ON EPIDEMIC CHOIEEA, THE PHENOMENA, CAUSES, PREVENTION AND TREATMENT, BY NELSON L. NORTH, M. D., v^ SURGION METRO POUT AN rOLICE, CONSULTING SURGEON TO WILUAMSBOROH DISPairSART, 810. REPRINT FBOH THE TRANSACTIONS OF THE MEDICAL ASSOCIATION, Of THE EASTERN DISTRICT OF BROOKLYN. WITH AN .A.^^iEinxriDizx:, BELATINO TO THK BROOKLYN CITY BIWEBiOI. BROOKLYN : DAILY TIMES STEAM PBBSSES, 12 & 14 SOUTH SEVENTH BTRSET. 1865. .A. F O Xj O O TT The following very imperfect Essay — the result of a notice in September last from the " Scientific Committee" of the Medical Association of the Eastern District op Brooklyn, that the author would be expected to open the discussion on Epidemic Cholera at the next regular meeting — was hastily penned during catch moments of leisure, which every physician of full practice knows are very uncertain, and very poorly calculated for careful or connected thought. The " Paper" — if it deserves the title — was not intended for the printer, and it goes to the Committee of Publication (by motion of the Society) in its original crude state, and hence its many imperfections. N. L. N. 73 Fourth Street, