the resources of the medical art;" " that it begins and ends its mortal course in a few hours, and that it destroys one half of those whom it attacks" That the result of the medical treatment of that disease generally adopted in all parts of the world, from its commencement in India, in 1817, down to the present time, has been too nearly thus disastrous, I admit ; but it does not follow, as a consequence, that the nature of the disease has ever yet been generally or fully understood. It is, therefore, I submit, premature to take it for granted that the malady is incurable, or that the medical art is barren of resources for its alleviation. I have also noted the observations of the Rev. Rector Campbell, in the Select Vestry. His remarks are, for the greater part, most judicious and pertinent, particularly where he points out the inutility of hospitals for the reception of Cholera patients, and the not only injurious but dangerous consequences of the removal, under any circumstances, of such patients to an hospital. The soundness of these observations my experience in the treatment of Cholera, which has been extensive, fully confirms. With his concluding remarks, however, in which he adopts the opinion of the London Commissioners, touching the alleged incurability of the disease, and supposes that, when attacked, the inhabitants must lie down and submit themselves, patiently, without a struggle, and without hope, to the onslaught of the destroyer, I cannot by any means coincide. f 14 I believe I have had, at least, as extensive experience in the treatment of Cholera as any other physician in this country ; and my experience has proved to me that Cholera, when treated upon principles consonant with an understanding of its true nature, is a most tractable and easily cured disease ; and, so far from being permitted to destroy one-half of those whom it attacks, may be combated, under ordinarily favourable circumstances, without the loss of a single victim. Since these opinions of the London Commissioners and of the Liverpool Select Vestry have been promulgated, I have looked anxiously for the publicly expressed opinion of the profession on such a momentous question, called for, as I think it is. As the silence of medical men, under the circumstances, might seem to give too much colour to the assumption that the disease is incurable, and not to be alleviated by medicine, and might seem to be an acquiescence in the statement that " it almost sets at defiance the medical art ;" and, as I can prove to the satisfaction even of the most unlearned, and have already, during the former prevalence of the disease, practically demonstrated that it is not only curable, but most easily curable, and that it can be encountered with a perfect certainty of success, I believe I need offer no apology for coming before the public individually on the subject. I beg, therefore, to propose, with your permission, in a few letters, through the columns of your widely-circulated paper, to explain, as succinctly as possible, my views of the true pathological nature of the disease, and to lay before the public a mode of treating it, which, in a very extensive practice in my own hands, and in the hands of others under my directions, was found, when fully carried out, to be universally successful. As the importance of the general knowledge of a method of cure, which should prove itself thus efficient, cannot be exaggerated, I presume I need offer no apology for soliciting a space in your columns, as the public press is only fulfilling its high destiny in ministering to aught that may contribute to the general welfare. — I have the honour to be, Gentlemen, your obedient servant, GEORGE STUART HAWTHORNE, M.D., Late Senior Physician to the Belfast General Hospital. 61, St. Anne-street, Liverpool, January 6ih, 1848, 1.5 1 LETTER II. Gentlemen, — Having, in ray last letter, joined issue with the London Sanatory Commissioners on the alleged incurability of Cholera, I think it right here to state, that I fully agree with them in the opinion they have expressed upon the non-contagiousness of the disease — a subject with regard to which, also, it is of great importance the public mind should be properly instructed. The opinion that Cholera is not contagious has not, I am satisfied, been hastily adopted, but has been founded on extensive and acute observation. From my own observation upon the disease, I had long since arrived at the same conclusion. Quarantine restrictions never retarded the entrance of Cholera into any country for a single hour. They never did good, but always a great deal of mischief. They embarrassed commerce, and injuriously excited the fears and cramped the industry of the people. It will be a great blessing to the community, in case of another invasion of the disease, if the alarm of the people be not increased, and all the concomitant evils aggravated, by any unnecessary and useless precautions. How the disease is propagated, and by what laws its progress from country to country is governed, are subjects involved in absolute mystery. It is pre-eminently " the pestilence that walketh in darkness." All the phenomena, however, attending its former and present progress over the earth go to fortify the opinion, that it is not propagated by contagion. We find it starting up in many places simultaneously, leaving intermediate towns, even where the intervening traffic has been extensive, untouched. Its mode of travel has been unprecedented, and, by its eccentricity, it has set all speculation as to the laws which regulate its course, at defiance. In marking its present career towards us, a truly remarkable fact to be observed is, that it follows, as nearly as may be, precisely the same course as formerly; and, more remarkable still, it leaves untouched those places it formerly passed over. Altogether it is the most abnormal scourge, that ever swept our earth. Unsubjected to those laws which have been observed to mark or retard the course of other pestilences, it surpasses them all in the width of its range, and outstrips them in the destructive rapidity of its progress. If, however, we cannot by any precautionary measures avert the approach of the disease, it must be satisfactory to \c> know that, when it does make its attack, it is within the power of the medical art successfully to cope with it. To explain by what way this can best be done is the object I have set before myself in these letters. I confess myself surprised that, in this enlightened era of medical science, Cholera should have been so extensively fatal as it undoubtedly has been. The more so, because I have never met with a disease which, when scientifically treated, was more manageable or more easy of cure. I find it becomes formidable only when neglected, or injudiciously treated. That it has not, generally, been judiciously treated is a fact which cannot be denied, It has been too much the practice among medical men blindly to follow the opinions of others, without examining or thinking for themselves. The inductive method of arriving at the truth cannot be of more use in any department of science than in medicine. Every physician should take care to compare the conclusions arrived at by other practitioners with his own observations of facts. Many of those who have written on Cholera in these countries have been mere theorists, without experience ; and, of consequence, the practice in that disease has too often been the sheerest empiricism. There has been no rational system universally pursued; nor has there been any regular plan of treatment generally adopted. Could there be a greater proof of the ignorance that has too much prevailed on the subject, than the observations of a correspondent to a London medical periodical, of deservedly high character, who stated that what cured the disease in one street would not cure it in another ! A mode of treatment which will not cure the disease alike in all streets, will cure it nowhere. Nothing could be more absurd, or indicate more forcibly the want of that correct knowledge of the disease, which observation and reflection should furnish to a medical practitioner, than the various nostrums for its cure which have lately found their way, from different quarters, into the London Times newspaper. The observing of these impressed me, additionally, with the importance of losing no time in having the public mind rightly informed upon such an important subject. Cholera, like all other diseases, should be treated on rational principles. The object of the physician should be, first, to ascertain what diseased action tends, either directly or indirectly, to destroy life ; and then, when that is ascertained, and not till then will he do so with propriety, he 17 i should address himself to the counteraction or removal of that diseased action. The first step, then, towards devising a plan for the successful treatment of Cholera is to ascertain, with as much accuracy as possible, what is the morbid action which, in this disease, so potently, and with such sudden violence, invades, and, if left to itself, so soon annihilates the springs of life. To this end we must pause, and contemplate the symptoms which present themselves at the commencement, and throughout the course of the disease. The pathognomonic symptoms are, sudden debility, tremours, numbness, and general uneasiness, pain of stomach less . or more severe, occasionally headache, whiteness and clamminess of tongue, and praecordial oppression, succeeded by purging, vomiting, and cramps. The disease varies, more or less, in its modes of attack, and in the general symptoms. The following, however, is the order in which the symptoms, generally, manifest themselves. The patient first complains of a general weakness and languor, and what he calls a lightness in his head, an unusual feeling over the body, weight and oppression about the heart, with a disposition to sigh, accompanied with a sensation about the stomach and bowels, which he describes as a feeling of emptiness ; his countenance is pale, and his features shrunk — the fluids appearing to have receded from the surface. These symptoms are followed by a rumbling sensation through the bowels. The sphincter, losing its contractile power, gives way, and the contents of the intestinal canal are discharged. The bowels are affected at intervals of a few minutes, and the discharges become more and more fluid, till they present the appearance of whey, or of rice or barley water — becoming, in many instances, nearly as clear and as transparent as rock water. The relaxation and weakness increase with each discharge. The stomach becomes sick, and the contents are thrown off. The patient now feels a desire for drink, but as soon as he has swallowed it, it is immediately rejected. The sickness and retching complete the relaxation and dilatation of the discharging vessels, and the whole fluid part of the blood escapes. In proportion to the escape of the serous or watery fluid from the bowels, the temperature of the body decreases, till it becomes as cold as if dead. The pulse sinks in the same proportion, till it ceases to be perceptible at the wrist. Cramps then come on with torturing severity, and the voice is hoarse and stridulous. The breathing becomes laborious, with a severe pain in the region of the heart ; and B 18 the patient tosses himself about, anxiously and in vain lookingfor relief, which change of posture cannot afford. A profound coma calms the closing scene. This is a description of the s} r mptoms as they occur in this form of the disease ; and the whole process described is sometimes completed within the space of one hour. In many cases the symptoms more gradually develop themselves. The discharges from the bowels are at longer intervals — the first consisting of the natural contents, the next of a whitish matter, which becomes gradually more fluid and colourless, till it presents the almost transparent appearance already described. Such modifications, however, differ merely in degree. They are produced, no doubt, by peculiarity of constitution, or habits of life, or by the greater or less intensity of the exciting cause. Now, a careful study of the symptoms thus described, as developed by the disease, is of the utmost importance towards enabling us to arrive at a just knowledge of what is the nature of the diseased action here indicated, as, upon such knowledge alone, can a rational mode of treating the disease be based. I shall, therefore, enter into a brief consideration of the pathology of the various symptoms, giving my views of the nature of the morbid action which in