Surgeon General's Office I No ¦,JS 1 , : '~^, / OBSERVATIONS ON THE NATURE AND TREATMENT OF THE CHOLERA MORBUS NOW PREVAILING EPIDEMICALLY IN ST. PETERSBURG. BY GEORGE WILLIAM LEFEVRE, M.D. A MEMBER OF THE ROYAL COLLEGE OF PHYSICIANS OF LONDON, OF THE ROYAL MEDICAL SOCIETY OF EDINBURGH, AND PHYSICIAN TO THE BRITISH EMBASSY, ST. PETERSBURG. " Si (jiiid novisti rectius istis, " Candidus imperti ; si non, hisutere mecuro." Hor. Epist. 6. ¦ * ¦ l v LONDON: HUNTED FOII LONGMAN, REES, ORME, BROWN, AND GREEN. l€ol. /\vmex we LONDON : PRINTED BY MANNING AND SMITHSON, i, LONDON-HOUSE YARD, ST. PAUL'S. I was appointed in conjunction with several of my colleagues to superintend a large though not very populous district during the prevalence of the late epidemic in St. Petersburg. tl had also to perform duty in rotation at le of the largest temporary hospitals, esblished during the first ten days after c appearance of the disease, and was subsequently removed to a less considerable establishment in my more immediate neighbourhood. Towards the decline of the epidemic, when the duties were much less severe or had almost ceased, I received a circular from the inspector of the district, Dr. Markuί, who requested me to communicate my observations upon the following I it. " Relatively to the invasion, mode of agation and progress of the disease in district, specifying particularly the ber of cases and deaths, as well as the \, condition, and mode of life of the 3ns attacked. ¦lly. " Relatively to the pre-disposing occasional causes of the disease. Ey. " Relatively to its character and toms both at its commencement and y its course and decline. Ihly. " Relatively to the contagiousness 3n-contag;iousness of Cholera, founding opinion upon positive facts ; and more cularly as regarding the attendants of sick, whether they were attacked with lisease during their attendance. Kily. " Relatively to the treatment and c means I found most efficacious durhe different periods of the epidemic." I conformity with this request I drew c substance of the following statement, bribing from my journal such observaas I had made for my own instrucwithout any idea of being called upon )duce them. In fulfilling this task, I was induced to V enter more at large into the subject, and as I imagine that the observations of an individual, or rather a comparison between the observations of different individuals during the late malady, cannot be wholly without interest, I have been induced to send the following to England for publication. Much apology is due for the imperfect state in which these remarks are presented to the public, but I do not offer them as an essay or a treatise, but merely as the results of the experience of an individual. I wish to invite the attention of the profession to the true nature and seat of the disease, in order that we may arrive at some more rational method of treatment. I am convinced that this can only be discovered by the joint efforts of the dissector and the chemist, and it will only be by their repeated application to the scalpel and the alembic, that they can hope for With respect to the question of contagion, I require more facts before I can positively make up my mind to say, whether under any circumstances Cholera can be considered contagious. As regards the present epidemic, such as I have lately witnessed it, I am hound to say that I have no rational grounds for believing it to be so. K'his question, however, demands great impartial consideration, and is in abler ds than mine. I have dwelt at some length upon the treatment, because I think it is the duty of every medical man to acquaint the public as early as possible with any plan that has appeared to him successful, in however small a degree. o if any thing I have suggested may enable profession to come nearer to the point of welling the intricacies of a disease which atens to make as much havoc in the t as it has done in the east, my object be fully answered, and I shall be end and gratified to say " Nee ego frustra." St. Petersburg, Observations on the Cholera Morbus. Invasion and Progress of Cholera 1 Symptoms of Cholera .19 Of the Pre-disposing and Exciting Causes . . .24 Is the Cholera contagious ? . . .32 Of the Diagnosis and Prognosis . . .37 Of the Treatment of Cholera . . . . .41 External Means ........ 54 Internal Remedies ....... 64 Illustrative Cases ..... . . 86 , y i -|— 11 — — — — t— "i!— i— — ii^iiiiiiiiiiriiiiiiiiiiiiii-- -* V- \_ L v — i 1 \ 1 1 I \ 1— — i rs» <- — » r; _4 1 j A i— l , L [ _I I • IiEEEEfI=EiPiSE|EI|EEEFEEEEEEEE ===-===3zz==±zzzz-zzz=z3dzEsZ3;=Z?sq|3=l^i== ffi==E=s=SEEEEFEsEiEss=EfeE=E====— i —^Xy\ — — z -^^ W 11 — __^ —^_, |~~Z7IZ — .Zj—^-JC^J^ | "T'^l^^ — — ~~~~ZZ~7ZI~-Z— ~~~ ! — — j , i z=_u | ±±i===4= id zzjzzzzzzzzzzzztzz pq te =============3== %'* SI izzzzzzzzzzzzzf zz if *« 'Z % fT g g 5- i » rEt=^===="======= ° .^ _______ — —^- —p— — ———— — «— ¦— — — —— — ——^ — — — ¦ — — - ! 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The progress of the Cholera Morbus through different parts of the Russian Empire is already known : and although its march has not been so satisfactorily accounted for, as could be desired, in order to illustrate the real nature of the disease and its mode of propagation ; yet sufficient evidence has been collected, that it has appeared epidemically in most of the great towns in Russia, where, after having raged for a short period violently, it has almost entirely disappeared, or dwindling down to a few isolated cases, has been unnoticed or forgotten, until, consistently with the character of all Epidemics, it has again returned, and though with less violence, has maintained the same character as upon its first appearance. 2 This has been particularly observed in manyparts of the interior, where it first appeared about twelve months ago, and having made great ravages for a short period, left the inhabitants in comparative security, till its re-appearance after some months of absence again plunged them into uncertainty as to the future prevalence of this new and terrific malady. The identity of this disease with the Indian Cholera, had been fully ascertained before it made its appearance in St. Petersburg. This was decided by the faculty of Moscow — a decision confirmed by the testimony of physicians, who had witnessed it in the East Indies. Among the most striking features in the propagation of this disorder, is what may be styled its eccentric motion ; — and, true to its Eastern character, it presented this feature here, not only in its passage through the country, but even in its dissemination over the different parts of a town which it invaded. In its progress from Tiflis to Moscow, it was observed to move in a zig-zag direction, rather than in a regular line of march. It would pass by a town which lay immediately in its path, to appear in another, which it must have reached by a very circuitous route. When it invaded a town, it, followed the same 3 X; touching at a point to fly off at a tangent, appear at a widely separated part from that re it first commenced, leaving the intermej spaces uncontaminated. Such was observed to be its character when it reached St. Petersburg, where it was first announced officially on the 14th of June, as having appeared in the suburbs. A few days sufficed for its dissemination over the capital; and this so widely and so generally, as in most cases to preclude all idea of mere connexion with infected persons being the sole cause of its propagation. I was myself called to see a case upon the 1 day of its appearance. The patient resided 1 the English Quay, a distance of at least c English miles from the place where it appeared. She was an old woman of f-seven years, who scarcely ever left her 1 ; she attributed her attack to indigestion, died in less than twenty-four hours with he symptoms of inveterate Cholera. In this respect, therefore, it agrees fully with the description given of it by those physicians who have been conversant with it in India. Krhe disease," says Dr. Kennedy, " would times take a complete circle round a vil- 4 OBSERVATIONS I and leaving it untouched pass on, as if it about wholly to depart from the district. l after a lapse of weeks, or even months, it d suddenly return, and scarcely reappearn the parts which had already undergone avages, would nearly depopulate the spot had so lately congratulated itself upon its )e. !^his whole passage is applicable to St. ersburg at the present moment ; for though autumn we were surrounded on all sides the Cholera, still we escaped during the ter and succeeding spring. Seven months elapsed since its appearance in places not distant from the capital, and we began to k that the Imperial City would escape its iges. " There is a striking resemblance," observes Dr. Kennedy, "between the propagation of the Plague, as described by Procopius, and that of Elt always spread from the sea coast to the d country ; the places which had escaped fury of its first passage, were alone cxi to the contagion the second year." People resumed their usual avocations and their ordinary diet; they began to regret the 5 Rtions they had voluntarily undergone in ining from various articles of food which considered dangerous. The profusion of fruit which pours into Petersburg from all the southern provinces, but particularly the grapes and water-melons from Astracan, had the preceding season been allowed to rot in the hampers in which they were im- Eie supposed preservative moans were now rally laid aside, and the houses were no ir redolent with the fumes of chlore, tar, uniper, which poisoned the antechambers. The Family Receipt Book was no longer conned over by day and meditated upon by night, and Buchan and Thomas had already been replaced by Fairy Tales and Travels in I he medicine chests and prescriptions of . confidential physician were altogether dised; castor oil and opium fell again to a crate price ; and, indeed, the confidence in faculty was much shaken, when it was ascertained that the means employed by the common people were equally successful with those adopted by the profession itself. Lome few, however, continued to use the c precautions as heretofore, and even took icine by anticipation. Some even fell vicito such an absurdity. In the midst, how, of this almost general oblivion of the , the Hydra-headed monster was upon route ; for the evil day had only been postid. !ie Journals announced publicly the invaof the Malady ; but the panic was by no is so great as upon the news of its having ied Moscow the preceding autumn ; for the s of the people had already been accusd to the name of Cholera, and it had lost its terrors. The friends to the doctrine of contagion saw immediately the full proofs of their belief realized, because they found the disease imported by a bargeman, in an infected barge, and from an infected station. Nothing could be more evident, nothing more conclusive. Kose of a contrary opinion disputed the , and with some degree of plausibility. If isease had been so imported, why did not lan fall ill before his arrival at St. Peters- 6 7 ON CHOLF.KA. Ew was it that none of his companions, exto the same causes, should have been ted also ? When, upon inquiry, it was found that within the space of three days the disease broke out in a dozen parts of the town widely separated from each other, the supporters of contagion awaited further evidence, and the anticontagionists increased with the increase of the disease. Towards the latter end of the preceding autumn, the government, aided by voluntary contributions from the nobility and merchants, had established additional hospitals in various parts of the town. No pains nor expense had been spared to render them fit for the reception of the sick, and they were not merely provided with necessaries, but every luxury was supplied which ingenuity could invent. Ehe zeal of many of the nobility to contri?, not only by pecuniary donations, but by example of their presence, to encourage and 'ide for the sufferers, was without bounds. I am personally acquainted with a nobleman, who, upon hearing of the Cholera having reached Petersburg, left his country seat at a long distance from the capital, hurried up to town, and was to be found from morning till night acting 8 OBSERVATIONS the good Samaritan, with as pure and disinterested intentions as his prototype of old. It is true he was a non-contagionist, and feared not infection, and this confidence adds much weight to the advantages of the doctrine, inasmuch as it stimulates the