*A?7lc 1865 1 

J _^ M _^_^, J ,^^^ M^^^^^^ M^lMl 



AMERICAI MEDICAL ASSOCIATION. 1 

Chap , | Shelf. :. | Jtfo .... JL/ | lil^.<.....J^A^A. M/l.Sxw! "tk^^^^jGiijrL.^ls, (Donor. I 

This collection of Books is a special deposit [ in the LIBRARY OF CONGRESS. I 

Surgeon General's Office 



>Jec&on, 







THE CHOLERA PESTILENCE. 

BY A. P. MERRILL, M.D., 

141 TVIA.CDOXJG-A.Tj STREET, 

NEW-YORK. 





THE CHOLERA PESTILENCE. 

BY 

At P. MERRILL, M.D., 

14-1 3VXA:C:DOTJG.A.:Li STEEET, 

NEW-YORK. 



Entered, according to Act of Congress, in the year 18C5, by 

A. P. MERRILL, M.D., 

In the Clerk's Office of the District Court of the United States for the Southern District of New-York. 



THE CHOLEKA PESTILENCE. ORIGIN AND PROGRESS OF THE DISEASE. 

The origin and progress of epidemics are among the secrets of nature. Their causes being wholly unknown to us, we can form no idea why they should have any existence, or why they should appear at one time and place any more than another. JBut that they have always prevailed among men we have abundant reason to believe ; and from long observation we have been able to learn some of the conditions which attend upon their rise, culmination, and decline. From all the experiences of mankind for so many centuries, we ought reasonably to expect that we might be able now to anticipate the advent of any particular epidemic disease, and prepare for arresting its progress. But in regard to these matters we are still ignorant, and pestilential epidemics come upon us as unexpectedly as at any former period, and no means are known to us by which their progress can be arrested. Whenever they begin to spread over the earth, all mankind must prepare for their devastations. 

It is an interesting historical - fact, that most of the general epidemics which have overspread Europe, frequently embracing a considerable portion of Africa, and sometimes extending to America, have had their origin in Asia. Thence they follow, 



THE CHOLERA PESTILENCE. 

sometimes immediately, and sometimes after several years' delay, the courses of commerce and travel westward and northward, making strides from city to city, often visiting also intermediate villages and hamlets, but strangely exempting, occasionally, certain settlements which seem most exposed, and then when least expected turning back to embrace them in its pestiferous grasp. Whatever may be the particular form of disease, and whether contagious or non-contagious, its progress is onward, and no human agency is able to arrest it, or divert it from its proper destination. 

These epidemics are generally preceded by certain kindred diseases of a comparatively mild and harmless character ; and as their climax of severity subsides, they are also followed by the same or similar non-fatal disorders. Thus the plague and yellow fever are preceded and followed by certain forms and grades of fever, but without the pathognomonic signs of these diseases ; and cholera is preceded and followed by certain disturbances of the digestive organs, in many respects resembling cholera, but not having all its distinctive marks. During the whole course of these epidemics, in any particular locality, these milder forms of disease are, indeed, constantly occurring, sometimes in so mild a grade as to be overcome by the remedial powers of nature alone, and readily yielding, in most cases, to very moderate curative measures. It is not less true, also, that epidemic diseases in their most violent and fatal stage, are always initiated in each individual case by these milder derangements of the system, and become intensified more or less rapidly by the force of the exciting cause, and the concurring predisposition of the sufferer. No patient is ever brought under the dominion of alarming and fatal symptoms suddenly, but the disease is commonly so mild in its inception and early stages, as 

4 



THE CHOLERA PESTILENCE. 

to deceive both the victim and his friends as to its true character and danger. ISTow, it is difficult to conceive of so uniform a concurrence of these conditions, without attributing both the milder and graver forms of disease to a common cause. The connection between them is so close and inseparable that it always becomes a matter of dispute, and sometimes of very angry dispute, among physicians, as to the true period of the beginning of the epidemic. It is undoubtedly true, as some have contended, that the epidemic disease has a substantial existence in such localities, previously to the manifestation of its distinctive and acknowledged characteristics — plague without carbuncles and buboes, yellow fever without black vomit and the sallow skin, and cholera without asphyxia and collapse — and the same conditions present themselves as the fatal period of the epidemic draws to a close, physicians being unable to draw the line of demarcation between the pestilence and its precedent and subsequent diseases, and hence the disagreement among them. The distinction so earnestly sought for cannot be made, for the simple reason that there is none ; and these disputes, which cast such odium on the profession will not cease, until it comes to be conceded that the whole course of the epidemic, from the earliest premonitory to the latest closing case of disease, proceeds from a common cause,* This concession is the more important, because, when it is made, both professional and public scrutiny will, at the proper time, be diverted from atrans-atlantic gaze, and concentrated upon our suffering homes. It often, nay, it commonly happens, that while whole populations are in fearful expectation of an epidemic approach, the dreadful disease is already in their midst, and rapidly culminating to its intensity among an unsuspecting people. 