its several stages gives rise to them. And to this part of my letter I beg particular attention, as upon my views on this subject I found my mode of treatment. Before, however, proceeding to do so, I may, perhaps, opportunely, pause to say a word upon what may be alleged as to the exciting or generating cause of the disease. Upon this subject much has been written; and the views entertained by the several writers who have treated of it have been widely various. Ingenious arguments have been adduced by all, in support of their peculiar views; but the evidence by which they seek to substantiate their theories is so conflicting, that to enter into a discussion of the points at issue, would require more space than is consonant with the limits I have at present prescribed to myself. I shall content myself with observing, that my own opinion is, that the disease is produced by some specific agent, of disturbing influence on the animal economy, forced from the bowels of the earth by subterraneous commotion. The sudden devastations of the disease in particular places, at great distances from each other, and, at the same time, can be accounted for, in my mind, on no other principle : and the fact that the disease is now retracking its former course, goes far to substantiate such a view. Those fissures in the earth, which gave vent to this deadly agent before, are doing so again. Whatever the character of the agent may be, it seems to me to act in some powerful manner in disturbing the electroproducing functions of the body, (if I may so speak.) That electricity is largely concerned in the animal economy is a fact now well established ; future discoveries will throw much additional light upon this interesting subject ; and the bringing of this animal electricity into some abnormal state appears to me to be the remote cause of all the symptoms which manifest themselves in Cholera. A very remarkable fact, indicative of such supposed electrical disturbance, is, that the bodies of those who have died of Cholera are, for several hours after death, affected with startings and contractions of the voluntary muscles, producing, in some cases, even temporary distortion of the features, and leading the friends to imagine the individuals still alive, thus presenting a phenomenon not to be observed after death under any other circumstances, and exactly similar in character to the appearances produced by the application to a dead body of the wires of a galvanic battery. On this subject, however, I am not in a position to enlarge. I merely throw out these hints as interesting subjects for physiological investigation and research. I would merely add, that a further confirmation of such a theory would seem to be afforded by the fact, that the disease is not contagious. But whatever be the exciting cause of Cholera, of whatever nature or character it may be, a careful study of the symptoms, as I have described them, proves to me conclusively that its primary operation is exerted on the brain and nerves ; and, from this affection of the brain and nerves, all the symptoms, as they develop themselves, flow as necessary consequences. The effect produced on the brain and nervous system is a paralyzation of their tone and energy, producing directly a diminution of the contractile power of all the muscular fibres of the body. This general diminution of muscular power accounts for the weakness and languor which occur at the commencement of the disease. From the diminished elasticity and contractile power of the vascular system, the blood and other fluids of the body, not being propelled with the usual force, tend to gravitate to the lower and internal parts. Hence the paleness of countenance, shrinking of features, and other symptoms, which indicate a receding of the b2 1! 2 fluids from the external surface. This gravitation and crowding of the fluids to the internal surfaces account also for the preecordial oppression, pain of stomach, &c. Further, the circulating power of the blood vessels being diminished, they do not carry the blood to the brain, either with the usual force, or in the usual quantity. The brain, therefore, being thus suddenly deprived of its accustomed support, becomes further impaired in its tone and energy, and is, thereby, rendered still less capable of exercising its functions. Hence arises the giddiness and lightness in the head, and the further paralysis and relaxation over the body. Again, the contractile power of the abdominal muscles, and of the muscular coat of the stomach, being diminished, these become relaxed, and produce that feeling of emptiness and want of confidence which is always complained of. The excretory vessels, (the extremities of the arteries,) opening on the internal surfaces of the stomach and intestines, sharing in the same general relaxation, become dilated, so as to permit a too free passage of the fluid which presses into them, allowing, in this way, the serum of the blood to escape. So complete has been the dilatation of these vessels, in many instances, that they have allowed the escape of even the red particles of the blood, giving to the fluid, passed from the bowels, an appearance as if raw beef had been washed in it. The sudden depletion of the vascular system, caused by this escape of the serous fluids, produces the vomiting. The same effect is observable from the extraction of blood, suddenly, from a large orifice ; the patient becomes sick and faintish, and the contents of the stomach are thrown off. The same takes place in uterine and other extensive haemorrhages. The escape of the serous part of the blood causing an effect on the constitution similar to that produced by blood letting, increases the relaxation. The relaxation and weakness thus increase with each discharge, till the whole fluid part of the blood passes away, the crude part becomes, as it were, stranded, and the vital powers are exhausted. This ushers in the collapse stage. In this last or collapse stage, the patient becomes of a livid or blue colour ; and the reason of this appearance is easily intelligible. The escape of the serous or watery part of the blood deprives it of that dilution or fluidity which is necessary to fit it for circulating through the minute ramifications of the vessels through which it has to pass. Hence the crowding of the red particles in the extreme vessels on the surface, which still become darker the longer they are deprived %\ of that due arterialization which they should undergo in passing through the lungs. The sense of suffocation felt in the lungs, at this time, and the pain and anxiety felt in the region of the heart, are produced by the viscidity of the blood ; the great excess of fibrine rendering it too crude to circulate through those organs. This, I may observe, has been satisfactorily demonstrated by dissection after death — the vessels of the lungs being found clogged with fibrine ; and polypous masses of the same substance, as has been related by Dr. Joenichen, a Russian physician, being sometimes discovered in the ventricles of the heart, so as in a great measure to obstruct all circulation. It is difficult to prove whether the cramps in the collapse stage are caused by the extensive vascular depletion that has taken place, or by the circulation being retarded by the crudity of the remaining part of the blood. The coma which in the collapse stage generally supervenes is caused by the congestion of blood, and accumulation of fibrine, that take place in the great vessels of the brain, and sometimes from effusion of serum into its cavities. Such are my observations upon the pathological indications of the symptoms in this disease ; and it has been necessary for me thus to dwell upon these matters, in order to prepare for the right understanding and ready appreciation of the remedies by which I propose to combat all such symptoms. In my next letter I shall proceed to lay before you a mode of treatment, by which the morbid action may be successfully counteracted in every phasis in which it presents itself, previously to the collapse stage, in which remedies seldom avail. A mode of treatment, which, from the pathology of the symptoms I have laid down, and from what I shall hereafter say on the mode of operation of the remedies, will, I am persuaded, recommend itself even to the most sceptical, as a method of cure, which, when timely and skilfully administered, has just pretensions to be styled infallible. I have the honour to be, &c, G. S. H. 61, St. Anne-street, Liverpool, Jan. 12, 1848. ĤĤa LETTER III. Gentlemen, — In my last letter I remarked, generally, yet briefly, upon the history, character, and symptomatic features of Cholera. In the present letter I propose to treat of the means of cure. Before entering upon this subject, however, it is necessary, in a medical point of view, that I speak of the prognosis of the disease, and of the various forms in which it presents itself. As to the prognosis in Cholera, I would briefly state it to be, — Favourable Symptoms : — The disease commencing with cramps of the voluntary muscles ; heat of skin at or above the natural standard ; pulse soft, full, and strong ; little thirst ; bilious vomiting, and purging. Unfavourable Symptoms : — No pain nor cramps at the beginning ; pulse small, and feeble ; heat of skin below the natural temperature ; tongue a pale white, clammy, flowing with saliva, cold, relaxed, and broad, having apparently lost all contractile power ; no secretion of urine ; serous and watery purging, and vomiting, and no smell emitted from the discharges. Disposing of the prognosis thus briefly, I proceed to observe that the disease presents itself in four distinct degrees of malignity, which it is necessary for me to describe, as information upon this subject is an essential preliminary to a judicious use and properly modified adaptation of general rules of treatment. I shall take these up in the order of their malignity. Ist. In the least dangerous form of the disease the attack commences with spasms of the stomach, bowels, and voluntary muscles ; heat of body at the natural temperature, with a strong full pulse, and slight retching or vomiting, unaccompanied by purging. 2d. The next in point of danger is, where the disease begins with pain of stomach, less or more severe ; oppression about the praecordium, headache, numbness of the extremities, with a prickling sensation over the skin, succeeded by purging and vomiting, or vomiting and purging, — in some cases, of bilious matter ; in others, of a whitish-coloured fluid. 3d. A more dangerous form of the disease than either of the preceding commences with violent pain of the stomach, increased on pressure ; intense pain across the forehead, and in the eyeballs; face flushed; pulse quick, hard, and bounding; a painful sensation felt over every part of the body, similar to r that experienced at the beginning of fever ; heat of skin increased to a morbid degree ; tongue exceedingly white, deeply coated, and furrowed; intense thirst, with deadly sickness at stomach ; vomiting and purging, — first of the natural contents, after which, the fluid matter discharged from the bowels is of a grayish-white colour, granulated, and mixed with particles resembling powdered ochre, and emitting a peculiar and intolerably fetid odour, exceeding any thing of the kind observed in almost any other disease. Though this is not the most rapidly fatal form of the disease, still it is fraught with great danger, requiring prompt and active treatment; and the recovery may be more tedious than even where the disease has assumed the most malignant type. 4th. In the last and most malignant form of the disease, the attack comes on with giddiness of the head, ringing of the ears and purging — first of the natural contents, then of a fluid resembling thin mucilage, or barley water ; pulse small and feeble ; heat of skin below the natural temperature ; without any vomiting, pain, or cramps. Here there is the greatest danger, and, if the disease be not instantly checked, the patient may go down into collapse in less than half an hour. Upon this form of the disease I would observe that the most rapidly fatal attacks in Cholera commence without any vomiting, pain or cramps, or previous warning whatever ; and, while, under all circumstances, under all more or less severe attacks of the disease, the earliest recourse ought to be had to remedial means, I wish to impress the importance of being specially prompt when the disease begins in this its most malignant and most insidious form, in which a delay of a very short period might be attended with fatal