opulent to exert themselves upon such occasions with proper philanthropic feelings. It could only have arisen from the fear of contagion, so much insisted upon by some few medical men, that many deserted their posts in the hoirr of danger, fled from the city in the day of her trouble, and shut their doors to all who had communication with her. It is not intended to attach blame to any individual, or to assert that the greater par were not influenced by motives equally laudable but fear is a great barrier to charitable exertions and though to be lamented, is seldom to be overcome. Such as fully believed in the doctrine of contagion could not reconcile it to their consciences to expose their families to its influence, and as such persons are known to be more susceptible of morbid impressions, so they would have been unjustifiable in exposing themselves ; but we merely wish to insinuate that fatalism 9 ¦be turned to good account, and that scepi and unbelief are of use in worldly affairs. Upon the appearance of the Cholera in Moscow, the emperor himself hurried off to that capital, and contributed much by his presence to calm the public mind. His presence here was not less valuable upon this occasion, as from misunderstanding on the one hand, and evil disposition on the other, every thing contributed to excite popular commotion ; but as soon as his majesty was apprised of the proceedings, he hastened to town from his country residence, and his presence not only quelled all temporary commotions, but disorder entirely ceased, and was not again renewed. Be people, not aware of its nature and little d in its history, began to be sceptical conng this singular disease. Ec suddenness of its attack, and more partily, its rapid termination, with the strange irances caused by its ravages on the human ;, created suspicions of an unpleasant na- The disease was attributed by the people to poison, and nothing apparently could be more authentic than the reports that were spread of miscreants taken in the act of putting poisonous drugs into the food and drink of the common people. How far these opinions were founded in truth it is foreign to my object to investigate, except inasmuch as considerable influence was produced on the public mind by this unfortunate belief; an influence which soon proved an insurmountable obstacle to affording assistance to many who were attacked. As for myself, I met with no direct proof of poison having been administered. Such popular commotions are by no means uncommon in the history of epidemics; nor is the suspicion entertained of poisoning so much to be wondered at, when in England, and in an enlightened class of society, a man was publicly tried for having poisoned his wife, and was only acquitted upon the evidence of four physicians, who testified that she died of the Cholera Morbus.* Whenever strict quarantines are attempted, for they will never be strictly observed, as we see by the daily accounts we have of the progress of the disease, there will be temporary discontent ; for as the working of a machine can never be perfect, unless all the parts move in harmony 10 fith each other, so in these cases, the best tentions will be frustrated by the subordinate agents being unfit for the service for which they were selected ; thus becoming not merely impediments to the working of the whole, but giving it altogether a different and opposite direction. For the sake of convenience the town was divided into different sections, and to each was appointed a medical inspector and a proportionate number of assistants ; and upon an average, every physician had from forty-five to fifty houses to attend in case of need, and moreover to perform the duty of a hospital during a stated number of hours every day. Euch were the orders delivered, and such the ngements made, even previous to the invaof the malady. 11 The variety of shapes under which this disease presents itself is so great, that it is impossible to specify all the symptoms which characterise its attacks. Sydenham, in speaking of the Cholera Morbus in 1669, observes, "Malum ipsum facile cognoscitur," but he is evidently speaking of a totally different disease ; and in spite of the opinions of some writers, who assert the Indian Cholera to be an aggravated form of the European malady, it is evident that the present epidemic differs toto ccelo from that described by the old Nosologists, if, perhaps, we except Sauvages, who speaks of a Cholera Indica. Dr. Keir, of Moscow, has lately proposed the following definition, which, with the exception of one clause ("aliquandocontagiosus"), appears to be perfect. " Morbus aliquando contagiosus, plerumque virium vitalium subita maximaque prostratio, ON CHOLERA. 13 oppressa debilisque Cordis Arteriarumque actio. Recessus sanguinis a superficie ad interiora, diarrhaeA. vomituque serosis raro bilis coloratis et fibrarum Musculorum spasmis ; animi facilitates parum turbatae." |\v on comparing this with the description by our great nosologist, Dr. Cullen, it is nt that the diseases are totally different; the principal symptom which characterises Jholera he treats of, is an inordinate sett of bile. M Humoris biliosi vomitus, em simul dejectio frequens." Bhe symptoms of the present epidemic code so exactly with those so fully described he Bombay Report of the Indian Cholera, I transcribe them verbatim. BThe attack was generally ushered in by 2nse of weakness, trembling, giddiness, lea, violent retching, vomiting and purging watery, starchy, whey coloured or greenish " These symptoms were accompanied or quickly followed by severe cramps, generally beginning in the fingers and toes, and thence extending to the wrists and forearms, calves of the legs, thighs, abdomen, and lower part of the thorax These were soon succeeded by nain constriction and oppression of stomach and pericardium, great sense of internal heat, inordinate thirst and incessant calls for cold water, which was no sooner swallowed than rejected, together with a great quantity of phlegm, or a whitish fluid, like seethings of oatmeal. " The action of the heart and arteries now nearly ceased, the pulse either became altogether imperceptible at the wrists and temples, or so weak as to give to the ringers only an indistinct feeling of fluttering. " The respiration was laborious and hurried, sometimes with long and frequently broken inspirations. The skin grew cold, clammy, covered with large drops of sweat, dark, and disagreeable to the feel, and discoloured of a bluish, purple, or livid hue. v There was great and sudden prostration of strength — anguish, and agitation. The countenance became collapsed ; the eyes suffused, fixed, and glossy ; or heavy and dull, sunk in their sockets, and surrounded by dark circles; the cheeks and lips livid and bloodless, and the whole surface of the body nearly devoid of feeling." To this description must be added as a pathoth 14 15 was universal in the stage of collapse, change and loss of voice was also very rkable from the commencement of the k. It was a peculiar sound, difficult to ibe. The patient felt as if he could not c, and yet there was little sense of conion or spasm about the glottis. Kie temperature, taken in the stage of col, when the skin was corrugated, and had deadly feel so peculiar to this stage, was ty-four and a half Reaumur taken under ongue, and only twenty-three in the hand. The patient was a young- woman in the prime of life, and had been ill only twelve hours. Be suspension of the urinary secretion was general, if the disease was prolonged bethe first stage. !ich are the symptoms of this formidable idy in its aggavated form, and with such for guide, it would seem hardly possible to ake it. Few cases, however, presented all symptoms enumerated in this extract, or bited such well defined marks. In many ipproach was insidious, assuming no one ire by which Cholera could be recognised, 16 and in the first days of the epidemic, the modes of attack were as various as the persons attacked. — See Case 6. Some were suddenly seized whilst walking in the streets, and seemed as if struck by lightning, of which I myself witnessed a case. Others, gradually, with what they supposed to be a slight bowel complaint, which they consequently neglected, till awakened to the real nature of the case by their extremities becoming cold. It is impossible to detail, in fact, all the anomalies which presented themselves ; but as there were some striking differences in the present epidemic, both from that described by the medical men who had witnessed the Cholera in India, and even in the disease which prevailed at Moscow, so I shall slightly sketch these, speaking only of what I myself witnessed, and of that class of symptoms which I found most prevalent. A collection of the experience of several medical men would be a useful document, inasmuch as it would elucidate one of the most marked characters of the disease : viz., its eccentricity ; for the accounts I have collected 17 Ei my colleagues differ much from my own rvations, and it is probable no two reports Id be alike. fhe affection of the head was almost univerbut it was of different kinds. Sometimes the patient complained of a sudden lancinating pain, which was of momentary duration ; at other times the feeling that is produced by fainting, dizziness before the eyes, dimness of vision, muscae volitantes, preceded the attack. The following Case illustrates a peculiar feeling in the head immediately preceding an attack of Cholera. The person was seized in my presence, whilst giving directions regarding the arrangements of a large hospital, over which he presided. He was sixty years of age, and apparently in perfect health ; whilst in the midst of conversation he suddenly put his hand to his head, and complained of a sharp pain passing through the temples, which lasted but for a few seconds ; he ascribed it immediately to having taken a pinch of snuff from a neighbour's box, which being stronger than that which he habitually took, it had got into his head. The sensation passed off, and he resumed his conversation. This took place at c in tl niner, ( )tl <|iient!v cold. It -- ill thflr anonwdie© which pi t junted them—lt < ta§ m from ittttdktt itneaw^the-Chutv !?!'iuiii> Aiiicil : ''imci ¦ ¦ from my colleagues differ much from my own observations, and it is probable no two reports would be alike. The affection of the head was aJmo r sal, bat it was of different kinds. Sometimes the patient complained of a sudden lancinating pain, which was of momentary duration ; at other times the feeling that is produced by feinting, dizziness before the eyes, dimness of vision, muscse vol it antes, preceded the attack. The following Case illustrates a peculiar fe< ing in the head immediately preceding an attack of Cholera. The person was seized in my presence, whilst giving directions regarding the arrangements of a large hospital, over wh fee presided. He was sixty years of age, and apparently m perfect health ; whilst in the midst of conversation he suddenly put his hand to bis head, and complained of a sharp pain passing through the temples, which lasted but for a few seconds ; he ascribed it immediately to hat ing taken a pinch of snuff from a neighbour $ box, which being stronger than that which be habitually took, it had got into his bead. The sensation passed off, and he re- Sjwacd bis conversation. This took place at 18 nine o'clock, p. m., at eleven he was seized with other symptoms of Cholera, and died of the disease after five days' illness. Though I have almost universally found an attack of Cholera preceded by something bordering upon vertigo, yet in one rapidly fatal case, no such feeling was present till it was produced by the weakness caused by the evacuations. Case, No. I. Noise and singing in the ears have never, as far as my recollection serves me, been absent in any case of real Cholera that I have attended. It even causes deafness in many, and this is generally the symptom upon which the lower class lay the greatess stress. Nausea and vomiting varied much in the present epidemic, and more particularly at its commencement, when they were seldom found in the distressing degree mentioned in the extract. As it advanced, they became more frequent, but many patients lay for hours together without rejecting any thing from the stomach, and several of these cases terminated fatally. In all instances the desire to drink was great, and the thirst insatiable; and this symptom remained as long as the more characteristic marks of Cholera were present. Cold liquids 19 they were taken they were seldom rejected. there vomiting did occur, it was very similar lat is seen in sea sickness : the patients lay ly in a horizontal posture, without much ?a or desire to vomit ; but when they raised heads, they commenced vomiting immedi, and with that kind of straining which we ;ss in sea sickness. The matter rejected differed according to the contents of the stomach at the time it was thrown up ; but where it was not coloured by food or medicines, was generally of a greenish cast. In some it had the appearance of coffee grounds ; and in others a quantity of pure bile was vomited. The more empty the stomach, the greater was the distress produced by the effects, but the patients always spoke of relief occasioned by free and copious vomiting ; upon the whole however nausea and vomiting were not the most distressing symptoms, and in this respect the disease differed from its Indian parent, for in the latter the vomiting is described as incessant, the patient not being able to retain the least thing upon the stomach, not even a grain of opium ; and the fatality of the disease was 20 attributed to the circumstance of medicines not being able to produce their effects on account of their speedy rejection from the stomach. The pain in the abdomen varied in different subjects : in some it was very acute, increased by pressure, or even by the touch, resembling peritonitis ; in others, a burning and twisting pain about the navel accompanied by a sense of spasm; in many instances very little acute pain was complained of. In some a rumbling noise, such as is produced by flatulency, was observed. Again occasionally in others, a heavy dull pain, expressed by a low and peculiar groan ; but in very few instances could I realize the following description. " The pain in the epigastrium and in the bowels was excruciating, the colicky pains were dreadful ; it seemed as if the intestines were torn in pieces ; the intervals of pain were very short; the pains commenced with the first effort to vomit, and did not cease till the disease terminated either by death, or sudden removal of all the symptoms." Neither in private practice, nor in the hospitals which I attended, did I witness any such sufferings as are here described ; and in proof of this,. I may mention a circumstance which 21 Krred during my attendance at the Sakoloff ital. A negro was brought in under suspicious circumstances; he believed himself in the agonies of death from being poisoned. He screamed most violently, begging for a priest to confess I: happened that at this moment a physician [ conversant with the disease was ascending stairs with me. " Ay, that 's the true Chocry," he exclaimed. I replied, this is the patient we have had, who has expressed sufferings in this manner ; we are accused generally to a low, moaning voice. Kpasmodic affections of the abdominal mus, and contractions of the recti abdominis, c witnessed in a child of four years' old, who 1 of the disease. (he veins of the lower extremities were often vn into knots, and the toes bent as in comcramps ; and though necessarily painful, B by no means so agonizing as described by y writers. X pricking sensation about the instep, or a ng similar to the commencement of the , was not uncommon; but this was little led till other svmDtoms succeeded. 22 Some complained of great pain in the region of the kidnies, and of other nephritic symptoms. Slight spasms in the chest have often pre:d an attack. These were of momentary ition and resembled a sharp instrument ing through the lungs, stopping the breath causing great anxiety; such as is frequently essed in a more advanced stage, where the ptoms are those of real asphyxia, occasioned :agnation of the blood in the heart and large Pthis stage the intercostals were thrown >ainful spasmodic action from the double imposed upon them. Spasms in the fore arms were not very frequent. A tremulous motion of one or two fingers, or of the fleshy part between the thumb and forekand twitching of the zygomatic muscles face were also found to give warnings of ETo these may be added a feeling which pa nts could never express — a restlessness, bodily and mental — a nervous excitement which mus be felt to be understood, and which affectec many who had, and many who had not the dis ease in question. 111 1 i s i m no^im 1111 1 1 o tc\ 111 oi qii ro iVif* f^flfWr* f*Q of* fV*n r* 23 Pthe human mind, or to calculate the action c latter, under uneasy impressions, upon ody itself. It is not possible to say whether this was the real and only cause, but certain it is that during the larger portion of time during which the Cholera prevailed, there was a general indisposition, a certain malaise, which affected almost every individual. Beople complained of uneasy sensations in bowels, a certain feeling which was new to n, a sense of dragging down, and a loss of in the whole system. Riis affection, whatever it might have been, not under the control of medicine ; it sub-1 with the decline of the disease ; hence I attribute it to nervous affection, and the effects of fear. Of all causes which predisposed to this disease moral affections were found the most frequent ; and their baneful effects were not merely confined to rendering their victims more susceptible of the malady, but they produced a decisively fatal influence upon the constitution itself. That many died of fright was a phrase reechoed by every medical man in the City, and fear may consequently be considered as the chief predisposing cause. I did not find that a previous weak state of health, (except in the old,) nor even the habitual derangements of the primae viae predisposed to this affection, unless these were caused by previous intemperance, and the abuse of wines and spirituous liquors. The effects of previous intemperance upon the system seemed to predispose it more than any other cause to the disease. The state of the weather was nearly ihe same during the first four or five weeks of the epidemic. The winds prevailed from the east, and ON CHOLERA. 25 h Ihermometer averaged about fifteen and a degrees off Reaumur in the shade. The s were warm without much dew. A sud?hange in the weather, which occurred tos the decline of the malady, when a cold accompanied by rain prevailed for several days, did not in the least influence it. I had been observed at Moscow and Riga, any great fetes where the lower orders j assembled, and where intoxication was a mon consequence, were always followed by irked increase in the ensuing day's list of lids ; but notwithstanding two such fetes i held here, accompanied by their usual re—inebriation, yet no augmentation in the ber of the sick followed ; because they took place at a time when the malady was on the decline, a circumstance highly characteristic of its epidemic nature, which, when upon the decrease, was not to be renewed by any communication between individuals. Imprudence and excesses of the table, the use of undressed vegetables and unripe fruits, cold liquids taken into the stomach when the surface is preternaturally warm, are all so many exciting causes. In short all those causes which are said to produce the common Cholera under 26 ordinary circumstances seem to have the same effect in the present epidemic ; but with respect to these particular inquiries should be made, as both the causes and effects are often very much exaggerated. The use of quass has been much condemned, particularly if taken when the body is warm ; but as it is the common beverage of the people, who continued to drink it in as large quantities as ever during the whole of the time, so, many cases that were attributed to it must be placed to other accounts, seeing what numbers indulged in it with impunity. If the disease be specific, and sui generis, it is evident that imprudence in diet cannot of itself produce it; but as it may predispose to it, so it comes under that class of exciting causes. It was observed of this malady, as Sydenham observed of the plague, that there was during its prevalence what he styled a Constitutio Epidemica; or that all kinds, or the greater pait at least, of the reigning distempers were converted into this prevailing epidemic. In this sense, therefore, an imprudence in diet capable of producing under common circumstances an ordinary bowel affection, would 27 Ie present case generate a Cholera Morbus, nuch as it did by this derangement become edisposing cause. Much obscurity must ys exist about predisposing causes, for they onjectural and not tangible, and where we i to see them they are frequently found not :ist. If irregularities in diet can generate the Cholera, then the disease can only be considered as an aggravated form of the malady already known in Europe. This has been asserted by men of eminence, who consider Celsus to have been perfectly conversant with it; but the difference between the symptoms and course of the present epidemic and that of which Celsus treats, is such as to preclude their identification. Though it is evident that intemperance was one of the chief predisposing causes, yet it was equally evident, that free and generous living were among the best preservatives against the Cholera. Among our countrymen of all classes, and we reckon more than two thousand in Petersburg, only thirteen died. Several of these were old and infirm ; and this must in a great measure be attributed to the difference in thpir mnrlpa nf livincr 28 OBSERVATIONS That it was rather ascribable to this than to any other cause, seems also probable from the following circumstances, which are much to the purpose. In a sugar manufactory, where all the workmen had an increased allowance of food of a wholesome kind, no individual was attacked. In another large establishment where the workmen were composed of slaves and freemen, the greatest mortality prevailed among the former, whilst the latter almost all escaped. Even in private families the same was observed to take place ; and it may thus be stated as a positive fact, and one well entitled to legislative attention, that pure air and good substantial living will be found among the best preservatives against the Cholera. The Russian labourer lives at all times upon hard fare; even his best food is much less nutritious than that of our peasant; he seldom eats meat, even when he has the means of procuring it. Black sour rye bread with salt sprinkled upon it, and occasionally a bit of salt herring or an onion, constitute his principal food. The long fasts also enjoined by his church, and the quantity of oil and dried mushrooms which he consumes during these periods, together with the baneful use of ardent spirit, which creates a kind of fictitious strength, all tend to undermine what little stamina nature may have originally given him; he is seldom a long liver, and soon falls a victim to any serious disease, even in his prime. To determine the proximate cause of a disease should be the first object of our inquiries, because it involves all the rational parts of practice. E:h has been written upon this subject wit to the Cholera Morbus, and many a rat natum has been advanced ; but, a ;o, none of them have been founded o indubitable evidence (nor had they been so could this evidence have been sufficient t have accounted for all the phenomena) ; thes theories have lived their day, to be replacec L others not less improbable, and not mor jfactory than themselves. Ktt is much to be lamented, that from unconllable circumstances a minute investigation of the effects produced by Cholera upon the body has not been generally attempted by dissection, during the prevalence of the epidemic in Petersburg. As all reasoning upon matters of fact is founded on the relation of 29 30 cause and effect, so it is most desirable to study well the effects of diseases upon the different organs, as from such knowledge alone can we be able to judge of their causes. Minute and repeated dissections of the patients who have died should never be omitted where there is a possibility of performing them. Among the various theories which have been formed of this disease, Some have ascribed it to concussion of the brain. Some to asphyxia. Some say the seat is in the solar plexus. Some consider it a species of tetanus. Some, and with much more probability, have defined it a catarrh of the intestinal canal. It would much exceed the limits of this paper to discuss the different theories here advanced. It may be allowed me to ask the following questions : — What analogy exists between the effects produced by Cholera and those by mineral poisons upon the system ? Is the bile really changed in this disease ? What are the changes it undergoes ? 