5 



THE CHOLEKA PESTILENCE. 

Other premonitory signs are of value in determining the question of common cause in the prevalence of epidemic disease. An epidemic of kindred pathological character among the brute creation not unfrequently precedes pestilence, affecting in some cases, beside all domestic animals, the wild animals of the forest, and even the birds of the air. These evidently feel the influence of the prevailing cause anterior to its development among the human race. This is one of the unexplained mysteries of epidemics, but the fact cannot be doubted by any one familiar with their history, that animals have sometimes suffered extensive mortality previous to the advent as well as during the continuance of pestilential visitations, and this has generally been considered one of their premonitory signs. Although the suffering animals may not have carbuncles as in plague, black vomit as in yellow fever, or watery dejections, as in cholera, they do, in all these premonitory affections, present symptoms of congestion, accompanied by signs of plethora, followed by prostration of vital energy and sudden death, as in all three of these diseases. And, further, we have reason to believe, that the local congestions so fatal to the animals are of the parenchymatous or membranous tissues, in accordance with these tendencies in the prevailing or approaching epidemic as developed in the human system ; thus affording additional evidence of their common origin. 

It cannot be too seriously considered, that visitations of epidemic disease are to be watched for and guarded against in small and isolated communities, as well as in large and more extended populations. An epidemic may appear and prevail in a single house, a small neighborhood, or a ship, and may become very fatal in such restricted bounds for days, and even weeks, before its ravages are extended to other localities in close proximity. It may 

6 



THE CHOLERA PESTILENCE. 

take weeks in crossing a street, or in surmounting a wall, and nothing is more to be expected than that it may prevail in one quarter or compartment of a ship without immediately extending to another. Indeed, epidemic diseases, which in their progress make so resistlessly the whole circuit of the globe, are often checked and for a while controlled by obstacles of apparently trivial character ; and they also expand and extend their sphere of operations without the agency of any means yet discovered. They may and often have appeared in ships at sea, which have not touched at any port where the disease was prevailing, and without the possibility of human agency. But wherever epidemic diseases do make their appearance, however extended or limited the sphere of their ravages, there they are likely to continue and prevail for a certain time, in spite of all efforts to expel them ; and there is no certain security for the residents of such localities, but in removal beyond the epidemic influence. 

All observation proves that pestilential epidemics are very insidious in their approaches and attacks, in respect of both communities and individuals. "Whole cities are often in a state of uncertainty for days and even weeks before it can be determined whether or no the epidemic is in their midst ; and nothing is more common than for individuals to be so deceived about their condition after an. attack of the disease, as to induce them to postpone the use of remedial measures, until it is too late to hope for relief. In regard to the great question of checking mortality, this is the important matter to be considered, because it is the only condition over which we have any certain control. The graver forms of many epidemic diseases are in fact curable by any means now known to us only in their early and inchoate stages, and before the more serious iocal lesions peculiar to and characteristic of the disease become 

7 



THE CHOLEKA PESTILENCE. 

firmly established. Hence the importance of such an understanding of the course and character of the disease, as will tend to secure the adoption of proper treatment, while it is practicable to obtain relief from it. 

In regard to American cities it must be considered, that whenever any pestilential epidemic, originating in the Bast, has already swept over a considerable portion of Asia and Northern Africa, and is found extending its ravages in Europe, to embrace the great cities nearest the Atlantic coast, in every stage of its progress being heralded by its common prodrome ; and when in addition to this we find the disease attacking the passengers and crews of ships while upon the high seas, midway between the two continents, then it is we have reason to expect its early appearance in our great commercial* cities, and prudence requires every attention to be given to the premonitory signs of the disease among ourselves. In the case of epidemic cholera, the premonitory affection to which our attention is uniformly called by writers, is diarrhea. This is not in fact the earliest manifestation of the disease, as I shall attempt to show when I come to treat of symptoms, nor is the looseness of the bowels diarrhea properly socalled ; but what is so generally spoken of as premonitory is really cholera in its mild and inceptive grade, and in no such case can it be known that the disease will not culminate to its malignant and fatal grade, in which it is not supposed to be curable. 