results. I have seen much of the fatal consequences of an error of opinion in this respect, the patient imagining that it could not be Cholera with which he was affected, because he had no vomiting, or pain, or cramps, when, in point of fact, it was the most fatal form of the disease ; and when the vomiting and cramps did come on, they were only the fearful harbingers of collapse and death. In the most malignant form of the disease, the first discharges always take place from the bowels, and the patient does not vomit till the disease has carried him into hopeless collapse, or till he is, at least, verging on that stage. A knowledge of this fact cannot be too strongly impressed on the minds of the public. As far as my recollection now serves me, all the cases of hopeless collapse to which I have ever been called, during my experience, were of persons who assured me that 28 till the perspiration not only corrects the diseased action, but also repairs the injury which the system may have sustained. In my next letter I shall, among other matters, make some necessary observations on the consecutive stages of the disease. : I have the honour to be, &c, &c, G. S. H. 61, St. Anne-street, Liverpool, January 29, 1848. LETTER V. Gentlemen, — The great secret in the treatment of Cholera is to lose no time in stopping the discharges from the bowels, if they exist, and in exciting warm profuse perspiration. This object should still be kept in view by the practitioner, no matter in what state he may find his patient. After giving such a dose of medicine as may stop the purging, his next effort should be, by the application of external heat, to produce a discharge from the surface. If the heat of the body be higher than natural, the perspiration will equalize it ; if lower, the application of external heat will restore it ; and if the body be covered with a cold clammy perspiration, it will change it to a warm one. I have directed that the perspiration should be continued for, at least, twelve hours, if the patient can bear it, keeping up, however, merely as much heat as may be found perfectly agreeable to his feelings ; his desire for drink, which is generally very great, being meanwhile gratified ad libitum. As soon as it may be proper to discontinue the perspiration, the patient's body should be rubbed perfectly dry, and he should be furnished with dry linens or flannels, and with dry sheets and blankets. He may then, if he desires it, be indulged with a little arrowroot, or sago, to which may be added a tablespoonful of brandy or half a glass or a glass of sherry ; which, given as often as required, will afford sufficient nourishment till the stomach recovers its healthy tone, and desires and relishes more substantial food. He may then have wine, beef tea, chicken broth, beef steaks, or mutton chops. Where , the purging has been quick and violent, if the patient be free from sickness at the stomach, his bowels should be allowed to remain undisturbed, if they will, till 57 the third day. They should then be gently opened, by means of an enema of a pint of a weak solution of soap and water. Should the patient be seized with bilious vomiting sooner than the third, day, which sometimes happens from the sudden discharge of the distended gall bladder, and should his bowels be confined, it will be proper to give him the enema earlier ; giving at the same time an emetic of ipecacuanha wine, to be worked off with warm camomile infusion. Should these means fail to settle the stomach, and give the peristaltic motion a downward direction, he may get two grains of calomel, and six or eight grains of the compound extract of colocynth ; and after some time the enema should be repeated till it produces the desired effect of clearing out the bowels, and carrying of the redundant bile; after which, should any irritability of stomach remain, it will be immediately relieved by one or two grains, as the case may be, of solid opium, followed up with bitter tonic effervescing draughts. If the patient have got a large dose of opium at the beginning, it will require two grains to be given now ; if he have had a small dose, one grain will suffice. Should the patient on the second day, as often happens after a malignant attack of the disease, complain of acidity of stomach with confined bowels, he should get two tablespoonfuls of the following mixture every thiid hour till relieved: — Sweet Spirit of Nitre, Tincture of Rhubarb, >of each half an ounce. Tincture of Colombo, J Compound Tincture of Cardamoms, three drachms. Bicarbonate of Soda, two drachms. Camphorated Julep, eight ounces. — Mix. After a few doses of the above mixture have been given, their effect on the bowels may be assisted, if necessary, by the use of the mild enema already mentioned. This mixture will neutralize the acidity in the stomach, and restore the healthy tone of that organ. It will also act gently on the bowels, cleanse the tongue, and cool the system, and will promote the restoration of the healthy secretion of urine, which is generally suspended in this disease. Should, however, the bowels be too much relaxed, the tincture of rhubarb should be omitted, and two drachms of the compound spirit of ammonia, and a suitable proportion of the tincture of opium, added. The stomach of a patient recovering from a malignant attack of Cholera is very weak, and the patient feels a craving desire for bitters and aromatic spices ; and, from the shock his stomach has sustained, he desires, and can take much stronger doses of these than would be agreeable to him under ordinary 88 circumstances. This craving desire should be gratified, as nature seldom errs in such matters. Bilious diarrhoea never occurs in the consecutive stages of Cholera, unless calomel, or some preparation of mercury, has been most improperly, and, I would add, most unwarrantably used in the primary treatment of the disease. When it does occur, it should be treated with the cretaceous mixture, combined with suitable proportions of the tinctures of catechu and opium, and in addition, if obstinate, by anodyne injections, giving at the same time small and frequentlyrepeated doses of sulphur, for the purpose of neutralizing the mercury, and for counteracting its action on the liver. The strength is at the same time to be supported by wine, beef tea, &c. Great care should be taken not to allow the patient to get out of bed, or stand in the erect posture, till the strength of the body and the healthy tone of the nervous system have been sufficiently re-established. Fatal consequences have sometimes arisen from not attending to this precaution. In a hospital, a woman, who had had a very favourable recovery from an attack of Cholera, lost her life by imprudence in this respect. Contrary to the orders of the superintending physician, and in opposition to the remonstrances of the attendants, she got out of bed, and while in the act of dressing herself in an erect posture, she suddenly fell on the floor in a fainting state. The excretory vessels, being unable to sustain the superincumbent weight of the fluids of the body, became dilated — the serum, or watery part of the blood, escaped into the bowels, and she passed several quarts of fluid, as clear as water, before she could be lifted into bed. She was dead within less than two hours afterwards, having manifested all the symptoms of one who had been bled to death. In directing the treatment of the mildest form of the disease, I omitted to state, that, should the practitioner find his patient affected with pain of stomach, headach, and vomiting, along with a hot skin and a full strong pulse, and should he find that the bowels have been previously much confined, he ought, before giving the antispasmodic pills or draught, as ordered, cause the bowels to be unloaded by means of an enema. I directed that the opium, whether alone or combined, should be administered in Cholera in the solid form. The reasons why it should be so administered are, that in that form it is more likely to be retained on the stomach, and if it be rejected, the fact can, by an examination of the egesta, be 39 more readily detected; and for the quantity thrown off an equal quantity can be immediately re-administered. On the other hand, if the administration of the medicine in a fluid state be followed by vomiting, the practitioner can have no means of knowing what portion of the dose has been rejected, so as to enable him to supply the deficiency. In this way he loses his reckoning, bewilders himself, and under such circumstances, in a malignant case, he may lose his patient. In adjusting the doses of the medicines, I directed ten of the pills containing ten grains of powdered opium to be given for a first dose, in the most malignant and rapidly fatal form of the disease, and under the alarming and dangerous circumstances there supposed. I prescribed ten, as I knew it required some experience and tact to graduate, in such cases, the exact amount of danger. Were the dose to be administered by my own hands, however, or under my own inspection, I would in many such instances, without hesitation, as I have often done, and always with success, give twelve of the pills for a first dose. I have given six of the pills to a little girl of ten years of age, and she experienced no narcotic effects from the dose; but, on the contrary, slept none all night, and had quite recovered and was walking about next day. All the other doses mentioned will be amply sufficient first doses for all the other forms of the disease for which they were prescribed. I shall pursue the subject in my next. I have the honour to be, &c, &c, G. S. H. 61, St. Anne-street, Liverpool, Feb. 2, 1848. LETTER VI. Gentlemen, — I have stated that the mode of treating Cholera, described, in the preceding letters, if timely, skilfully, and vigorously employed, will cure the disease in every instance. "What I mean by timely employed, is any time before the disease has carried the patient into collapse. When the serous, or watery part of the blood, all,J or nearly all, escapes into the stomach and bowels, the remaining crassamentum, or fibrinous part of the blood, becomes too 40 crude to circulate. The pulse then ceases to be felt at the wrist, and the body becomes as cold as ice, communicating to the touch a sense of coldness never felt in the human body under any other circumstances, whether dead or alive. This is called the collapse stage. Now, after the disease has arrived at this stage, little good can be effected by medicine. The recoveries from this stage are to be chiefly attributed to the vis medicatrix natures. This is not a mere assertion. It has been provedl I have seen more instances of recovery from collapse in persons who utterly refused to take any medicine whatever during the whole course of the disease, than I have witnessed in those who had been treated by the popular remedies. These were persons of peculiar habits of body, — thin, lean, emaciated habits, with little fibrin e or crassamentum in their blood. The great advantage which these persons enjoyed, in this case, from the tenuity of their blood, was, that the heart, arteries, sinuses, and lungs, did not become obstructed by the masses of fibrine which obstruct the circulation in the collapse stage in those of more robust habits, and of more healthy bodies and sounder constitutions. I have been called in, on passing, to see an emaciated old woman, lying on a truss of straw, on a cold damp earthen floor, her body and features collapsed, clammy and cold as a mass of ice, with scarcely any covering over her, and with not a vestige of a pulse to be felt at the wrist, or any part of the extremities. She was urged with intense burning thirst; and, with her hoarse stridulous voice she cried incessantly for cold water, which was no sooner swallowed than it was rejected from the stomach. This poor creature I could not persuade to take any medicine; but I directed hot substances to be applied round the body and extremities, and to allow her urgent desire for cold water to be gratified. On passing next day I had the extreme gratification to find her out of danger; her pulse full, soft, and regular ; the natural heat of the body restored ; the veins full, and the countenance and hands restored to their natural appearance. Such instances as this, in both sexes, have frequently come under my observation ; but more frequently in the case of old women than in men of the same age. I think it right here to state that, from the nature of the disease, no person of a robust, corpulent habit of body could recover from collapse. Let no exertions, therefore, be spared to arrest the progress of the disease, before it arrives at this stage. The cramps in the collapse stage of Cholera are truly frightful, and the pain produced by them is most excruciating. 