31 Does the blood undergo any other change than that produced by the separation of its aqueous parts ? Bthis process chemical, mechanical, or ? Khat is the state of the other secretions exed chemically? Kthat peculiar smell of the perspiration to ttributed to a mixture of urine secreted iously from the surface of the body? Is the Cholera a new disease ? Knot the primary cause a spasmodic action the capillaries, causing sudden revulsion c internal surfaces? Is not this proved by the sudden abstraction of blood from the whole surface by the diminution of animal heat, by the corrugated appearance of the skin from the emptiness of its capillaries, and by the copious secretions of the internal mucous membranes, which, when allowed to continue too long, deprive the blood of its former fluidity, and prevent the heart from propelling it in this inspissated state through the smaller vessels ? I this not countenanced by the use of opium, h overcomes the spasms, and, conjoined external heat and frictions, restores the 32 balance between the external and internal mucous membranes ? Are not these opinions strengthened by the greater probability of curing the disease at its commencement, before the spasm has too long existed, and the blood been deprived of its serum ? IS THE CHOLERA CONTAGIOUS? With regard to this important question, my experience has hitherto been too limited for me to offer any decided opinion upon the subject. It requires a mass of evidence, and a patient investigation of many circumstances, which, though at first sight plausible frequently prove deceptive, to make up one's mind positively on this question. As far as my practice is concerned, both in the quarter allotted me, and also in private houses in different parts of the town, I have no proof whatever that the disease is contagious. The first patient I saw was upon the third day of the epidemic, and upon strict inquiry I could not trace the least connexion between the patient, or those who were about her person, with that part of the town where it first appeared, a distance of several versts. As regards the attendants of the sick, in no one instance have I found them affected by the disease, though in many cases they paid the most assiduous attention, watched day and night by the beds of the affected, and administered to all their wants. Bknew four sisters watch anxiously over a severely attacked with Cholera, and yet ye no injury from their care. I one case I attended a carpenter in a large where there were at least thirty other who all slept on the floor among the ngs ; and though it was a severe and fatal no other instance occurred among his anions. In private practice among those in easy circumstances, I have known the wife attend the husband, the husband the wife, parents their children, children their parents; and in fatal cases, where from long attendance and anxiety of mind we might conceive the influence of predisposition to operate, in no instance have I found the disease communicated to the attend- As for many reports which have been cir- D 33 I culated, and which primA facie seem to militate against the statement, I have endeavoured to pay the most impartial attention to them ; but I have never found upon thorough investigation that their correctness could be relied upon, and in many instances I have ascertained them to be designedly false ; so that as far as proof can be drawn from my own limited experience, I have none to offer in favour of Contagion. The present disease has borne throughout the character of an Epidemic, and when the reports advanced in proof of its contagion have been minutely examined, they have been generally found incorrect; whereas it is clear and open to every inquirer, that the Cholera did not occur in many places which had the greatest intercourse with Petersburg at the height of the malady, and that it broke out in many others which have been subjected to the strictest quarantines. The difference however between contagion and infection requires to be more fully explained, if they are not synonymous terms. If a disease can be proved to be infectious, it may by the same reason be proved contagious, because the question will then resolve itself into predisposition or peculiar susceptibility. 34 A person who in one condition or state oi body is capable of receiving the disease by what is termed infection, or as it were a concentration of the miasma such as occurs in the wards of a hospital, will in another state contract the disease from a much minuter quantity, or such as may be communicated by the touch ; for we have no measure of the quantity of deleterious matter with which an atmosphere may be impregnated ; we can judge only by the effects, that some morbific matter is present, though we are not able to detect it by the nicest analysis. Idiosyncrasies teach us, that some substances are cognizable to some persons and not to be recognized by others at the same moment, when both are placed in the same circumstances. The scent of a flower will produce a morbid effect upon the olfactory nerves of one person, whilst another will hardly discover any smell There is a disorder to which some people are subject in the hay-making season ; it is attributed to the pollen of flowers, which, dispersed through the air and penetrating the nares, irritates the mucous membrane to such a degree as 35 36 OBSERVATIONS Buse constant sneezing and even inflamn. It is called the hay asthma. 8s illustrates the meaning of peculiar susility and predisposition, for very few j are subject to this affection, though eds are exposed to it at the same time. lose who are so affected must be said to a peculiar irritability of the mucous memiof the nose ; but this is not reducible to r demonstration, and we can only judge of ause from the effects. Be same arguments may be applied to conn, and the same susceptibility of impression reduce to a relative what was supposed to absolute fact. The question regarding predisposition consequently can never be fairly solved till we are able to decide a 'priori and from the appearance of an individual, whether he is susceptible of receiving morbid impressions from being placed in circumstances capable of producing them. In marching a regiment over the Pontine Marshes we cannot decide h priori how many soldiers shall fall down ill of Malaria. The same doubts may exist regarding Cholera as have long existed with regard to puerperal ON CHOLERA. 37 Kiar circumstances, a disease reputed to be ontagious may not be converted into a gious one. The arguments which have hitherto been adduced on both sides may be compared to the two knight-errants, who, after having fought some time about the metal of which the shield was made, gave up the contest when they had examined both its sides. OF THE DIAGNOSIS AND PROGNOSIS Sould be hazardous to say that a common 1 complaint, or a fit of the colick, is an kof Cholera ; and yet many such a comement has proved to be so in the end. It is utterly impossible to determine the nature of the complaint till the symptoms are at their height ; but when once the Cholera physiognomy is present, a child would be able We are often placed in perplexing situations in this respect ; we are exposed to the censure of the fastidious, if we pronounce a case to be Cholera, which, terminating favourably in a 38 OBSERVATIONS short time, convinces them to the contrary. We are doubly blamed if we treat that lightly which afterwards proves to be Cholera. Yet to say that all the successful cases have not, and that all the fatal ones have been Cholera, is to rob the profession of what little merit it may have. If it is dangerous, therefore, to form hasty opinions, it is equally so to be over cautious from a regard to our medical reputation. In our investigation, therefore, we must take into consideration the age and habits of the patient, and weigh well the symptoms, taking due care that he be not induced by fear of the disease to lay too much stress upon trifles; and our questions should be particularly guarded. In paying particular attention to the symptoms, we must not alarm the patient by laying stress upon any of them ; for of all things to be dreaded, fear is the most so in this complaint. When we have well considered the case and made up our minds, we must reply to the questions of our patient by evasive answers, or even by positive denials when the disease is actually present ; for we may truly say with Pope, in such circumstances, that " Blunt truths more harm than little falsehoods do." ON CHOLERA. 39 These observations apply to doubtful cases also, the diagnosis soon becoming evident when the disease really exists. »As to distinguishing at the onset what species Cholera we have to deal with, that will be almost impossible in many cases; nor will it be of practical utility. If there be one symptom more characteristic than another of the Indian Cholera, it is the watery nature of the stools. kSydenham's description of the Epidemic Chora of 1669 is not less terrific than that quoted from the Madras Report. KThe prognosis varies much in this disease, as is often difficult to determine what may be 5 consequences of the attack hereafter. In slight cases, and in previously healthy subjects, where the symptoms yield to the first remedies, it will always be favourable. In severer cases, if the pulse and animal hea are renewed after having been suspended, am keep up to any thing approaching a natiira standard ; if the pains do not suddenly subside but assume more of a colicky character ; if th faeces become more formed, the clammy per spirations cease, and urine be again secreted in small quantities ; if the countenance return t original tone ; all these may be considered as favourable prognostics. A sudden cessation of all pain after severe suffering from cramps in the bowels, or a continued increase of spasms, becoming more and more insupportable ; the rejection of every thing taken into the stomach ; a complete loss of pulse and animal heat, which are not to be reproduced by frictions or any of the means usually employed ; difficulty of respiration ; a sense of suffocation ; the peculiar countenance, moral depression, and no symptoms of reaction, are all unfavourable prognostics. As regards the Prognosis, however, it would require a separate Treatise for its explanation, for it differs in every individual case, and nothing but experience in the disease can ex- 40 / I! treatment of diseases is divided into two Is, the rational and the empirical. The ° ier is founded upon certain principles, and means are adapted to certain indications, hus we know that certain drugs will at all ;s, cceteris paribus, produce certain effects upon the system. flic action of the heart and arteries is reduced the influence of digitalis. rrecisely the contrary effect will ensue from employment of ammonia. the nerves are paralyzed by the action of , internally and externally employed. They are strongly excited, on the contrary, by the action of nux vomica ; hence we say that digitalis and lead are sedatives, and ammonia and nux vomica stimulants, because such effects are excited by the employment of these drugs upon the system in a state of The empirical practice, on the other hand, is determined merely by use, and acts according to no physiological laws with which we are acquainted : thus bark and arsenic, two very different substances, cure a fit of the ague, but we know not what action they exert upon the system to produce this effect. Such medicines so applied are called specifics. In our choice of treatments we prefer the rational method, because we see, or seem to see more clearly a path which must always be more or less obscure; but this method is founded upon the relation of cause and effect. Thus cold suddenly applied will cause an inflammation of the mucous membrane of the nose and fauces, and this is called catarrh. To remedy this we make use of such means as will counteract the 'effects of a known cause upon a known part of the animal economy — viz., the mucous membranes. The cause and effects, at least in their due relations, are not known as regards Cholera, hence the method of cure has not been rational. As no one medicine, nor any class of medicines, have yet been found that will in the greater number of cases cure the disease ; so the practice can neither be called rational nor emnirical, 42 Vfcj if we employ the word empirical