While no means are known by which pestilential epidemics can be arrested in their progress, and they continue to overspread the habitable portions of the earth as with a pall of death, regardless of preventive measures, we must, for the preservation of human life, place our reliance for protection mainly upon this providential fact, that all these destructive diseases are curable in their inceptive stages. Whenever heads of families, and every individual 

8 



THE CHOLBEA PESTILENCE. 

man and woman, shall be persuaded to watch for the early symptoms in their own persons, and in the persons of their children and dependents, with a view to early and judicious treatment, then, and not until then, will these epidemics cease to be extensively fatal. 

In a long experience with the two great pestilential epidemics of modern times, I have had no good reason to suppose that in any one instance either yellow fever or cholera has been communicated by personal contagion ; and I have often observed that in all those places where these diseases have most prevailed, there is the least apprehension on this account. It is not in the West-India Islands, in Yera Cruz, or in IsTew-Orleans, that we most frequently meet with believers in the contagiousness of yellow fever ; or in' the great cities of the East that we encounter fears of contagion in cholera ; but in regard to both diseases we hear most of contagion where they have prevailed least. In regard to small-pox and measles the case is different, and it is considered an act of great imprudence to employ nurses for the sick who have not gained an immunity from the prevailing disease. During the prevalence of yellow fever and cholera, on the contrary — and I believe the same is true of the plague — none are so likely to escape the prevailing disease as those who spend their time in attendance upon the sick, whether they have previously had the disease or not. Nor have I ever known either of these diseases to attack any person who had not slept at night in the infected region. In spite of all the influences of early education, and of preconceived opinion founded upon the teachings of the schools, I am forced to these conclusions by my own personal observations, extending over a period of forty-five years in the South, where pestilential diseases most prevail. - 

1* 

9 



THE CHOLERA PESTILENCE. 

PREDISPOSITION TO THE DISEASE. 

In regard to the liability of different classes of people to epidemic diseases,, the same rules hold good, with few exceptions, in all of them. The predisposition is much in proportion to the extent of those habits and conditions of life which are in violation of the sound principles of hygiene. Conditions and circumstances which tend to impair the health and vigor of the system, and especially to a disturbance of healthy nervous function, lay the person constantly liable to the action of the exciting cause. These conditions embrace, of course, diet and beverages, which should be such only as will promote good digestion, and such as providence has provided for our sustenance ; cleanliness and regular habits as to exercise, labor, rest, and sleep. Any violations of propriety in regard to any and all of these matters, incur the dread penalty of liability to epidemic disease, and at the same time materially lessen the chances of recovery. Artificial excitement from the use of intoxicating drinks may afford some degree of protection while the excitement steadily continues, but this must always be followed by more or less of indirect debility, which strongly invites attack, and such subjects suffer severely. Those portions of cities which are built upon made ground, especially if the drainage be defective, invariably suffer most, and probably for the reason that they have been made to approximate the condition of natural marshes, which are known to be insalubrious. Want of effective drainage is, indeed, under any circumstances favorable to the spread of epidemic diseases. 

There are many agencies of predisposition which cannot here be enumerated, but no agencies of this kind should be confounded, as they often are, with the cause of epidemic disease ; for this is a very 

10 



THE CHOLEEA PESTILENCE. 

different thing from those influences which, by their deleterious power over the human organism, prepare the system for • its attack. Were they really causes of pestilential diseases, we might expect them to be ever present in certain localities ; and we should be wholly at a loss to account for the fact, that such diseases as yellow fever and cholera have never visited certain cities whose defective police would seem most to invite them. The cause of epidemic pestilence, in whatever form, is some mysterious and hidden entity, of which, like the principle of gravitation, nothing is known but its effects. That which produces cholera, like many others of which history gives account, has its origin in the East, whence the disease travels westward — and sometimes eastward also — producing the same disease wherever it goes. It never affects the people of a city in all its intensity upon first reaching it, but from moderate beginnings it becomes gradually intensified by the process of cumulation, until the highly predisposed are made to suffer the severer grades of the disease, and after an uncertain time it disappears gradually as it came, while the predisposing causes all remain. 

There can be no doubt, however, that cholera, yellow fever, and other diseases prevailing epidemically, continue sometimes for many years to occur, in occasional or sporadic cases, in localities which have once been visited by the epidemic disease ; but never in those cities which have not been thus visited ; showing that their proper cause, after having been once introduced, does not always wholly disappear with the subsidence of the epidemic. Such is the case with the city of New- York. Until 1832, it had never been visited by epidemic cholera, and, notwithstanding the existence of predisposing causes even in higher degree than since that period, no case of cholera had ever been seen. Since this first 

11 



THE CHOLERA PESTILENCE. 

introduction of the disease until now, sporadic cases have occurred at short intervals, and it may well be doubted whether the city is ever entirely free from the disease, but it prevails as an epidemic only when approached by the disease, as in the first instance, from the East. In looking for the advent of another epidemic, a careful discrimination should be exercised, not to confound these sporadic cases with those produced by the onward march of the devastating pestilence. Cases of cholera may truly occur, and be truly reported, without justifying the inference that the great epidemic is operating in our midst. 