4J The cause of cramps in this stage is different from that which excites them at the commencement of the disease ; I mean before purging has commenced. I have already stated, that cramps, at the commencement of an attack, are indicative of its mildness. They prove that the brain and nerves are not so extensively paralyzed as they are in the more malignant form of the disease. This can be made more intelligible to the reader by illustration. When a certain amount of irritation is applied to a nerve, all the muscles with which that nerve communicates become cramped, and more or less pained. Increase that injury, however, so as to destroy all sensibility in the nerve, and all those symptoms and effects cease. In like manner, when the brain and nerves are, originally, but partially paralyzed and impaired in their energy, this will manifest itself in the milder form and character of the symptoms. The cramps in this case, while they prove that the brain is the original seat of attack, and that its functional powers have been disturbed, also prove, by their existence, that its total energies have not been completely overthrown. In the collapse stage, however, the cramps do not arise simply from the primary exciting cause ; but from the shock which the brain has sustained from the sudden vascular depletion which has taken place ; as we see exemplified in animals which have been bled to death, which generally die convulsed. The brain, being suddenly deprived of the packing and bracing support given to it by the blood, loses its power, and, from that loss of power, it fails in its command over the voluntary muscles ; and these muscles, in consequence, exert their uncontrolled contracting power in the way we see them do in the fearful cramps which occur in the collapse stage of this disease. That the cramps in the collapse stage are produced by this cause, is clearly proved by the result of an accidental experiment, which occurred in a case which shall be described in this letter. With these preliminary observations I proceed to state that, though remedial means avail little in this stage of Cholera, it is still, even here, the duty of the practitioner to give his patient every chance of recovery which his skill affords. From what has been already stated in this and in the preceding letters, the reader will perceive that the indications of cure, in this stage, are to restore the energy of the brain and nerves, as far as this is now practicable, and to refill the depleted circulating vessels. The accomplishment of these objects can be effected, only, by the means already directed in the primary stages. The same medicines and Ui cordial stimulants may be here given for a first dose, with equal freedom, as they were directed to be administered in the primary stages. The only objection to this is, that patients who die in this stage, for reasons formerly stated, generally die comatose ; or, in other words, sleep away, as it is called ; so that if a large dose of opium were given, and the patient were to die, as it is most likely he would, his friends or relatives might naturally suppose that the large dose of opium had caused him to sleep the sleep of death. In treating this stage of the disease, the circumstance referred to should be explained to the friends of the patient before any medicine be given. For the reason just stated, I always, in such case, try the effects of four of the antispasmodic pills, and the draught, with the cordial stimulants, for a first dose, till I see if this and the other remedies are likely to prove successful ; when, if necessary, a little more may be given. In this stage, however, the fluids having been already drained off, there is seldom any, or, at least, much purging, so that four of the pills will be generally sufficient ; as they, and the other medicines and cordial stimulants, are ordered here with a view chiefly to restore the tone and energy of the brain and nerves. The second indication of cure, in this stage of Cholera, namely, to re-fill the depleted circulating vessels, can, as formerly stated, be accomplished only through the agency of the absorbent vessels opening on the internal surfaces. The grand agent, and the only one, which we have at command here, as in the primary stages, for exciting those absorbents into vigorous action, is perspiration, produced by the application of external heat, as formerly directed ; and this agent will here again cause the absorbents to accomplish the object desired in refilling the depleted circulating vessels, even in the collapse stage of Cholera ; but the patient, notwithstanding, will die, unless his recovery be favoured by such a habit of body as I have described above. No patient with any other habit of body can recover out of collapse in Cholera. For though, through the means directed, the depleted circulating vessels may, and will, if it be tried, be completely refilled, still, if the patient be of a robust corpulent habit of body, such fibrinous obstructions and congestions will have occurred as will assuredly prove fatal ; and the medical art affords no means for removing these. These facts have been so thoroughly established, that they enable me to foretel, with certainty, what will be the result of my efforts for the recovery of a patient from the collapse stage of Cholera. i-S To prove that the depleted circulating vessels can be effectually re-filled by the combined agency of perspiration and drink, I shall now state a case, which might rather be called an experiment, though an accidental one. A man, aged forty-seven, of a thin spare habit of body, was seized with violent symptoms of Cholera, at three o'clock a.m. I was called to him at eight the same morning. On entering the house I heard him screaming from the violence of the cramps. I found his extremities quite cold and livid ; his pulse scarcely perceptible at the wrist, small, fluttering, and very irregular ; his countenance ghastly ; his face and hands of a livid colour, and the skin of the latter shrivelled and corrugated. He had incessant purging and vomiting of a fluid nearly as clear as water, with an insatiable desire for drink. He was so weak and exhausted as to be unable to get out of bed. I had the body and extremities immediately surrounded with jars and bottles of hot water, bags of hot salt, and hot bricks, and, three minutes afterwards, I gave him a suitable dose of the antispasmodic pills and draught, which I caused him to wash down with a glass of hot punch. The heat was gratifying to him, and wherever a cramp seized him he begged that something hot might be applied. During this process I directed my attention particularly to the pulse. After the heat had been thoroughly applied, and the pills and the hot punch had been administered, the pulse became gradually more distinct and full, and, at the same time, improved in strength and regularity. On referring to notes taken at the time I find that, at the end of fifteen minutes after the application of the external heat, and about twelve minutes after the administration of the medicines and the hot punch, the cramps had entirely ceased. The pulse was then pretty full, and of tolerable strength and regularity; the countenance had become more full and natural, and the hands less shrivelled ; the temperature of the body and extremities, which rose with the pulse, had arrived at the natural standard, and a profuse perspiration issued from every part. The patient expressed himself completely relieved. I then gave him a large draught, as much as he desired, of warm whey, of which he had been drinking previously to my arrival. As the symptoms then appeared favourable, and as extensive experience had given me the most positive assurance of the successful result of the mode of treatment, I left the patient, promising to be back in half an hour. I, at the same time, gave the attendants strict orders to keep up the perspiration, and not to let the patient 41 have any more drink in my absence, lest he should throw off the medicines ; but I directed them to have a jug of hot toast-water prepared at my return. After taking my leave, I was so much pressed by business that this patient entirely escaped my recollection, until, about two hours afterwards, T received a message that he was as ill as ever. On my way to him it occurred to me that if my directions had been strictly followed he must be cramped again, as the profuse perspiration which issued from his body when I left him, if continued and not supplied by drink, must, before then, have produced a draining effect on the vascular system, equal to that which had been produced on it by the previous discharge from the internal surfaces. Accordingly, on entering the house, I again heard his cries; and was met by his friends, who, in despair, told me that he was cramped worse than ever, though they had strictly followed my directions in keeping up the heat, and in refusing to comply with his desire for drink, which was urgent. Though an accidental experiment, it was one very important and curious. I was anxious, therefore, to note down, with accuracy, every particular. His face and hands, which before were livid, were then of a crimson hue; the prominences on these parts were sharp, and the depressions were hollow; the skin seemed to be sticking to the bones, without any apparent intervening substance ; the course of the veins was marked by hollow lines ; the body and extremities had become almost dry, and, on touching them, their morbid heat and parched state communicated to the hand a very unpleasant sensation; the respirations were quick, with great anxiety and pain in the region of the heart ; and the thirst was most urgent. There had been no discharge from either stomach or bowels after the medicines had been administered. The pulse at the wrist was felt like the ticking of a watch, at intervals of a few seconds ; fluttering very quick, and presenting to the finger a degree of smallness similar to that of a very fine needle. Keeping my finger placed on the pulse, I ordered the patient to drink warm toast water, ad libitum. The rapidity with which the drink was absorbed, and the sudden effect produced on the pulse by it, were very remarkable, not a minute having elapsed after it was swallowed till I felt a perceptible change. The intervals between the flutterings of the pulse became gradually shorter and less perceptible. As the pulse became fuller, it became more and more distinct, till it bounded full and strong. The veins filled in the same proportion till they became distended like rods. The breathing became natural, 4-5 and the pain about the heart ceased. The cramps then disappeared, and a profuse perspiration again issued from every part of the body. This all occurred in the course of eleven minutes ; and the patient in that time drank above a gallon of fluid. As the vascular system filled up, the complexion improved, till it became nearly natural, but rather florid. The external heat was gradually removed, the temperature of the body was reduced to the natural standard, and the patient felt free from every complaint. He was convalescent the next day, though weak ; and he was walking about on the fourth day. This accidental experiment proves that the cramps, in the collapse stage, are caused by the vascular depletion. It also shows how rapidly the drink is carried into the circulating vessels, when the action of the absorbents is excited by perspiration. , When patients in the collapse stage of Cholera urgently crave cold water for drink, their desire in this respect should be gratified. At the same time a little sweet spirits of nitre should be added to the cold water, as it proves very grateful to them, and, in some instances, produces salutary effects. When the collapse stage is treated in the way I have directed, however, the patient's desire for cold water soon ceases, and he relishes hot drink best. Stimulating embrocations, so much lauded as a remedy in the collapse stage of Cholera, never did good, however injurious they may have proved. Neither did frictions, so much recommended in this stage, ever do any good, but always a great deal of mischief. They annoyed the patient ; they excited vomiting, even if it did not previously exist ; they increased his restlessness, exhausted his remaining strength, and hastened his death. After the patient has been completely rallied from the cold collapse stage by the