according to the signification given it by the older writers, who implied by empirical practice such as had been sanctioned by use and experiment. If we may be allowed to give a name to the practice generally adopted in Cholera, we shall call it Symptomatical. tit is evident that of all the different methods is must be the most unsatisfactory, because ing founded neither on theory nor on experience it must vary with every different case that presents itself; as each constitution being different, the effects of disease upon it will be different also. That such is the case in the present epidemic every physician who sees the disease will be ready to acknowledge, whilst he regrets the melancholy truth of the statement ; and he will be obliged to confess that after having tried the different specifics proposed, and after having been foiled in attempting to discover a rational method, he has in most Sses been reduced to the third plan, or that of mating symptoms as they presented them- If these premises are granted and the statenaturally 43 54- ! follow, that as such practice is unsatisfactory, it has been also unsuccessful; for upon comparing the results of each medical man's practice during the whole of the present epidemic, it will be found upon an average that he lost one half upon the whole number of his patients ; that during the first days of its invasion he lost eight-tenths of those who were really attacked with Cholera, whereas during the decline of the disease he saved the same proportion; and that taking the whole number of cases which presented themselves during two months that we were afflicted with this pestilence, more than half resisted all the effects of medicine, and perished either of the disease or its immediate consequences. How does this accord then with the accounts we daily see in print, and which have all the testimony that their authors can require respecting their veracity? Before we solve this problem it may be allowed perhaps to digress a little, and inquire if this seeming contradiction be new in the history of medicine, and if it be confined entirely to the disease in question. Some analogy has been mentioned between puerperal fever and Cholera as regards the 11 D 44 question of infection ; the same will hold good with respect to the anomalies in its treatment. cE T e subjoin the following extracts from Dr. eh's last work upon this disease. EPuerperai fever was prevalent in Derbyshire the adjacent counties between 1765 and , and was described by Dr. Butter of tis opinion was that bleeding ought never to d in this disease unless when complicated inflammation, and even in these cases ngs of three ounces were sufficient; that the best remedy was ten grains of rhubarb and ten grains of cordia 1 confection every day till the stools became natural, and that this mode of treatment never failed. " In 1787, about ten years after Dr. Butter wrote, a puerperal fever was prevalent and fatal in London, and was described by the late Dr. John Clarke, ... Of the patients attacked with this disease, more than tzvo thirds died ; bleeding was injurious; emetics were hurtful; bark and cordials, though indicated by debility, were inefficacious. Er. William Hunter, and Richter, the proof medicine and surgery in Gottingen, were ' the most useful minds that ever appeared profession. If any men could, such men 45 Rt be trusted for giving accurate reports of .ease. Yet compare the accounts which i distinguished men have left of their exnce in puerperal fever. !Dr. William Hunter used to say in his lee- s — ' Of those attacked by this disease, treat n in what manner you will, at least three out aur will die. We tried various methods, 3ding, refrigerants, stimulants, mithridate,) every thing failed.' " Richter, speaking of the child-bed fever, says, ' I have often seen the child-bed fever, and always treated it successfully. I have also seen cases, both near and at a distance, in which the fever was treated differently from what I am accustomed to treat it, and the patients died. I therefore think that I have a right to offer my opinion about the nature and treatment of this fever.' " Richter, at the time he wrote this, was sixty years of age. The inexperience of youth therefore will not explain it; and it is explicable only on the supposition, either that old as he was he had never seen the epidemic puerperal fever, or that if he had, the epidemics which he had seen were singularly mild." Bhall add from the same authority the n of four eminent men in London, who 46 had tried a plan of treatment employed by M . Doulcet, of the Hotel Dieu, and who made a report upon the same to the Royal Medical Society of Paris in 1782. After having been foiled in every thing else, he at length tried emetics. •• From losing every patient, he now lost none. During four months nearly two hundred were cured : five or six refused to take the medicine, and all these died. Ehen this account arrived in England, it ed, as may be easily supposed, a strong on ; and the practice was tried by various ans with different results. " Dr. Walsh said it was infallible. " Dr. Denman, that it was eminently useful. " Dr. Lowder, that it disappointed him. " Dr. John Clarke, that it was injurious.*" r[n comparing these accounts of a well known ease with those we receive of the Cholera Morbus, we shall certainly confess there is a great analogy in the anomalies which they both IJI CoCU L • I extract the following from the Madras Report: " One thing however, I fear, is certain, viz., • "An Account of some of the most important Diseases DiTiiliir to Women London Afurrtiv. 1829." 47 that we are as yet as little acquainted with its origin, as its mode of cure ; for example, I read from Bombay, that a number of cases of the Epidemic Cholera have lately appeared in the island, but that its mode of treatment is now so well understood, that its re-appearance causes no alarm : at the same time, I hear from the camp of a corps now on its march, * We lost about ten people a day: no one returns alive from the hospital tent; and our Doctor says, there is no cure for it. One medical man boldly estimates his cures by thousands, while his no less zealous neighbour is heard to say, though he has followed the same plan of treatment, he has failed throughout.'" Without referring, however, to the history of the disease, and its treatment in India, than which nothing can be more contradictory, let us compare the accounts of those who have practised in the late epidemic in Russia. It was asserted, that the only salvation consisted in bleeding, resorted to in the first stage of the disease; and this upon such good authority, that the government, in its zeal for the public good, gave orders to the different medical men all over the empire to employ the lancet immediately upon being sent for. 48 49 I was soon discovered that this was not an ersal remedy ; and though the lancet was loyed, the blood frequently would not flow, the order was very judiciously counterded. Rwas then discovered, that if perspiration i be once excited, the danger was over; various ingenious modes were contrived for ccomplishment. Dr. Loder, of Moscow, observes, v La chose la plus essentielle et la plus pressante, est de debarrasser le corps la plus promptement possible dv Miasme, et ccci s' opere par la transpiration." Dr. Jenicken, in his reply to Dr. Loder, says on the contrary, " La transpiration me paroit superflue ; si elle est profuse, elle peut devenir Of internal remedies calomel and opium were the most in repute. I saw Dr. Menkoffski last autumn as he was on the point of departing for Saratoff, and I asked him what plan of treatment he proposed to adopt : he replied, bleeding at first, and then calomel and opium. I saw him a year after upon his return, and he told me he had no success with this plan, but when he changed it for warm baths and small doses E 50 of magnesia and rhubarb, he was very successful. Without going into further detail previous to the arrival of the disease in St. Petersburg, we came to that period which seemed to found a new era in the history and treatment of Cholera, and refer to Dr. Leo's practice and the subnitrate of bismuth. This was believed to be a specific, and no medicine was ever more generally distributed than was this invaluable remedy. What was the reply to the inquiries made respecting its use in this capital ? One practitioner observed he considered it all but a specific. A second, that it acted as a poison whenever he had seen it employed. A third, that if the patient did not die of Cholera, he died of congestion of the brain, where bismuth had been administered. With regard to bleeding, the same difference of opinion prevailed. When I was performing duty at the Sakoloff Hospital, no case recovered in which bleeding had been resorted to. My successors informed me that afterwards all the cases that were bled early in the disease recovered. 51 Ke physician asserted that he had not lost ient; he took away a tea-cup full of blood aye an infusion of lime-flower to drink. Bith respect to the use of opium, many asd that typhus fever was a necessary consnce of its employment, and yet of twentycases in public practice that I so treated, one died of typhus —seven died within -eight hours of the attack, the rest re However difficult a task it may appear to reconcile such discordant and contradictory reports, we shall again refer to the history of puerperal fever, which comes very apropos to save our credit. " Another remarkable circumstance about this disease is, that when it is most prevalent it is most dangerous. Each case is much more difficult to cure than when it occurs seldomer. The practitioner finds that although the group of symptoms resembles what he was formerly accustomed to, he has now to deal with a disease far more obstinate and destructive, and his usual remedies are not so successful as formerly; he loses case after case in spite of his best efforts. When it has thus been raging for a considerable time, it at length subsides ; the e2 52 OBSERVATIONS cases become less frequent and less severe; the practitioner finds his treatment becoming more successful, partly because experience has taught him to detect it earlier and to treat it better, but probably also because the disease has itself become milder." In the first place then we should apply to those who have never lost a case, the words of Dr. Gooch to Richter, viz., that though they may be sixty years old, they have never seen a case of Epidemic Cholera. Those who have been so uniformly successful have either only met with cases of common Cholera, or treated the other when upon the decline. For this circumstance alone stamps the identity of the present epidemic with the Eastern disease, viz., that upon the onset, whatever may be the practice, it is almost universally fatal ; and I appeal to the candour of my colleagues if, during the first ten days of its invasion, it did not sustain this frightful character. This, too, is the grand secret, this the reaj solution of the problem, this unravels all the intricacies, and forms a bond of union between elements which appear so discordant. The Epidemic Cholera upon its first invasion baffles all attemDts to conouer it ¦ but it trra 53 Ily loses its intensity, and towards its decline mes as tractable as other disorders of the entary canal. I we are asked why it should so operate i its first invasion, we can only confess our ranee and reply, that medicine is an art and i science, that the one is founded on princiwhich are known and immutable, the other 1 one that is unknown and is ever varying^ the vital principle. Kis this which governs, by its own peculiar , the animal economy ; that regulates all ispositions, susceptibilities and impressions, which distinguishes the animal from the line he fabricates. laving endeavoured to prove that the apparent >rds may be reconciled to a great extent by idering the epidemic in its different stages, ye subjoined some observations upon the rent remedies that have been employed, upon the methods of treatment which I found most successful. EXTERNAL MEANS: tu+> The use of baths was at the commencement of the epidemic almost universal ; but they soon fell into disuse, and upon the whole maybe considered as having been prejudicial. They were often succeeded by great exhaustion, and many were taken dead out of the water. The difficulty of transporting a patient from his bed to a bath was often considerable, and very inconvenient to him ; and as the object could be equally attained by frictions with hot cloths, or bags of hot sand applied over the whole surface, much distress and fatigue were spared the patient by substituting these means for baths. Unless they are employed at the commencement, when the excitement is still considerable, they will invariably do harm ; but if easily administered and sufficient attendants are at hand, they will often be serviceable in this stage and prove very comfortable. The horizontal position has been particularly 55 Bimended during the whole course of this se, and this must be disturbed by imon in the common bath. Vapour baths are much less prejudicial in this respect, because this position may be maintained upon the simple and judicious plan upon which they are constructed. If the surface be cold without the vital powers being too much exhausted, the use of the hot-water bath is indicated ; but as all the effects can be produced with much less inconvenience and less risk by the vapour bath, it should always be preferred. If, however, the hot-water bath is used (and some patients will insist upon it,) the temperature should be regulated by the state of the body at the time it is immersed. If a patient in the state of collapse, when the temperature is at twenty-fourdegrees, be plunged suddenly into a bath at thirty degrees Reaumur, much pain and uneasiness will be caused by the sudden transition from cold to heat. Neither should he remain longer in the bath than is necessary to restore the heat and perspiration, if this be the object. Khs are upon the whole a doubtful remedy, lore effectual and less prejudicial means >c substituted for them 56 BLEEDING. Few remedies require more decision in their employment than general blood-letting, and upon no subject is there a greater diversity of opinion. An indiscriminate use of any remedy must naturally bring it into disrepute, but in the present epidemic bleeding has been most decidedly beneficial, if employed judiciously. Those who consider the disease a species of asphyxia, employ it under all circumstances and in all stages, and relate marvellous cures performed upon those who were apparently dead. The case of the young man who had only nephritic symptoms, but with total loss of pulse, illustrates its utility in restoring the circulation (see Case 6). Bleeding from the arm in the first stage, when the pulse is full and the temperature not reduced, is often sufficient to cut short the disease. The quantity of blood to be drawn should be but small ; eight ounces will be sufficient to allow the remainder to circulate more freely and relieve the heart, and this will not too much exhaust the patient. The blood is 2"enerallv thicker than usual 57 highly carbonized, and forms a loose coagulum. I do not know if the blood of Cholera patients has been analysed during the present epidemic. The patient usually feels immediate relief, particularly where the head has been much affected. He should be bled in the horizontal posture, and remain quiet for some time afterwards. The operation of medicines is generally much facilitated by a small bleeding. The absence of the pulse is no prohibition to the use of the lancet, unless this is accompanied by other symptoms of great debility, and the system has been exhausted by previous evacuations, and the surface is covered with a cold clammy sweat ; in such instances I have never seen blood-letting serviceable, though many assert the contrary. In some cases the pulse ceases to beat very early, but upon opening a vein the blood flows slowly at first, gradually the current becomes fuller and stronger, the pulse beats very sensibly, and the heart thus relieved is enabled to continue the circulation. A few minutes later, the blood perhaps would have been so inspissated as to have precluded all utility of opening a vein, and asphyxia would hivp fnllowpfi from thp imnpdimpnts afforded to 58 the arteries of the heart and lungs ; hence it is that this disease requires such constant attendance, and such prompt decision upon the part of the practitioner. There are some cases, perhaps, in which even in the first stage bleeding would be inadmissible, as with the old and debilitated, and such as have indulged in the use of spirituous liquors. Upon the whole, however, there is no one remedy that can be quoted as having been more universally beneficial ; and with regard to its use we may say again with Celsus, " Si vires sinunt sanguinem mittere optimum est." Leeches may be used to relieve local congestions, but are more useful in the after treatment. They are too slow in their operation for such a malady. Capping offers much greater chance of success ; but it is hardly used in this city, and there are no expert cuppers. BUSTERS AND SINAPISMS fiiE amongst the most efficacious means that c can employ for the cure of Cholera. It mo.v be slid of them tliil thcv st essential also in the after-treatment, am sufficiently employed will very much curtai ) period of convalescence. tThe most common purgatives in use hay en calomel, salts, and castor oil ; but the ter has been employed with the greates ccess, and is an invaluable remedy. A full dose of calomel is often useful in the beginning of the convalescence, as it acts upon all the secretions ; but the simple purging, which is so requisite after this disorder, is best effected by small and repeated doses of castor 67 Ec stomach unfortunately is often inclined ject the dose, which may sometimes be jnted by adding a tea-spoonful of brandy, ung it upon peppermint-water. X regards the use of purgatives, the same vation is applicable as with regard to antilodics; they are no specifics, but are given nbat and relieve certain symptoms. They are indicated as long as the bowels do not perform their functions regularly, and the motions have an unusual appearance ; nor is there any fear of re-producing the disease by their continuance, so long as we take these marks for our guide. It is much more likely to recur from neglecting to administer them ; and the quantity of unhealthy matter which is often evacuated for a long time after the disease has been subdued, warrants the assertion. Dr. Hamilton in his valuable Essay on Purgatives, has justly observed that their effects are not merely confined to expelling faeces from the intestinal canal, but that they act upon the secretions and change their morbid Ence it is that he was so successful in curany diseases by these means, because he rered in their use till this change was ced. f 2 68 Sydenham, in treating of the cure of the Cholera, observes, that to administer purgatives in this disease is to extinguish fire by pouring oil upon the flames, " ignem oleo extinguere," but he speaks of the disease at its fhere is evidently a diseased action in the le of the inner surface of the mucous memie, so much so that some have considered Cholera as a catarrh of the intestinal canal. This action is most vehement at the commencement, and if not subdued, is speedily fatal ; but even in those cases where we have been fortunate enough to cut short the disease by the measures to be detailed, we cannot suppose that parts which have been so disordered should return immediately to their healthy state, and more particularly, when we consider that the extensive surface of the mucous membrane of the intestines has been thrown into morbid action. It is with the body as with the mind, habit becomes second nature, and if a morbid action be allowed to prevail for any length of time, the difficulty of overcoming it will increase with its duration ; hence if the morbid secretions of Cholera are not thoroughly expelled, a 69 ON CHOLERA. cause will always exist for a recurrence of the malady. To obviate this, therefore, purgatives should be administered not only to expel what has been already secreted, but to empty the vessels of what they still retain, and excite in them a new and healthy action, of which we can judge only by the appearance of the faeces ; and when they are natural both in colour and consistence, then only should be discontinued the use of purgatives. Kthey are neglected in the treatment of era, fevers and chronic inflammation will icessary consequences. Ealts and senna have been proscribed in this ase, and consistently with the contradiction reigns upon the subject, some practitioners i spoken of curing all their patients by the of Glauber salts ; whilst a physician well ersant with the disease in India, has assured that he has seen Cholera produced by the mon black dose, which is a composition of ; and senna. The same observations will apply to other purgatives in this, as in other diseases. 70 EMETICS. The employment of emetics has not been very general, nor has it been attended with much B3ss, except in those cases where popular dies have been taken and have produced ting. From an absurd idea, that poison had been distributed and mixed with the food and drink of the people, it was a common practice with them to drink large quantities of milk and oil when they felt indisposed, because they considered them as antidotes to poison. The natural consequence of such potations was copious vomiting, and several authentic instances of cures so produced are upon record. Phe same means when regularly prescribed )hysicians were not found to have so good ffect, but some reasons may be assigned for failure. In the first place, faith and confidence are no small adjuncts to the efficacy of remedies, and these are implied by the self-administration of In the second place, a man finding himself 71 ill, believing himself to be poisoned and having the means of salvation at hand, applies to them immediately. If his illness depended upon indigestion the effect of the remedy would be certain, and more particularly, as no time would be lost in its administration. if on the contrary he were to wait for medical ice before he used these means, two things ild be evident, viz., that the time in which f might have proved serviceable would have ised, and that he had no particular faith in remedy. Now we know that faith removes intains. I was called in the night to see an under er of police who supposed himself attacked l Cholera. Upon entering his chamber I id him groaning in bed, and his wife was inistering oil and milk to him. A table>nful of each were poured down his throat, as soon as they were rejected from his stoh they were immediately repeated, and whole cure consisted of this plan of treatt — He recovered. Ehas been equally recommended for the ' Cholera, but it has, as far as we can correctly, no title to consideration be;s emetic property. 72 IMr. Wilson states, that the routine pracin Malwah was to drench the patients with 3 draughts of salt and water. This must ttended with the double effect of emetic purge, and administered at the outset Id meet the indication of the first stage of lisease." — Kennedys Notes. OF CALOMEL AND OPIUM. Ray be fairly asked, what led to the uni-1 employment of these at the commence, and what to their subsequent disuse? Kie second query is answered by the first, it the universal employment of them which ;d their disgrace. It must be the same with every remedy that is employed indiscriminately, no matter what testimony it may have in its favour — it may have cured hundreds and thousands — still it will finally be abandoned and proved to be worthless, unless it has been employed upon some known principle, and given to fulfil some indication. What effects are to be expected from a combination of calomel and opium 1 no other than the gradual introduction of mercury into 73 ¦system, for the opium will prevent any ative effect of the calomel. Is the introduction of mercury into the system sufficiently rapid to produce any good effect in this disease, particularly at its commencement ? This question certainly must be answered in the negative. Btie calomel being so combined, and not actis a purgative, can be of no use therefore in first stages, and the good to be expected t be derived from the opium. The quantity of this will often not be sufficient to produce the desired effect, and hence the combination will fail in both instances. It is only when calomel is given in very large doses, so as to act upon the mucous membrane of the intestines, that it can be beneficial at the onset. But though this combination may fail where administered empirically, it may be of signal service in many cases where we wish to produce a general mercurial action ; and especially in the sequel of Cholera. In slight cases also, where the quantity of opium is sufficient to allay the spasmodic action, whilst time is allowed the calomel to act gradually, this combination may be of service ; but it in i isf vluirp flip <;anip fatp as all the vaunted 74 Ems which, when administered indiscrimi, lose even the merit to which they are entitled. Eiere mercurial action is indicated, as in the ie inflammation which sometimes follows, el may be given combined either with 1 or hyoscyamus ; the latter seems to be E calomel given in large doses, as a scruple If drachm, I have had no experience ; nor find that it was so administered during resent epidemic. Ri difference of climate must be taken into eration when such remedies are to be yed, and in such doses. In investigating the truth of the specific action of calomel and opium, we shall probably find them to have succeeded when employed scientifically, and to have failed when used empirically; and in searching for the truth of twenty other specific remedies we shall perhaps meet with the same conviction. It is necessary also to inquire at what period of the disease so much success has been obtained by any par- Kr remedy ; for it is from this omission in ivestigations that we have been led away the reports handed over to us, of certain 75 remedies having been successful in so many These same remedies have proved equally successful in our hands when employed under the same circumstances, and at a period of the Epidemic when nature herself will be all but sufcient to work out her cure. It is in the commencement of the disease that every thing fails, and that no class of medicines seems to have the least control over it ; for in this particular also, as in many others before mentioned, the analogy holds good between the Cholera of the two zones. THE SUBNITRATE OF BISMUTH. In corroboration of this assertion no better proof can be alleged than the boasted efficacy of bismuth. No medicine was so generally administered, and none was reputed to have had more success by the faculty in general. Its indiscriminate employment in all cases, from the slightest attacks to the moribund condition of the patient, brought it into disrepute. Its continued use also, after the symptoms which indicated its employment had subsided, caused cerebral congestions, and the patients died of the treatment as freely as of the disease. 76 OBSERVATIONS It had been recommended by Dr. Leo to continue it during the whole course of the disease, and to administer no other remedy ; but the Doctor had prescribed it thus successfully when the disease was already upon the decline, and as it is in many cases extremely useful, so at this period it would be peculiarly beneficial ; and as the symptoms would rapidly decline under its use, the danger of administering it too long was naturally avoided. It was said to have completely succeeded in Warsaw, so that it was vaunted as a specific ; but when it was resorted to in the commencement of the same epidemic, which had travelled to Dantzic, it shared the fate of many of its predecessors, and was declared to be null and void in its effects. Upon the whole, however, much good is to be derived from the prudent employment of this remedy. When used as an antispasmodic and not continued beyond the time indicated for its use, it has produced most beneficial results. No remedy seems to quiet the cramps and vomiting more effectually than bismuth, nor, when employed in moderation, does it produce those unpleasant effects upon the system which follow the use of severer remedies. If administered, the plan proposed by Dr. Leo is 77 K»est, with the precaution of discontinuing soon as the vomiting and spasms have d. Bthis effect be not produced after six or doses, it is useless to continue it unless are symptoms of amelioration. In the treatment of the present epidemic I have followed a plan suggested by the experience of others, and I have never abandoned it during the whole prevalence of the disease. Ktave no other grounds to offer for my adce to this plan than a success, upon the !, greater than many others that were cd. Previous to the invasion of the disease, I had collected from authors and practitioners in general who had some experience in it, all the evidence I could obtain; and upon comparing opinions, and calculating the chances of cure from the different means employed, I selected those which, according to these testimonies, had succeeded the best. Popular remedies deserve also more attention in this than in most other diseases, for till some more certain light is thrown upon the nature and seat of the disease, all our practice must be empirical; and of nostrums, let us take those which have the greatest evidence in their favour. 78 OBSERVATIONS The testimony of a ship captain is as valid as that of a physician, when the question is merely one of practical result. The use of opium, therefore, appeared to me more worthy of trial than all other remedies hitherto employed, because it has the greatest mass of testimony in its favour, both popular and professional. It has been a general rule, with physicians in the East, to recommend their patients to apply to the laudanum bottle in all cases where medical aid could not be immediately procured, and this is saying a good deal for the remedy. In one report with the perusal of which I was favoured, I read, that small phials were placed upon the table after dinner with the wine decanters ; and moreover, that they were placed upon posts by the road side, that, should the traveller be seized suddenly, he might resort to this remedy. Such was the opinion entertained of the efficacy of laudanum. It is needless to enlarge upon all the corroborative evidence, such as may be procured from captains of vessels, who have saved many of their crew by their being acquainted with this medicine, or to quote the testimony of many individuals who have been benefited by its use. Among physicians, however different their 79 theories may be as to the nature of the complaints, it seems that all employ this drug in some shape or other, and at some period of the complaint ; so that upon the whole it may be said to approach nearer to a specific than any thing with which we are acquainted. That it relieves spasm more certainly than any other remedy, we have positive evidence ; and if Cholera does not immediately depend upon spasm, it is always more or less accompanied by it, so that in the employment of this remedy we are fulfilling a direct indication ; and from the practice I have had in this comilaint, though it may have been more limited lan that of many of my colleagues, I am warmted in saying it has almost answered my xpectations. The following is the practice I have almost universally adopted in cases of Cholera where I have been called in at the commencement. If the patient is robust, the pulse still perceptible, and the system not too much reduced by evacuations, I order from six to eight ounces of blood to be drawn from the arm, the patient being first put to bed, in the recumbent posture. The following draught is then to be given : Laudanum and aether, of each twenty-five 80 tops. Strong peppermint water, an ounce and If. If this be rejected, it should be repeated immediately ; if the second be likewise not retained, then a clyster of linseed tea with fifty drops of laudanum should be administered. It often happens that the patient after taking the first dose falls asleep, and wakes in perfect health. I A large sinapism to the abdomen, and bottles hot water to the feet, should not be omitted ; these means produce speedy relief, an ounce castor oil should be prescribed as soon as the >mach and bowels are quiet. I Such is the most successful practice in slight ses, and I believe many a severer attack has en prevented by this method of proceeding ; I had given full directions to many of my tients how to act in case of not immediately ding medical aid, and all the houses I attended re prepared with these draughts. It may have happened that some have been taken unnecessarily, but I am convinced that many a case has been cut short by immediately applying to this remedy. Kit would be well if this always succeeded, t often, after a short respite, the symptoms ;urn, the vomiting continues, accompanied 81 calves of the legs. Bsuch cases, three grains of bismuth should yen every two hours, and continued till the ting has ceased, and the spasmodic action ly or wholly subsided. The bismuth should be discontinued, for the symptoms which seemed to demand it have subsided ; and in this sense only I consider it useful, and by no means a specific for the disease. If it be continued for any length of time, it is in many cases followed by congestion of the brain. If this mode of employing succeeds, as soon as the necessity for continuing it ceases, then the castor oil should be resorted to as in the first-mentioned instance, for this is a sine qud run* When the shock is thus broken, and the patient begins to recover, nothing farther need be done than to keep the bowels open and return to food gradually; beginning by mucilaginous diet, and by degrees adding veal and chicken broth to the meal. If slight delirium should occur, a few leeches to the temples, and a blister to the back of the neck will generally relieve it. ¦the means detailed above did not succeed, c not myself been able to succeed by any . Ido not mean to assert that these are c; 82 OBSERVATIONS f r means I have employed, nor that more is necessary ; but they are those ich I rely the most, and if employed the attack will often be attended with I Many other symptoms require attention even der this plan of proceeding. The cramps may often be relieved by friction with the hands, or with some narcotic and stimulating embrocations. The colicky pains which remain afterwards, and are renewed by every attempt to go to stool, are best relieved by clysters of starch and opium. Cataplasms of hemlock or henbane applied over the whole surface of the abdomen, and renewed every four hours, are of much service in relieving these after-pains. I The nausea and vomiting are more relieved r the saline effervescing draught than any her remedy. Cold drinks do not seem to be^ ore prejudicial than warm, and when much >sired by the patient should be given freely, smonade iced has often been taken with (vantage, and even the lower orders have ank their quass as usual, and with seeming The nitric acid may be given here also with" 83 E. benefit as a common drink, .riity drops c diluted acid added to a pint of water, tened to the taste, is a grateful beverage. If the stomach remain very tender to the touch, and there is appearance of subsequent inflammation, leeches should be applied, and when they have bled freely, a large cataplasm of narcotic herbs and linseed-meal applied over their bites. In this stage calomel is particularly indicated, and it should be given so as to affect the system ; but the patient must be narrowly watched during its use, and when the gums begin to be affected, it should be suspended. Some fatal cases have occurred, where its continuance has been followed by swelling of the parotid gland. Kis better to give it in combination with jyamus than with opium. Three grains of lei and one of hyoscyamus may be given three hours, till the effect is produced. E^s soon as the mouth becomes affected the ammation subsides. It is what we see in s, where we can witness its effects. It is here a specific. I is by no means incompatible with this ice to give anodyne injections to relieve pasms of the bowels. As soon as the desired effects are produced g2 84 by the employment of the mercury, we must return again to the castor oil, and continue it till Is long as the motions are of a dark colour pitchy consistence, it is necessary to purge, his is a source of irritation ; and, though a equence only of the disease, may still reuce it. It is therefore necessary to int the motions daily, and by their return leir natural colour we may prognosticate eturn to health. When the pains cease after copious evacuations by castor oil, the cramps subside, and the motions are natural, the remaining debility will gradually disappear as the stomach digests the food which it receives, and which is the best ''Ml I ( • Costiveness will often remain for some time, and requires enemas. It remains to speak of the treatment of the typhus fever and other nervous affections which are both a sequel and a part of the disease itself, but they require nothing peculiar, except that we should be cautious of giving stimulants and antispasmodics too soon ; but I have extended these observations already much beyond my original intention. Imperfect as they are, I offer them as having ! occurred to me during my practice in the present epidemic. They have no pretensions to novelty or originality as far as regards the practice. It is perhaps the oldest extant, but it appears to me the most successful hitherto adopted. Rave introduced the subject of puerperal because I think there are some striking dences, and it helps to explain the contradictory opinions in the treatment of Cholera; contradictions which are not new in the history of medicine. The great desideratum is to ascertain the real seat of the disease, whether we are to look for it in the nervous system, or revive the humoral pathology. Pthe cause be not evident, let us try to the effects and discover the parts of the system upon which it most operates ; but this can only be hoped for in repeated and minute I now conclude this imperfect sketch in the words of the late Dr. Gooch. I* our object is to learn only what has bee upon a subject, the pursuit of knowledg ti easy task ; but if it is to learn what i on a subject, the pursuit of knowledge i task of life." 85 No. I. CASK OF CHOLERA TERMINATING RAPIDLY, AND UNACCOM PANIED BY MANY OF THE MOST USUAL SYMPTOMS. Admiral , aged 56, was observed to go more frequently than usual to the water-closet after dinner on the 29th J. ne. He had been quite well previously, ate his dinner as usual, which consisted of roast veal without vegetables. He took no notice of this looseness, and went to bed at his usual hour. He was moved several times during the night, but without pain or uneasiness. His lady being alarmed sent for me without his consent at six o'clock a.m. of the 30th ; as I was absent, another medical man was sent for, who gave him some castor oil and laudanum. I saw him myself about eleven a.m., and was immediately struck with the change in his countenance ; for the Cholera physiognomy was decidedly formed, and that singular expression given to the features which can never be mistaken when once witnessed. It has not improperly been described as a 87 Emntenance which does not belong to the indidual himself. The tongue was rather foul, but moist and still warm, surface cooler than natural ; skin slightly corrugated, and of a bluish cast ; respiration still free ; pulse 68, small and depressed, no tendency to fever. Frequent loose watery motions resembling whey that has not been well strained, but with small pieces of curd floating in it; no pain whatever in passing motions ; no colick nor pain about the umbilicus ; urine passed freely with motions. No nausea or vomiting. Upon enquiring whether there were any spasms in the legs or arms, he replied in the negative, but complained of a slight pain in one ancle which was hardly worth noticing. No vertigo or affection of the head, but a faint sensation caused only when he rose from his couch to go to stool, and this not till after several hours from the attack. A singing noise in the ears complained of from the commencement. I requested him immediately to go to bed, for he was in his clothes lying upon a sofa. He complied with great reluctance, for there was great moral depression and evident fear of the disease. 88 tl ordered him to continue the medicines that id been prescribed for him, and recommended ctions and hot bottles of water to be applied the feet, with sinapisms to the stomach. I returned again at three p.m. The pulse was no longer to be found ; the w-hole body was Rlead colour ; the respiration laborious, yxia was evidently produced. The sensorium was quite free, but the moral depression great ; he requested to see a priest, and died at five p.m. There was no vomiting nor even nausea during the whole course of the disease, neither were there cramps or spasms, except towards the close, when the heart, being no longer able to iropel the blood, the intercostal muscles were irown into spasmodic action. Fear had operated powerfully upon this patient; he had called upon me repeatedly the preceding week for instructions how to act in case of being attacked. He had made several changes in his diet, and as I learned from his friends his mind had been much occupied for some time with the Cholera ; as soon as he believed himself attacked he gave himself up for lost. 89 No. 11. CASE OF CHOLERA TERMINATING FATALLY IN EIGHT HOURS, AND IN \\ HICH THE SYMPTOMS WERE NOT OF A SEVERE CHARACTER. lld man of sixty, in the service of Gene- , applied to me at eight o'clock ; he had been seized two hours previwith slight giddiness and other sympof Cholera, had vomited three times, had il loose stools, and complained of cramps i legs and arms. ¦le pulse was good, and the animal heat rently not diminished. ¦described the draught and other remedies c mentioned. Two hours afterwards I saw him again, the pulse was more feeble but distinct, a cold clammy sweat covered the whole body. There was very.little anxiety, but the Cholera countenance was formed. He scarcely complained of pain, never uttered a groan, and died at two p.m., retaining his faculties to the last. No. 111. CASE OF ACUTE CHOLERA WITH TENDENCY TO INFLAMMATION OF BOWELS, TERMINATING FAVOURABLY. lung woman of twenty-five was seized ten p.m. with excruciating pains in the nen, recurring at very short intervals and 90 • t • 1 Mill /* 1 with increased agony. She had been formerly subject to colick ; but was aware from the first that this was an attack of Cholera, judging from the difference of feeling and intensity of Ke ascribed the attack to having eaten some beans for supper ; but though convinced S nature of her complaint was quite devoid r. I saw her an hour after she was seized, she had been four times to stool, the three first motions were solid, the last watery and like whey. She complained of great cold and shivering. There was a peculiar change in the countenance, and some difficulty of articulation. The feet were quite cold, and a clammy sweat was sensible upon the lower extremities, whilst the upper were bedewed with warm perspiration. The breathing was hurried and she was very restless, the pulse very low and weak. She complained of a rushing noise in her ears which almost caused deafness. Urine was passed with each motion. Two table spoonsful of castor oil and fifty drops of laudanum were given immediately : this was retained about half an hour, and then rejected. Thirty more drops of laudanum were given in a glass of hot brandy and water, a large sinapism was applied 91 over the abdomen and bottle of hot water to the feet. She soon felt relieved after the second close, but the spasms still continued. A saline effervescing mixture was given every hour, and every second hour three gains of the subnitrate of bismuth. The following morning I learnt that the pains had gradually subsided, and that she had slept a little. The cramps were much diminished, the countenance less anxious, voice more natural ; noise in ears still continues ; tongue moist, perspiration general, pulse fuller ; had made water freely ; still a sense of acute pain all over abdomen, much increased by pressure, or by turning in bed or by weight of bed clothes. She had taken four of the bismuth powders, which I ordered to be discontinued. Twelve leeches applied to the abdomen. Re felt immediate relief from the leeches, was more comfortable in the evening ; Is confined, all the other painful symptoms lished. Two table spoonsful of castor oil to be given early in the morning. Ie passed a restless night, took the oil ; it had operated twice freely; the motions and foetid, resembling pitch, and passed considerable pain and tenesmus ; complains 92 of head being light and spasms in the chest, some fever. The third day of the complaint the pain in he abdomen continued, increased by motion and pressure, and even by the weight of the >ed clothes ; no motion, general sensation of cold and shivering, head-ache and vertigo. LTwo table spoonsful of castor oil to be given the morning. She passed another restless night, and all the symptoms much aggravated ; the oil has not operated. Eighteen leeches ordered to the abdomen, and a solution of Epsom salts in almond milk every two hours. The leeches again produced immediate relief; the bowels being still confined, a purging clyster was ordered, and a pill composed of three grains of calomel and one of the extract of hyoscyamus to be taken every three hours. She passed a quiet night without much pain; no motion, thirst and nausea, tongue moist, less head-ache. Pulse nearly natural, rather depressed ; abdomen still painful on pressure. Two table spoonsful of castor oil to be taken immediately. Severe pain after taking oil, which operated several times ; each motion produced great 93 Pness, which she described as running all the bowels, and succeeded by spasms, of bearing down in bladder. Warm ne fomentations and cataplasms of hyous and conium to be applied frequently, grains of extract of hyoscyamus to be given at bed time. She slept well all night; several dark-coloured motions passed with less pain, pulse and heat natural, feels much better; but towards the evening of this, the sixth day, was seized with general rigor and violent pains in all the limbs, succeeded by heat and determination of blood Iroat and tongue very sore, gums inflamed, llary glands much swollen, considerable ism ; ordered a lotion for the mouth and c of castor oil. rpt ill from general irritation ; seven motions and foetid, and passed with much pain ; towards evening head and affection of mouth relieved by the purging; some tenesmus, had an anodyne injection, calomel discontinued. Had taken sixteen grains in all. Hyoscyamus continued at bed time. From this time the complaint gradually diminished, the pain of the abdomen subsided, and though she was subject to griping colicky pains, there was no tendency 94 to inflammation. She continued the anodyne injections and cataplasms ; the bowels remained torpid for a long time after, and required castor oil. The appetite and strength returned with the use of tonics. No. IV. CASES OF INCIPIENT CHOLERA CURED IN THE FIRST STAGE. A shop-keeper of sober habits called upon me about eight o'clock, a. m., and informed me la; had been seized, about an hour after he rose, with giddiness accompanied by a desire to vomit, and he felt unable to pursue his occupa- X pulse was full and quick, skin rather er than usual, slight twitching pains in the ; of the legs; had three stools of a watery 3 and accompanied by pain in the bowels. Ordered him to lose eight ounces of blood, to go to bed, and take the draught with laudanum and sether. ¦c following day he was in his shop as , and had no return of the complaint. No. V. t footman, of rather disorderly habits, came ne late at night, and was suddenly attacked 95 E giddiness, nausea, vomiting, cramps and symptoms of Cholera. A draught readyred was given him immediately; he went I and slept soundly all night, and awoke n the morning. Some days after he was attacked in a similar manner, and had again recourse to the draught, which relieved the immediate symptoms ; he remained unwell for a day or two, and then resumed his occupation. No. VI. X WHICH THE MOST PROMINENT SYMPTOMS OP CHOLERA NOT OCCUR TILL THE SECOND DAY OF THE DISEASE. A young man of thirty-three was admitted into theSokoloffHospital about two p.m. He reported himself to have been in perfect health previous to his present attack. He had been seized about nine a.m. with shivering and vertigo, succeeded by most excruciating pains in the loins. He had no vomiting or diarrhoea, and made water freely. Ie extremities were quite cold, there was Use at the wrist, the lips were black, and ountenance ghastly. The restlessness of ody was extreme. He was ordered a warm bath and some castor 96 oil, and the loins were rubbed with spirit of turpentine and laudanum. Two grains of calomel were given every hour. The following day he was bled from the arm, and leeches were applied to the loins. The pulse became distinct soon after, and vomiting and diarrhoea succeeded. — He died on the fifth day. What a striking difference this case presents from the description given by Cullen of the Cholera Morbus ; yet it was a well-marked case of this disease, not to be mistaken by persons conversant with the physiognomy of the present epidemic, and which is not observed in the worst cases of common Cholera; for it is not an emaciation produced by evacuations alone, but is present before the system has been so exhausted as to allow of this supposition. It is the outward and bodily sign of the disease itself.