SYMPTOMS AND CHARACTER OF CHOLERA. 

Diarrhea is not, as has been generally believed, the first and earliest symptom of this disease, and those who know themselves to be exposed to the operation of the epidemic influence, should not wait for its appearance before they resort to treatment. On the contrary, the earliest noticeable manifestation of an attack is impaired digestion, accompanied by discomfort, and a sensation of fullness about the region of the stomach. This is soon followed by a collection of fluid in the bowels, with rumbling and distention. After these symptoms have continued several hours, and sometimes even for several days, the contents of the bowels are discharged, and frequent watery stools succeed ; and this is called the stage of diarrhea. But it sometimes happens that the fluid thus collected in the bowels, being principally confined to the upper portion of them, is not discharged before, collapse takes place, and in some cases there is no discharge, from the bowels at all before death. Although it is true, therefore, as we are always advised, that diarrhea is a sufficient indication of the presence of the dis- 

12 



TIIE CHOLERA PESTILENCE. 

ease, requiring, however mild it may be, the application of remedies, it is also equally true, that it is in the power of those who are attacked to meet the disease with remedial measures at a still earlier stage, and at a time when it is still more easily arrested and cured. These early signs of disease are not active and painful — sometimes they are barely sources of discomfort — but they are always sufficiently decided to be cognizable to every one who is aware of their true character and significance, and watchful of their appearance. It is true of all pestilential diseases, that they have an inchoate stage of considerable duration, in which they are really mild diseases, and quite under the control of remedies ; and nothing is more important than that all classes of people should be informed in regard to the inchoate stage of cholera, in which it is more easily cured than most other pestilential epidemics in their corresponding stage. 

It may be presumed that nearly all persons are acquainted with the symptoms of common diarrhea, in which the evacuations are caused by an increased peristaltic movement of the bowels, tending to a forcible expulsion of th^eir contents, very much as in the operation of purgatives. More or less pain' precedes and accompanies the discharges, caused by irritation of the fecal contents ; and although relief attends upon each discharge, the patient is sensible that the cause of increased action is not removed. Not unfrequently the discharges are reduced in quantity as they increase in frequency, and the sensations of fullness and urgency to stool become greater as the disease continues. There is more or less soreness on pressure, an increase of some of the secretions, discharges of mucus, and sometimes tenesmus and hemorrhage. 

Now, in that stage of cholera commonly called diarrhea, the symptoms are different. There is a 

13 



THE CHOLERA PESTILENCE. 

gradual distention of the bowels from watery accumulations, causing discomfort, but little or no pain. When these accumulations of water reach the lower bowels, there is a strong desire to discharge them, and such discharge having taken place, entire relief follows, and the sufferer is apt to believe that his indisposition is thus ended. He returns to his repose, or goes on with his business, as if nothing unusual had happened to him, and will not easily be convinced that so serious a disease as cholera can have such an unimpressive beginning. And this accumulation and discharge of fluid may be repeated once, twice, or even five or six times, before the unsuspecting victim becomes aware of his true condition. Cramps, vomiting, cold extremities, congested skin, thirst, and prostration of strength, make their appearance when least expected, and then both the sufferer and his friends discover that the disease is serious and alarming. He is now in great danger, as his condition is one from which the smaller portion of those who are attacked recover. So far as the bowels are concerned, it is a condition which has few resemblances to diarrhea., all secretion and absorption being suspended, but more closely resembling the condition of the bowels in the cold stage of malignant fever, in which there is frequently the same kind of watery stools, discharged very much in the same way. Probably the pathological condition of the mucous membrane in both cases is the same, differing only in degree. By peculiar nervous derangement there is congestion of the mucous membrane lining the intestinal canal, which nature attempts to relieve by free exudation of serous fluid resembling hemorrhage, except in the color of the discharge. It is not secretion, as in diarrhea, from increased action of the muciparous glands, but that pouring out of the fluids consequent upon congestive paralysis, which precludes all 

14 



THE CHOLERA PESTILENCE. 

secretion. In diarrhea, therefore, there is increase of function, and in cholera a suspension of function ; a very important distinction too often overlooked. In the one all the secretions are increased ; in the other all are suspended. 

We often meet with a similar condition of the intestinal membrane in that violent form of congestive fever sometimes denominated in the South cold plague. This is characterized by sthenic congestion, or plethora, not to be relieved by internal stimulation, and the application of heat externally, although to the inexperienced these remedies appear to be indicated by the great prostration of strength and coldness of the surface of the body. In yellow fever, also, this condition frequently exists, and is always considered dangerous, as it does likewise in severe cases of cholera morbus ; and in all such affections serous discharges from the bowels are common, simulating this symptom in cholera, but in no case are they so profuse and rapidly prostrating. In the other cases referred to they are secondary to exuberant excitement, but in cholera they are primary characteristics of the disease. They are in general accompanied by an excess of vital power above the standard of health, to be benefited in the inceptive stage by sedative remedies, but the disease insidiously and stealthily goes steadily on to a condition of great depression, collapse, and death. 

The only chance of recovery under any treatment yet proposed, is from reaction, and fortunately this takes place in many cases unexpectedly, and sometimes without the agency of remedies. From a state of great depression, with the blood drained of its thinner portion, and stagnating in the blood-vessels both large and small, and when all hope seems at an end, the nervous system is mysteriously relieved of its derangement, its normal energy is gradually restored, and the blood moves on in its accustomed 

15 



THE CHOLEEA PESTILENCE. 

course. It would seem as if the patient might have been suffering from a protracted chill, which, after closing up the very fountain of life, and paralyzing every normal function, is suddenly relieved of this condition by an abnormal and almost equally dangerous reaction, as in the second stage of periodic fever ; but differing from fever in the essential fact, that in cholera there is no regular periodic movement, no deference to that law of fever which secures to the patient at least one diurnal remission and exacerbation. Here then we have a case of extreme morbid congestion without chill, and persistent morbid reaction without any fixed period of intermission. The resulting excitement, as in fever, is somewhat in proportion to the degree of previous depression, and as spontaneous intermission is not to be expected, there is the greater need of such remedial measures, as may tend to moderate and tone down to a safe and healthy standard, this extraordinary effort of nature to afford relief. 

TREATMENT. 

To determine the proper treatment of cholera, we must consider its pathological character in its different stages, and then seek for remedies suited to the varying conditions as they are presented. From the inception of diseased action until the period of reaction, the prominent characteristic is congestion ; and this mainly of the mucous tissues and the skin. Certain parenchymatous structures become involved in the prevailing congestion as secondary and incidental conditions, and are principally important as, by the loss of healthy function, they influence secretion and nutrition. That disordered innervation lies at the foundation of the pathological condition called congestion, has long been believed by many physicians, and the truth of the 

16 



THE CHOLEKA PESTILENCE. 

proposition would seem to admit of little question when it is proved, that the best reliance for relief is to be placed upon that class of remedies which act specifically upon the nervous system, to control and regulate nervous function. The primary influence of the exciting or epidemic cause I conclude, therefore, is upon the nervous system, over which a certain class of medicines exercise special power. Opium has generally been considered the most* prominent of these remedies, and it may be taken as a proper representative of the whole class. This is considered our most effective remedy for the irritative stage not only of cholera, but of fever and some other diseases ; but while it is powerfully remedial of these cases of disordered- innervation, it has also the effect to impair glandular action, especially of the digestive organs. Mercurial remedies are therefore considered almost necessary adjuvants for the readjustment of these secretions ; and the two remedies are commonly used in conjunction. 

But strychnia is a neurotic remedy, widely differing from opium and its congeners. It is at once corrective of disordered innervation and promotive of secretion, absorption and nutrition ; more than answering the purposes, in congestive diseases, of opium and calomel combined. In the inceptive or irritative stage of* cholera, this remedy appears to exercise the same power over the disease that quinia exercises over intermittent fever. In some respects it is, indeed, the more convenient and efficient remedy of the two ; for while quinia requires to be used principally in the stage of intermission of fever, which can occur only once a day, strychnia may be used in cholera from hour to hour without such interruption. In that disturbance of the digestive function to which I have referred as constituting the earliest manifestation of disease, and when the mucous membrane of the stomach and bowels is begin- 

17 



THE CHOLERA PESTILENCE. 

ning to pour into those cavities the serous fluid characteristic of gastric and intestinal congestion, strychnia may be relied on to relieve the morbid condition so promptly and effectually, as to dispossess the patient of all apprehension, and render it difficult to convince him that he has been in any danger of an attack of the disease. And this is just the stage in which all who are watchful of their health during the prevalence of the epidemic should be treated and N cured, not waiting in any case for the characteristic discharges from the bowels. 

The second stage of cholera is when these discharges from the bowels begin, consisting, in the first place, of fecal matter mingled with the collected fluids, but afterward, of the latter alone. The blood is drained in this way of its watery portion, just as hemorrhage would drain off the white and red parts together in case of discharges of blood. What remains of this vital fluid is thickened and unfitted for the nutrition of the body and the support of vital energy. Hence the sudden prostration of strength, not only in cholera, but in other diseases in which these discharges occur, and much in proportion to their extent. There are some cases of cholera in which these discharges do not occur at all, but the patient sinks equally and the disease is as certainly fatal. In such cases the principal congestions and exudations are in the upper portion of the intestinal canal, and there being no peristaltic movement, on account of partial paralysis of the bowels, there is no ejection of fluid except from the stomach. The prostration of strength in some instances is even more rapid than in cases attended by alvine discharges, the intensity of the nervous disorder being evidenced by partial insensibility and want of muscular contraction in the intestines. Hence the almost uniform fatality of that misnamed variety of the disease sometimes called cholera sicca, or dry cholera. 

18 



THE CHOLEEA PESTILENCE. 

In this second stage, then, sometimes called cholerine, or choleraic diarrhea, we have the disease in increased severity, and generally increasing rapidly in alarming symptoms. We have, as in cold plague, and in algid fevers of all kinds, severe and increasing congestion with its legitimate results — watery stools, suspended secretions, and prostration of strength, followed by deterioration and thickening of the blood. More active remedial measures are now required, and it is in this stage that blood-letting has been found useful. It is indeed a powerful remedy for sthenic congestion, but in using it, there is danger of sudden prostration from too sudden a discharge of blood, which can only be guarded against by the exercise of proper skill in the operation. But the blood in such cases circulates very slowly, and is slowly discharged from an orifice in either artery or vein, affording some security against sudden and dangerous prostration. By repeated small bleedings, reaction may be induced, and as it comes on, the blood will flow more freely. It is one of the advantages of this treatment, that the reaction is less violent than when it occurs spontaneously or is produced by other remedies in use, and the chance of recovery from this stage is proportionally greater. 

In this congestive stage also, strychnia is a most efficient remedy, but in most cases it must be given to produce decided constitutional effects. As vomiting is a common symptom, it is sometimes difficult to be certain of the quantity retained in the stomach ; and as the powers of absorption are impaired, we can only judge of what portion of this or any other remedy becomes available, by the effects produced. When calomel is administered in cases of cholera or fever, while the mucous membrane of the intestinal canal is severely congested, it is sometimes ejected from the stomach and. passed through the bowels 

19 



THE CHOLEKA PESTILEKCE. 

unchanged and without loss by absorption or decomposition ; and this is no doubt true, to some extent, of many other remedies. This enables us to account for the fact that much larger doses of powerful medicines may be given with safety in these affections than in other diseases. Strychnia, in its proper dose, is among the mildest of all our remedies for disease, but in such quantity as is often necessary to overcome the disordered innervation of cholera, it is actively tonic, and in inviting reaction, its tendency is to produce an undue amount of cerebral excitement, and cause almost as much embarrassment in the treatment of the stage of reaction as we have had in that of depression. 

If reaction do not follow this second stage of the disease, the next serious difficulty is the stage of collapse. Hitherto, notwithstanding the depressing influences of congestion and watery stools, the vital power is supposed to be above the standard of health, but now it sinks below that standard, and this is called the stage of collapse, which, like the preceding stages, varies in degree and extent while life remains. The pulsation of the radial artery ceases ; the skin is more severely congested, cold, and clammy ; the tongue, cold and moist ; the respiration is labored and the breath cold ; the eyes are bloodshot, the countenance shrunken and ghastly, and the plumpness caused by the cellular tissue, lost. The patient experiences intense thirst, from the loss of the most fluid portion of the blood, but the stomach rejects every kind of drink while the absorption is suspended. All secretion is also at an end, and the liver, kidneys, and smaller glands are reduced in volume and at rest. He is cold, and finds discomfort and pain in the application of heat ; is rapidly sinking and uninfluenced by stimulation. This is a condition of extreme danger, and in a large majority of cases ends in death ; but in vigorous subjects, 

20 



THE CHOLERA PESTILENCE. 

whose constitutions have not been impaired by imprudent living, reaction sometimes follows, either with or without the use of remedies, and the patient recovers. 

In this stage of collapse, sinapisms are found to be a powerful remedy, and they may be extensively applied, with their usual effect upon the sentient nerves, when other remedies are inert or cannot be retained. They are, indeed, powerfully remedial in all congestive disease, exercising great influence over nervous function, and sustaining vital power when other remedies fail. For such purposes, all other external applications are comparatively worthless. But the extent of their application must be in proportion to the urgency of the case. In congestive fever and in cholera, which are much alike in this extreme condition, mustard has sometimes been applied to nearly the whole surface of the body, removing and reapplying the sinapisms, as the vital powers rise and fall, and taking care that no one part remains under their influence, at any one time, long enough to cause vesication. The painful cramps are relieved by this external treatment, the whole nervous system is impressed, the skin becomes more sensitive and ceases to sweat, the stomach and bowels are less disordered, and reaction comes gradually on, even after prostration has been extreme, often giving signs of an immediate dissolution. Although the result is not always so favorable, occasional success proves the value of the remedy. 

As in some other forms of intestinal disease, the vegetable acids are of service in cholera, especially when serous discharges are prevailing. It may be that in diarrhea, and in the early stage of cholera, while the absorbents are acting, the special influence of these acids is, to correct the deterioration of the blood. I have found the citric acid most useful and agreeable, but good cider vinegar, or white wine 

21 



THE CHOLERA PESTILENCE. 

vinegar, answers the purpose when the other cannot be obtained. 

In the prevalence of fatal epidemic diseases, it always happens that a large portion of the sick are treated, in the early and curable stage of the disease, either by themselves or by other non-professional persons, or that all treatment is neglected. Many are deterred from resorting to medical advice on account of the mild and insiclious nature of the attack, or from regard to the expense ; and a large majority who come under medical treatment, are placed in the hands of physicians at too late a period to promise much hope of success, however good the skill employed. Nothing is more important, therefore, than that certain remedies, known to be useful in the early stages of the disease, should be popularized for common and universal use. In cholera this is the more to be desired, because of the mild and tractable nature of the disease in its inception. While the epidemic influence continues to spread without the possibility of control, all other means of prevention and preservation are of small importance when compared with this, by which men and women of every degree may have it in their power to apply the proper remedies at the proper time. Whenever this subject receives the attention it deserves, then will cholera cease to be ranked with the most fatal of human diseases. 

CHLOEOFOKM INTERNALLY. 

- Much doubt has hitherto been entertained by authors, as to the propriety and safety of using chloroform as an internal remedy, except in very small doses, on account of its supposed poisonous quality ; but I have succeeded in proving, by abundant experiment, that it is not only the most efficient, but the safest of all our remedies acting specifically upon 

22 



THE CHOLEEA PESTILENCE. 

the nervous system. The effects produced are not of a sedative or anaesthetic character, as when given by inhalation, and therefore its internal use involves none of the risks incurred by that method of exhibition. Taken into the stomach in proper quantity, chloroform promptly relieves the nervous system of that morbid irritation which deranges the circulation of the blood, thus relieving the capillary vessels from the torpor and paresis which favor a sluggish movement of that fluid ; and this is done without being followed by the morbid or febrile reaction which has heretofore been considered the necessary sequel of congestion. I suppose it differs from opium and other hypnotic remedies in causing sleep, by equalizing nervous and arterial action, instead of disturbing the equilibrium of these functions, by inducing a degree of cerebral congestion and consequent lethargy. The stupor caused by hypnotic medicines generally is supposed to differ from natural sleep mainly in this — that it proceeds from accumulation of blood in the brain exceeding that of the standard of health, differing in degree from that amount of determination of blood which causes wakefulness, sometimes the effect of the same remedies. But the sleep produced by chloroform taken into the stomach is more nearly allied to that of health, cerebral and nervous function being restored, and the quantity of blood circulating in the brain reduced. In other words the disorder of nervous function is relieved, and sleep is at once the consequence and the proof of such relief. 

Let all this be as it may, certain it is, that persons becoming wakeful from anxiety, grief, or other mental emotion, are at once quieted and enabled to enjoy refreshing sleep under the operation of chloroform in suitable doses internally ; and in more positive and serious cases of cerebral disorder producing wakefulness, the effect is the same, requiring 

23 



THE CHOLERA PESTILENCE. 

only that the quantity'given be in proportion to the urgency of the disease. The following cases are mentioned in illustration : A man lying insensible and helpless in the street from sunstroke, was relieved and put into a sound and healthful sleep by a single tea-spoonful of chloroform poured into his mouth ; and when he awoke, he "was restored to health. Another, suffering in a similar manner and nearly to the same extent, from drinking ice- water while heated and exhausted by labor, was relieved and cured in the same way. A man suffering with congestion of the lungs was seized with violent hemorrhage, and, losing a large quantity of blood, became insensible and convulsed. Two tea-spoonfuls of chloroform poured into his mouth and swallowed, checked the hemorrhage immediately, and two tea-spoonfuls more being given in half an hour, he recovered ; but in this case sleep was not produced. 

Congestion of the stomach, cramp colic, epilepsy, apoplexy, asthma, hemorrhage from various parts of the body, dysentery, diarrhea, cholera morbus, and many other diseased conditions dependent upon disordered innervation causing congestion, have often been relieved by chloroform internally, and generally by its being given in sufficient quantity to produce sleep. But the most remarkable effects of the remedy, affording the best illustrations of its great power, value, and harmlessness, have been exhibited in the chill of fever, and especially in what are called congestive chills, sometimes causing violent and persistent convulsions. Children are most liable to such convulsions, and I have never known chloroform, given internally to the extent of producing sleep, to fail in giving relief in such cases. Sleep is the effect to be sought for in all extreme cases, and sleep insures safety and a return to health with- 

24 



THE CHOLERA PESTILENCE. 

out febrile reaction, and with little danger of a recurrence of the disease. 

A gentleman with a large family of children, on leaving the city during the last summer, was advised to take among his medicines a vial of chloroform, for such uses as are above indicated. In preparing for the homeward journey on his return, and when the children were all hooded for travel, a child aged two years, apparently in perfect health, was seized with a violent convulsion. ]STo physician was at hand, and all was alarm, dismay, and confusion ; but the vial of chloroform was soon thought of and resorted to. The first half-teaspoonful was mostly wasted upon the struggling patient ; but in a few minutes the quantity was repeated with somewhat better success, and even a third and fourth dose was in part administered. How much was really swallowed cannot be known, but probably not less than one half of the four half-teaspoonful s. The child was entirely relieved and fell into a sound sleep. The journey occupied the night, and upon arriving in this city in the morning, no sign of disease remained except the partial excoriation of the skin and neck by the chloroform which had spread over the surface. While the skin suffers in this way from the application of chloroform, the mucous membrane of the mouth and throat scarcely feels the effects of the stimulation, even when the remedy is given, as it was in this case, without admixture with any other fluid. Were parents generally as well advised of the value of chloroform, and as well prepared for its immediate administration to their children, there would be a great reduction in infant mortality from a class of sudden and fatal diseases, which must in a majority of cases be treated without the advice of a physician. In all cities these cases make up a large item in the mortuary reports. 

The great power of this remedy in all cases of 

2 

25 



THE CHOLERA PESTILENCE. 

disordered innervation, causing congestion in any organs of the body, as shown by the numerous experiments in my practice during a period of thirteen years, entitle it to be preferred over all other neurotic remedies in all diseases of this character ; and it remains to be proved whether it will not be as effective in cholera as in the other diseases depending upon nervous congestion referred to above. Certainly it is a remedy to be kept in every household for immediate use in fatal diseases which, from suddenness of attack, and the very common accident of coming on in the night, must generally receive their early and frequently their only treatment from nonprofessional persons. It should supersede the use of blood-letting and opium in these cases, and seems destined, indeed, to take the place of paregoric, peppermint, Godfrey's cordial, and other remedies of this kind now in such general and popular use. It will be found more'eu'ective and safer than any of them, and quite as easy of administration. But it should never be given by inhalation without the advice and assistance of a physician. Besides being less efficient in this form, its inhalation is always attended with more or less danger, especially in cases not accompanied by severe pain, as in surgical operations. 

In view of the usefulness and harmlessness of chloroform used as an internal remedy, and the rare occurrence of its excessive use by inhalation, it is to be hoped that it may soon be taken from the list of poisons, and sold by druggists without reserve. There are many medicines so sold, and in popular use, which are at once more dangerous and less useful. Restrictions have been imposed upon chloroform, under the prevailing belief that it is even more dangerous when taken into the stomach than when inhaled into the lungs; but this is now fully disproved, and there is no reason why it should 

26 



THE CHOLERA PESTILENCE. 

longer be regarded as a poison. Considering the importance, too, of placing the remedy in the hands of the poor, especially in case of the prevalence of an epidemic requiring its use, it becomes-a question of public interest, that manufacturers of the article should be entitled to a drawback of the tax imposed upon the alcohol consumed in making chloroform, that it may be afforded at cheaper rates than at the present time. Indeed, the public charities which are making themselves so useful in mitigating the evils of life, should consider the propriety of measures to enable the poor to enjoy the benefits of this great gift of God to man. 

27