means which I have directed, and after the depleted circulating vessels have been thoroughly refilled, should a tendency to coma manifest itself, with symptoms of congestion in the brain, along the course of the spine, or in the lungs, which, if the patient be more or less of a corpulent, robust habit of body, will assuredly be the case in a greater or less degree, in one or other, or, it may be, in all of these respects, the effects of scarifications and cupping may be tried, at the nape of the neck, between the shoulders, or along the course of the spine, or as near as may be convenient to wherever the seat of the danger is indicated. Where the coma is profound, however, the eyes suffused and fixed in their 1(5 sockets, with the pupils contracted and insensible to the stimulus of light, there is no use in torturing the patient with remedies : no patient ever did, or ever will recover under these circumstances. What is called consecutive fever in this disease never occurs unless the patient has either gone into collapse, or approached very near to it. In no instance does it occur unless there have been considerable watery discharges from the bowels. This fever is caused by the congestions which take place in different parts of the body ; and some die of it, after having apparently escaped all the horrors of the disease. These congestions may, in the consecutive stage, give rise to inflammations of the brain, stomach, bowels, or other organs. Should such inflammations occur, they will be best treated by sinapisms, fomentations, and local bleeding with leeches, followed by blistering if necessary. I have often seen a violent mercurial fever, which had been produced by enormous quantities of calomel, which had been improperly administered in the treatment of a mild attack of the disease, mistaken for consecutive fever. In my next letter I shall notice a few of the most popular remedies which have been employed in the treatment of Cholera, in these countries, in India, and elsewhere. I have the honour to be, &c, &c, G. S. H. 61, St. Anne-street, Liverpool, February 5, 1848. LETTER VII. Gentlemen, — Amongst the objectionable remedies which have been employed for the cure of Cholera, the first I shall notice is blood-letting. With regard to this remedy, I would remark that I cannot conceive how any rational practitioner could think of using, for the cure of this disease, a remedy which produces on the constitution an effect the very opposite to that which it should be his object to accomplish — a remedy which would aggravate rather than relieve the symptoms. The effect produced by blood-letting is relaxation. It is with this view it is generally employed ; as, for instance, in inflammations, and in certain cases of rigidity. The depletion of the vascular i: system by blood-letting, suddenly removing the accustomed pressure or bracing support from the brain, has the effect of diminishing the tone and energy of that organ, and, of course, of the nervous system. Hence the supply of energy to the muscles is lessened, and a corresponding diminution of the contractile power of the muscular fibre is produced. Now, from what has been stated in the preceding letters, the reader will at once perceive that a precisely similar state of things takes place in Cholera. I need not say, then, that bloodletting should be at once discarded from the treatment of the disease ; for every man possessed of a reasoning mind, who has read my preceding letters, will at once perceive that it deprives the patient of many of his chances of cure ; and that, by diminishing the force of the resisting power of the vessels through which the serum of the blood escapes, it tends only to hasten the fatal event. AH the symptoms at which any man could grasp, in justifying the use of the lancet in the early stages of Cholera, can be at once relieved by a free perspiration. I was once taken to visit a young gentleman of eighteen years of age, who was seized with premonitory symptoms of Cholera. One of the same family had, a few days before, died of the disease, in a few hours' illness. He complained of great praecordial oppression ; violent pain over the region of the stomach, increased by pressure ; great sickness and retching, but nothing ejected from the stomach ; a painful feeling over every part of the body, as if he had been beaten with a stick ; and severe headach. His face was flushed, his eyeballs swollen and painful, with a feeling as if they were about to start from their sockets ; his tongue white, his skin hot and dry; pulse one hundred and twenty, exceedingly full, strong, and bounding. His bowels had not been affected. After cautioning the medical gentlemen present not to allow such symptoms, as those of which the patient complained, to betray them into the use of the lancet in similar cases, I ordered the patient a suitable dose of the pills and draught prescribed in my preceding letters, with as much mild warm drink as would wash them down. I then ordered hot substances to be applied to his feet, and different parts of his body, with a view to produce perspiration ; and, after giving the attendants the necessary directions about what drink he was to get, and when he should have it, I took my leave. After the lapse of an hour, I again visited him, and found him perspiring freely; his skin quite cool; his pulse sixty, soft and regular ; and he was entirely free from pain of every kind. He declared that he was then as 48 well as ever he had been in his life, and expressed a wish to get out of bed. The crushing about his heart and the pains flowed off with the perspiration. He said that he had not perspired many minutes till he was free from pain, sickness at stomach, and every complaint. He had quite recovered, and was walking about next day. I need not waste your valuable space, or the reader's time, with further comment on so absurd a remedy as bleeding. The next remedy which I shall notice is calomel — a medicine which, in these and all other countries, has been universally used for the cure of the disease. Calomel, like blood-letting, tends only to hasten the fatal termination in Cholera. It does more. Those who escape or recover, in spite of the effects of it, do so at the expense of a ruined constitution. The reasons which are given by medical writers for using it in that disease are absurd, and are founded on a total misconception of its nature. Some say that they give calomel, combined with opium, as a stimulant. — " Powerful stimuli," say they. Opium, as has been already stated, is a powerful and very valuable stimulant ; but the chief stimulating effect produced by calomel, in that disease, is on the mucous membrane of the stomach and intestines ; increasing the discharges from them, which it should be the object to prevent. Mr. Orton, in his work on "Cholera," says that the calomel was found adhering to inflamed patches on the internal surfaces of the stomach and intestines of many of those who died of Cholera in India. No doubt it had stimulated these parts with a vengeance ! The following are that gentleman's words : — " Calomel was frequently found at the bottom of the fluid contents, and adhering in various places to the mucous coat." In a note appended to the same he adds, — " I have been informed by a practitioner, in whose observation I have great confidence, that he had frequently found this medicine adhering, chiefly, to those parts of the stomach which were inflamed." — [See Mr. Orton's Essay on the Epidemic Cholera of India, page 42.] Here, then, is positive evidence of the destructive effects of calomel, even in India — the boasted birth-place of the practice. Others, again, say that they administer the calomel with a view to restore the biliary secretion, which they allege is suspended in the disease. On this subject I beg leave to observe, that the suspension of the secretions in Cholera is not the cause, but the effect of the morbid action. When the morbid action is corrected, the secreting organs generally resume their functions without any assistance. And even 49 though they should not, it is only after the disease has been cured that medicine will have any salutary effect on those organs. First, then, cure the disease ; and afterwards, if necessary, let attention be directed to the secretions. I would remark, however, that though, for a very obvious reason, the suspension of the secretion of urine is a characteristic symptom of Cholera, yet it does not appear that the secretion of bile is ever, for any length of time, suspended in that disease, even though it does not come off in the discharges. On a post mortem examination of the bodies of those who have died of the disease, the gall bladder has been always found distended with bile. It is not, therefore, so much a suspension of the secretion of bile, as a retention of that fluid, which accounts for its non-appearance in the discharges. Did time and space permit, I could satisfactorily explain the cause of its retention in Cholera. Ido not conceive it right, however, to allow that explanation to occupy the space which should be allotted to more important matters ; particularly as, when the disease was cured, I never knew an instance in which the secretory organs did not resume their functions ; and even though calomel should not counteract the effects of other remedies, which it does, or produce destructive effects on the constitution, I cannot see any use in employing it in a disease where it has no time to act. If the discharges be profuse and water} 7 , and follow each other in quick succession, as, in a malignant case, they generally do, they may carry the patient beyond the boundaries of human aid in less than an hour. In such cases the calomel has not sufficient time to be absorbed, even though the absorbent vessels were in a fit state to take it up. The absorbents on the internal surfaces, in that disease, however, do not act at all, till the morbid action is corrected. Those cases, therefore, in which calomel produced salivation, did not deserve the name of Cholera. The advocates for the use of calomel in Cholera, say that all their patients who have been salivated by that medicine have recovered; and this alleged fact, they presume, is an argument in favour of its employment for the cure of that disease. Now, to those who do not understand the subject, this would appear to be a very plausible argument. A little examination, however, will show the fallacy of it. First, I would remark, that many have been subjected to treatment for Cholera who never had the disease at all. Secondly, during the prevalence of the disease, individual cases do sometimes, nay often, do occur in which the vis medicatrix natures would succeed in throwing off the disease without the aid of D 50 remedies, or in spite of the counteracting effects of the calomel. And, lastly, opium, which is generally administered in conjunction with the calomel, and an accidental perspiration may succeed in curing a very mild case of the disease, as has been already stated, notwithstanding the prejudicial effects of the latter medicine. Now, whatever calomel may remain in the stomach and intestines of these patients, after the disease has been cured, will, no doubt, be absorbed, and will salivate them in good earnest ; and will thus, after the cure of the disease by other remedies, produce a new disease, in some cases worse than Cholera itself. Hundreds have, in this way, been so disabled as to be rendered incapable of earning a loaf of bread for themselves, and have been left to drag out a miserable existence, with shattered and ruined constitutions, from the effects of the calomel administered to them for the cure of Cholera. But none of these facts prove that the calomel, or the salivation produced by it, had any efficacy in the cure of the disease. The fact is, calomel will not act on the system in any way to produce salivation, until the morbid action constituting the disease has been counteracted and reversed, either by the agency of other remedies, or by the reactive power of nature herself. The enormous quantities of calomel which were given to patients in Cholera, during the prevalence of the disease in these countries, were of themselves sufficient to destroy life, even though the individuals to whom they were administered had been, at the time, free from any specific disease. Twenty grains of calomel and two grains of opium, to be repeated every two hours till the symptoms should abate, were directed to be given in the books and pamphlets published on the subject at that period. A physician, who is now a vicar in some parish in England, in a letter published in the London Times newspaper, about two months ago, says that the best remedy he ever saw employed (and it was in New York he had seen it) was twenty grains of calomel and two grains of opium for a dose. A physician told myself that his dose was forty grains of calomel and two grains of opium. I shall content myself with only one specimen of the extent to which the calomelizing practice has been carried. A man was admitted into the Belfast hospital, whose mouth was nearly hermetically sealed up from the effects of calomel, which had been admi- nistered to him for the cure of an alleged attack of Cholera, so that no food could be conveyed into his stomach but beef tea, thin gruel, or milk, and these he had to suck in through apertures between his remaining teeth. Such an extensive 51 excoriation and ulceration of the gums, jaws, lips, and cheeks had taken place, from the salivating effects of the calomel, that extensive adhesionshadformedbetween these surfaces throughout their whole extent. His lips and cheeks adhered firmly to the gums and jaws, so that Mr. Moore, the talented and skilful surgeon to the hospital, was obliged to dissect these parts asunder to cut out masses of flesh between the inner angles of the jaws, and to stuff the inner sides of the cheeks and lips with lint, soaked in oil, to prevent their re-adhesion to the subjacent parts, and to gag the jaws asunder with corks, till these parts healed. Why unnecessarily inflict such misery ? I have not only already amply proved that calomel is unnecessary for the cure of Cholera, but I have now shown that it is destructive. I have cured from two to three thousand cases without a single grain of calomel. I have a right, therefore, to form a judgment on the subject. I trust I have now set the bleeding and calomelizing mode of treating Cholera at rest ; and as I have directed a mode of treating that disease, which, if timely and skilfully employed, will infallibly cure it in every instance, I shall not delay further by noticing any more of the nostrums which have been recommended for its treatment. In conclusion, lest any one, from the foregoing remarks, should be deterred from the use of calomel in other diseases where it may be requisite, I would observe, that we do not possess a more safe or a more valuable medicine when skilfully administered, in cases where its use is proper. I have the honour to be, &c, G. S. H. 61, St. Anne' Street, Liverpool, Jan. 12, 1848. LETTER VIII. Gentlemen, — In directing the mode of treating Cholera I prescribed such remedies and such doses of medicines, for each modification of the disease, as were severally suited to persons of adult age. The same mode of treatment, and the same remedies, are equally applicable, and equally efficacious, in all ages, down to infancy, care being taken, merely, to regulate the application of the remedies, and proportion * 52 the dose of the medicine, according to the strength and age of the patient, except in respect to the dose of opium, which, in the treatment of infants, cannot be thus graduated. The head bears a much greater proportion to the size of the body during the period of infancy and childhood than it does during that of adult age. For this reason infants and children are more liable to diseases of the head and brain than persons full grown. For the same reason, also, infants and children, from the anatomical proportions of their different organs, are more susceptible of the narcotic effects of opium than adults are. It has been already stated that the specific effect of opium is to contract the diameter of the blood vessels, and to lessen their containing capacity. Hence, if too large a dose of opium be taken, in a state of health, the contracted blood vessels no longer contain their usual amount of contents, and the consequence is, that the blood is forced, in unusual quantity, into the more yielding parts and cavities of the body, such as the lungs and the sinuses of the brain, producing congestions of those parts in a greater or less degree, according to the amount of the dose taken. It is in this way that opium destroys life, by producing apoplexy of the brain and lungs. Thus, then, it is obvious that infants and children are peculiarly susceptible of being narcotized by opium, so that that medicine should be administered to infants and children with the greatest caution. An infant can neither bear the rough treatment which may be sometimes necessary in saving the life of an adult person, nor can it make sufficient effort to take the necessary antidotes to an excessive dose of medicine. I have lost an entire night's sleep in saving the life of an infant, of one day old, from the effects of one drop of laudanum. Infants, as well as adults, may be seized with Cholera. In such cases, the former, as well as the latter, not only can take with safety, but require, much larger doses of opium than would be proper under ordinary circumstances. Still, even in Cholera, the opium must be administered to infants and children with much circumspection ; the practitioner relying for the cure, in their case, chiefly on the other cordial stimulants and perspiration. With these cautionary remarks, I must leave the regulation of the dose of opium to infants and children to the judgment of the practitioner, as the proper dose will vary, not only from year to year, but even from week to week. Before leaving this subject, it is proper that I should describe the proper method of saving the life of a patient from 53 the fatal effects of too large a dose of opium or laudanum, whether intentionally or accidentally taken. This I conceive to be necessary from the fact, that, when Cholera suddenly invades a town, before proper discipline be established, accidents of this kind may occur from inexperience, or from want of proper caution. I was once called to visit a woman whom I found in a state of profound narcoma, from the effects of eighteen of the an tispasmodic pills already prescribed, which had been administered to her by three different medical men, who, following each other at longer or shorter intervals, and who, not inquiring if she had been previously visited, or if she had previously taken any medicine, each gave her six of the antispasmodic pills, making eighteen in all, in the course of not more than two hours ; and the result was what I have stated. It may be right, here, to state, that on strict inquiry from this woman and her friends afterwards, I found she had not had Cholera at all, but merely a sick bilious headach, arising from an obstinately constipated state of her bowels, which had not been moved for above eight days. Her respirations, when I was first called to her, were irregular, stertorous, and very laborious ; and her pulse was slow, very intermitting, and irregular. I immediately ordered an infusion of a quarter of a pound of the best coffee in a quart of boiling water. After, by various means, I had succeeded in arousing her to a state of consciousness, I caused her to drink, one draught after another, of the strong coffee, till the whole quart was taken, when the narcoma was removed, and she was able to keep awake. She recovered by means of the coffee alone. Had I not felt confident, from her habit of body, that I could save her by this means, I would have given her an emetic at once ; but I was anxious to prove what the coffee itself, unaided, could do, particularly as, on inquiry, I found that the absorption of the opium had gone on for two hours. Had she taken a larger dose of the opium, and had I not succeeded in awaking her so as to cause her to drink the coffee, I would have bled her largely ; and by this means I should have succeeded in saving her, as I succeeded in the following case : — Several years ago I was called to a lady in this town, unaccustomed to the use of that medicine, who had taken three fluid ounces of laudanum, at least an hour, if not more, before I saw her. On my arrival I found her sound asleep, with stertorous, interrupted, and difficult breathing. With great difficulty I succeeded in causing her to drink a pint of warm water, in which I had dissolved a proper dose of sulphate of zinc. This, as soon as it was swallowed, was imme- 54 diately rejected from the stomach, clearing out that organ of all its contents, with all the remaining enormous quantity of laudanum which was then yet unabsorbed. I then said, — Thank God! I hope we shall yet save her. This congratulation, however, did not last long. She then reclined on her pillow : in less than one minute her face, hands, and neck became nearly as black as a coal ; her features became distorted; her pulse became imperceptible at the wrist; she drew one stertorous, interrupted, convulsive respiration, and, to all appearance, died. She was literally dead, as far as the complete cessation of all the functions of life was concerned. About a minute after, the dark colour left her face, neck, and hands, and her countenance remained pale and ghastly. Her friends, who were standing round, then exclaimed that she was dead, I replied, that I was sorry to admit that it was so. It could not then have been less than two minutes from the last convulsive respiration she drew, and from the time that the pulse had become imperceptible at the wrist. I knew the cause of death, and that there remained but one remedy which could avail under the circumstances ; and to that I had then recourse, without one moment of further delay. I immediately bound a ligature round the arm, and opened a large orifice in one of the veins, but there was no circulation, — the veins did not fill, neither did any blood follow the lancet. I, however, continued to strip the contents of the vein out through the orifice with my finger. The blood came at first in globules, very black, and of the consistence of treacle. It became gradually more fluid, till it trickled down the arm, and then ran in a stream, when the pulse returned to the wrist, and the blood issued in a full stream to a distance from the arm. When about half a pint of blood had flowed, irregular convulsive, stertorous respirations returned at short intervals. When I had taken, at least, a quart of blood, the respirations had become regular, free, and natural ; and the pulse bounded full, regular, strong, and rather quick. I then stopped the bleeding, when I found no difficulty in awaking her, and in causing her to drink large draughts of a strong infusion of coffee, which took off" all desire for sleep, and in a very few hours she was quite well, and continued so. This lady is now in the enjoyment of good health, and the occurrence took place some years ago. The case is one of such practical importance, that I believe it to be my duty to give it insertion here. All the parties who witnessed the occurrence are yet living, and will, no doubt, read this letter. Now, had I been less conversant with the specific effects of opium, and had I been less familiar with the modus operandi of that medicine, I could not have saved the life of the lady referred to ; and should the publication of the above case be the means of saving but one life, under similar circumstances, no one will rejoice at it more, or feel more thankful, than I shall. With regard to the treatment of the above case, I must remark that, had I, when I arrived, been aware that so long a time, from the taking of the drug, had intervened, or that so much of the poison had been absorbed, I would have bled the lady without one moment's delay ; but it was not till afterwards that I was given to understand that the family had first sent to their own medical attendant, and, not finding him, to several others, before they came for me ; so that, at least an hour had elapsed after the laudanum was taken 4 before I saw her. Again, I should have bled her the moment the face and hands became livid ; but, as she went off, almost instantly, convulsed, I, still ignorant of the quantity of the medicine which had been absorbed, at first flattered myself that it might be merely a fit, and did all I could to restore animation, till I soon found that she was virtually dead ; and that the cause of her death was as firmly fixed in the constitution as the effect it had produced. Both the respirations and the circulation had all ceased for at least three minutes, before they were restored by the bleeding, and the extremities were beginning to feel colder. This I particularly remarked ; and the blood in the veins was beginning to coagulate, so that I feared, at first, I would not succeed in getting it to flow. In the case of such accidents, the first duty is to ascertain, if possible, what quantity of the medicine has been taken, and what time has intervened ; and the subsequent measures are to be regulated accordingly. In all cases where the narcoma is so profound that an emetic cannot be administered, the patient should be largely bled, which will never fail to restore the consciousness. Then, an emetic of sulphate of zinc may be given, and its operation followed up with copious draughts of strong infusion of coffee, which will soon remove all desire for sleep. I never saw this fail. I never yet allowed a patient to die from the effects of opium to whom I was called at any stage. Should a patient, suffering from a dangerous dose of opium or laudanum, when first visited, be able to swallow, an emetic should be instantly given, and should be followed up by the strong coffee, and this will generally succeed without the necessity of bleeding. Should it not, however, appear to do so, let the patient be instantly bled, which, indeed, in a On oG good strong constitution, is generally the safest practice. Where the patient has been merely slightly narcotized, without any stertorous breathing, or any decided symptoms of congestion of the lungs or brain, the strong coffee alone will generally answer the purpose, without either an emetic or bleeding. The best emetic in such cases is sulphate of zinc, and where a very dangerous dose of opium has been taken, a large dose of the zinc should be administered. The sulphate of zinc is more certain in its effects than another remedy usually had recourse to in such cases, namely, powdered mustard, and is, in general, more safe* Should, however, the sulphate of zinc not be convenient, the mustard will answer the purpose, and a table spoonful of the powder given in a pint of warm water will act instantaneously. A smaller dose is not so safe, as it might be retained on the stomach, and might prove too irritating. I have the honour to be, &c. } G. S. H. 61, St. Anne-street, February 26th, 1848. LETTER IX. Gentlemen, — The next duty which presents itself to me is to point out the precautionary measures which should be adopted by health committees, in the different towns in the kingdom, with a view to preserve the lives of the poor inhabitants, who may not have the means of self-preservation within their reach. I have already stated that hospitals for the reception of Cholera patients are worse than useless ; that to remove a patient affected with Cholera from his own habitation, however humble, to a hospital, is utterly out of the question, — such a step being totally incompatible with the ascertained proper method of cure. The precautionary measures to be adopted, therefore, and the necessary remedies and appliances to be employed, in the cure of Cholera, must be provided for, with a view to their applicability to patients in their own houses. With this view, dispensaries should be opened within convenient distances of each other, and in as many parts of the town as will place one within an easy reach of all the inhabitants resident in the different localities. At each of these dispensaries, there should be stationed at least two medical men, furnished with all the medicines, prepared according to formulae t and ready for use, together with the ' 57 other remedies and appliances necessary for the cure of a case of the disease. These medical men should be prepared to attend, alternately, every call at a moment's notice, and they should be furnished with the means of conveying every requisite to the houses of the patients as quickly as they can arrive themselves. These requisites are, the proper medicines to be administered, with a glass of spiced whisky, which may be used as a substitute for brandy, to wash them down, and small bags of hot sand, to apply round the bodies and extremities of the patients. A man, with a hand-cart, can convey these quickly to the places where they may be required, and the bags of hot sand in the hand-cart may be covered close with a blanket, to prevent the escape of the heat. At each dispensary there should be deposited a large quantity of fine sand, washed clean from all impurities, or earthy particles. There should also be provided, at each dispensary, a proper apparatus for heating the sand, and a large quantity of it, while the disease prevails, should be kept constantly hot, and ready for use. Each dispensary should also be furnished with a sufficient number of small woollen bags, of different sizes, for holding the hot sand ; and these, when required, should be filled, not more than about half full, so as to allow the inclosed sand to spread, and to comply closely with the inequalities of the different parts of the body and extremities against which the bags are placed ; and the bags should be tied tight at the mouth, with cords, which should be stitched to the bags. The sand-bags should be of different sizes ; as, for instance, the soles of the feet would require larger bags to be placed against them than would be required to be placed under the armpits. When one patient is cured, the porter, with the hand-cart, (who should always keep in his book a regular account of the number of bags delivered at each house,) should bring the bags back to the dispensary, and empty the sand out of them into the common stock, to be again ready for use when required. In this way, not one life need be lost ; and the expense would be very trifling indeed. It is remarkable how little medicine is required in the treatment of Cholera. If taken in time and properly treated, the expense for medicine, on an average, would not exceed a shilling a head for those treated. Not one in ten of those who apply in proper time would require a second dose of medicine ; unless it were some mild aperient on the second or third day. In all towns, before the disease appears, proper discipline should be established. The days of experimenting in the 58 treatment of Cholera have gone by. lam not presuming too much when I say, that what has been ascertained to be an infallible method of treating the disease, should be at once universally adopted by the public authorities of all the towns in the kingdom ; and no medical man should be employed by them, to attend the poor, who would not previously undertake to treat Cholera according to that method. No other mode of procedure will prove successful. If every medical man is allowed to follow his own caprice, and to begin again to have recourse to further experiments, the result in these countries will again be as disastrous as it was formerly. Those who are able to pay for medicine and advice may choose their own medical attendant, and no one has a right to dictate to them ; but the poor have no choice, and they should be protected. These observations are made merely for the guidance of health committees, and not from any apprehension that the mode of treatment I have directed will meet with any serious opposition, at least from the well-educated part of the profession. I natter myself, nay, I feel confident, that the mode of treating Cholera which I have prescribed, and the reasoning on which it is founded, has carried conviction to the minds of all, and that it will be universally adopted by every respectable medical man in the kingdom. I am not, however, bound to suppose that those employed to attend the poor are always selected from the class of practitioners to which I have referred. It is, therefore, necessary to success that there should be a controlling authority exercised in the matter. Of the necessity and advantage of this precaution I had ample experience on the occasion of a former visitation of Cholera. The medical attendants should exercise great care and vigilance in ascertaining whether or not their patients have been previously visited, or have previously had any medicine. Neglect in this respect may lead to unpleasant consequences, an instance of which I gave in a previous letter. It is too late to begin to prepare for a struggle with Cholera after the disease has made its appearance. In such a case many lives would be sacrificed before all the machinery could be got into working order. It is, therefore, the duty of health committees to have all precautionary measures taken, and to have every requisite provided, before the disease arrives, to enable the medical men to grapple successfully with it when it makes its attack. For this reason I have thought it advisable to submit these few directions to the 59 public, and, if they be followed, I have no doubt they will be found to answer the purpose, and the fear of being removed to a hospital will no longer deter the poor from giving timely notice of their illness to the medical attendants. I have the honour to be, &c, G. S. H. 61, St. Anne-street, March Ist, 1848. LETTER X. Gentlemen, — In my last letter I advised health committees to exercise a controlling authority in securing the adoption of a uniform mode of treating Cholera by the district medical attendants. Of the necessity, as well as the advantage, of this precaution, I could give numerous instances which came under my own observation during the former prevalence of the Cholera in these countries. Having determined, however, that no act of mine shall either wound the feelings or hurt the reputation of a fellow practitioner, I refrain from giving them here, merely contenting myself with throwing out the hint for the guidance of those to whose management the care of the poor may be committed during the prevalence of such a direful malady. In bringing these letters to a close, it may be expected that I should suggest some rules and precautions of a prophylactic tendency, or, in other words, that I should prescribe some means of rendering individuals less obnoxious to an attack of the disease. On this subject I shall offer but few remarks. From what I have written on the true nature of Cholera, it must be obvious to every one, that nothing predisposes an individual more to the influence of the malady, or tends more to increase the malignancy of an attack of the disease, than fear. It is, therefore, of the greatest importance that the public mind should be relieved from all unnecessary apprehension with regard to the true nature and character of that disease. If, then, in what I have written on Cholera, I have inspired the minds of the public with confidence, by convincing them that Cholera is a perfectly curable disease, and that it becomes formidable only when neglected, or injudiciously treated, I have done more to render individuals insusceptible of an attack of the malady than could be accomplished by any other means. I may observe, however, that it is of the first 60 importance to keep the digestive organs in healthy trim, and that nothing is more conducive to the attainment of this object than temperance both in eating and in drinking, with the observance of regular hours both in eating and in sleeping, avoiding unnecessary fatigue and late hours, and every thing that has a tendency to weaken the nervous energy and to diminish the muscular power. Exposure of the body in damp or wet weather should, as much as possible, be avoided. The body should be warmly clothed, and kept in a perspirable state. During the prevalence of the disease, those who can afford it should wear a silk dress next to the body, or at least next to their flannels, if they should wear them next to the body. Those who cannot afford a silk dress should at least wear a flannel dress next the body during the prevalence of the disease, with an occasional shower bath, and a free use of the flesh brush, which will brace and invigorate the general system. Silk is a nonconductor of electricity, and, if T mistake not, persons affected with Cholera suffer in a greater or less degree from the greater or less abstraction of that essentially necessary element from their bodies. The food should be plainly dressed, substantial, easily digested, and nourishing, and such as will tend to improve the healthy tone and digestive powers of the stomach. Every thing of the slop kind, such as broths, soups, or stews, should be, as much as possible, avoided, while the disease prevails in the town ; roast or broiled meats are the best. The state of the bowels should be particularly attended to. They should be kept regularly and freely open by suitable mild aperient pills, as the digestive organs cannot be otherwise kept in a healthy state. Violent purging should be carefully avoided, and no saline or drastic purgative whatever should be taken during the prevalence of Cholera in the neighbourhood. With these remarks I take my leave of this subject for the present, and, in doing so, I beg leave to tender to you, Gentlemen, my most grateful and sincere thanks, for the liberal and handsome manner in which you have, in your valuable and widely-circulated paper, given insertion to my numerous letters on Cholera ; and, should what I have written be the means of saving even only one life, it will be a source of great gratification to you ; and no one, I assure you, will feel more grateful than, Gentlemen, your ever obliged obedient servant, GEORGE STUART HAWTHORNE, M.D., Late Senior Physician to the Belfast General Hospital. 61, St. Anne-street, Liverpool, April 5, 1848. 61 TESTIMONIALS. In proof of the universal success of the mode of treatment which I have described in the foregoing letters, I beg to refer the reader to the following addresses and testimonials : — "To GEORGE STUART HAWTHORNE, Esq., M.D., Physician to the Belfast General Hospital, q-c, $c. " Dear Sir, — The Dungannon Board of Health take leave, now that Cholera has subsided in this town, to convey to you their most grateful acknowledgments for the eminent services you have, under Providence, rendered in checking that destructive disease, which has raged with such virulence amongst us. From the success of your treatment, they have ample proofs of its superiority, and cannot omit expressing their approbation of your humanity, and of the alacrity with which you hastened to the relief of those who were seized with that dreadful pestilence. Your exertions to preserve life, and your anxiety to afford immediate relief to the sufferers labouring under this terrible malady, are beyond all praise. "As a memorial of their sentiments, and as a token of their unfeigned gratitude, they beg your acceptance of the accompanying Piece of Plate ; and they assure you, Sir, that you carry with you their sincere affection and esteem, and their best wishes for your professional advancement and future success. " Signed by order of the Board, "JOHN PEEBLES, Secretary. "Board-room, Dungannon, Dec. 2ith, 1832." " INSCRIPTION. " Presented to George S. Hawthorne, Esq., M.D., Physician to the Belfast General Hospital, &c, &c, by the Board of Health, and the Inhabitants of Dungannon and its vicinity, as a Token of their unfeigned Gratitude for his successful Treatment of Cholera in that town." The following letter is from that highly respectable and able practitioner, the late Doctor Dawson, of Dungannon: — "To GEORGE STUART HA WTHORNE, Esq., M.D., of Belfast. "My Dear Sir, — It being now more than fourteen months since I had the happiness of becoming acquainted with you, and having received from you the most important information on the subject of Cholera, I think I cannot better evince my gratitude than by stating the result of my practice in Cholera cases during the above period. " Upon this awful epidemic making its appearance here, we commenced our treatment with giving calomel, combined with opium, and repeating the dose at intervals of four hours, at the same time giving warm brandy and water, enemas, and applying heat externally. This mode of practice proving unsuccessful, it 62 was thought expedient, by the majority of the Board of Health, to despatch one of its members to Belfast, to obtain the assistance of some one of the faculty who had taken part in the treatment of Cholera there. Fortunate, indeed, it was for the inhabitants of Dungannon that you were selected ; for sure I now am, from experience, that had we obtained the aid of a person who would have pursued the same mode of treatment as that with which we began, (the calomelizing system,) instead of recording 60 deaths out of 340 cases, we might have had to lament as many deaths, in proportion to the cases, as have occurred in those districts, where, unfortunately, mercury has been used. I may now recal to your recollection that of the above number of deaths many of the cases had been so freely impregnated with calomel, that we found it impossible to check its action on the aliamentary canal. Some, too, of the cases were concealed until in articulo mortis. So, that if we were to make the foregoing deductions, the deaths would be few, indeed, compared with the number of recoveries. Since the disease ceased here, I have had many, very many convincing proofs, for several miles around this town, of your superior mode of treatment. Amongst others, I might select that of a neighbouring village, unhealthily situated in a low valley, with a canal flowing into its centre, where I attended 33 cases, (without the advantage of an Hospital,) of which number only five died; and what, perhaps, is singular, the first man and first woman who had the disease are living and well, and you may easily imagine that the latter was very ill, when I tell you that the coffin was prepared for her. In truth, I never saw so frightful a case of collapse in Hospital (much less out of one) recover. So that from the moment you corrected the false ideas I had imbibed of Cholera, I have not used calomel, or any other medicine in the treatment of this frightful disease that tended in the least degree to increase the peristaltic motion of the bowels. On the contrary, I have given opium, (as the sheet-anchor,) combined with the other diffusible stimuli and plenty of watery dilutents, as set forth in your invaluable pamphlet ; and my success has beem in proportion to the promptness and boldness with which I have administered them. Would to God, my dear Sir, your mode of practice, in Cholera, y, as more generally known, as then it would not be so fatal a scourge as it unfortunately now is ! Did time permit, I could relate some very extraordinary recoveries out of collapse, under very discouraging circumstances ; but, as my present object is to communicate to you the pleasing fact, that the more I see of this disease, the more I am convinced of the excellence of the mode of treatment introduced by you, and to assure you that I have not forgotten the invaluable services you have rendered, not only to the inhabitants of this town, but also to " My dear Sir, your ever gratefully obliged Servant, "WM. DAWSON, M.D., M.R.C.S.L., " Member of the Board of Health. "Dungannon, 16th January, 1834," The following addresses were forwarded to me when I was superintending the treatment of Cholera at Newtownlemavady, in the county of Derry, by the late Sir Francis Workman Macnaghten, Bart., of Roe Park, county Derry : — "To GEORGE STUART HAWTHORNE, Esq., M.D., of Belfast. "Dear Sir, — I received the enclosed paper last night, and to my being in the neighbourhood of your present labours I am indebted for the gratification of forwarding it. I believe I may say, that, with reference to its population, no place has had more cases of malignant Cholera than Bushmills. I can add, from my own knowledge, that no individual, who, at the commencement of his disease, had the fortune to fall under your care, was lost to his family ; that, shortly after your arrival, mortality ceased — that implicit reliance upon you was manifested by all — and that despair was relieved by the most cheering expecta- IB tions. You have, under Providence, by your skilful, active, and indefatigable exertions, rescued many from death, and many, many more, from consequent affliction. In a consciousness of your beneficence you have the best reward ; yet, I trust, you will receive a well-merited offering of gratitude with pleasure. The tribute is due by those who, with the gracious permission of God, have been delivered from pestilence and calamity by your immediate means. " I am, dear, Sir, your faithful, and (in common with others) your grateful humble Servant, "F. WORKMAN MACNAGHTEN. "Roe-park, Thursday, the 3rd April, 1834." "To GEORGE STUART HAWTHORNE, Esq., M.D., of Belfast. " Dear Sir, — We, the undersigned, beg leave, on our own behalf, and on that of the inhabitants of the parishes of Billy and Dunluce, to return you our most sincere and grateful thanks for your very efficient and unremitting exertions during the late visitation of epidemic Cholera in Bushmills and its vicinity ; and which, owing to your skilful management of the disease, under Divine Providence, has now almost entirely been removed from among us, rendering your further continuance here no longer necessary. The liberality you have manifested, in frankly and undisguisedly explaining, both to medical men and others, your clear and effective mode of treatment, deserves our warmest acknowledgments and commendation. And it is but justice to you, Sir, to declare, that not a single death took place in any of those cases which occurred subsequently to your arrival in Bushmills. " We remain, dear Sir, with much esteem, your very sincere friends, "F. Workman Macnaghten, Bart., Hugh Anderson, William Trail, M.D., Robert M'Naull, James Morewood, Clerk, Robert Taylor, Walter B. Mant, Archdeacon, William M'Mullan, James S. Moore, J.P., William Anderson, James O'Hara, Clerk, John Gwynne, James Milligan, Clerk, John Moore, Hugh Hamill, Pres. Mm., Robert Stewart. W. M'Laughlin, P.P., " In addition to the above, in which, as members of the Board of Health, we most sincerely concur, we, the undersigned, feel it our duty to express our most unqualified conviction, that your plan of treatment is the best and the only safe one ; and that, if sufficiently early and efficiently put in practice, even in the most virulent form of the disease, and universally adopted, it is calculated to save many a useful life, and render a most formidable disease comparatively mild, and less fatal than most other epidemics. "We are aware that your skill, talents, and experience, give you a great advantage in the treatment of Cholera ; and we hope that a discerning public, and your medical brethren, will speedily award you, with one consent and one voice, that commendation and praise which you so well deserve, and which, we trust, you will long live to enjoy. " Wishing you health and happiness, we remain, yours, very sincerely, "William Trail, M.D. Robert Dunlop, Surgeon. Arthur Macaw, Surgeon. " Bushmills, April 3, 1834." 64 "To GEORGE STUART HAWTHORNE, Esq., M.D., Belfast. " Dear Sir, — I have the honour to enclose you an address from the inhabitants of Killyleagh and its vicinity, unanimously agreed to at a numerous meeting held this day. " I am, dear Sir, with respect and esteem, A " Your obedient Servant, " ROBERT HERON. " Killyleagh, 12th December, 1834." t At a numerous and respectable meeting of the inhabitants of Killyleagh and its vicinity, convened on Friday, the 12th instant, agreeably to an extensively-signed requisition, for the purpose of expressing their gratitude towards Dr. Hawthorne, for his eminently successful exertions in the treatment of Cholera in Killyleagh, — Robert Heron, Esq., J.P., Seneschal, in the chair, — the following address was moved by James Bailey, Esq., J.P., seconded by John Martin, jun., Esq., J.P., and unanimously agreed to :—: — "To GEORGE STUART HAWTHORNE, Esq., M.8., Senior Physician to the Belfast General Hospital. " Sir, — The people of Killyleagh and its vicinity take this public opportunity of evincing the high sense of gratitude they feel towards you for your eminently successful exertions in the treatment of Cholera, since you have been called to our town to render your valuable professional assistance in staying the progress of this fearful epidemic. They know, Sir, that any public demonstration of esteem on their part will go but a very short way to relieve them from that debt of gratitude they must always entertain towards you, for your very energetic mode of coping with, and effectually checking, this virulent disease ; for the kindness and promptitude with which you have instantaneously attended the summons of the poorest of our townsmen, when: attacked by it ; and for the very great success, without one single exception, which has, under Providence, attended your treatment of Cholera Morbus in Killyleagh. For this, Sir, we feel grateful, and if, on any future occasion, the testimony of any of the inhabitants of this place, expressive of their firm, their earnest conviction, to the efficacy of your mode of treating this disease, would be of the slightest service to you, in your professional career, you may rely that the people of Killyleagh will always be ready to bear the same testimony ; and you have their free consent to use this humble, though sincere, acknowledgment of grateful respect and esteem, in any way, or on any occasion that you, Sir, or the public, may require. " Signed on behalf of the Meeting, "ROBERT HERON, J.P., Seneschal. " Killyleagh, 12th December, 1834." SMITH. ROGERSON, AND CO., PRINTERS, MERCURY-OFFICE, LIVERPOOL.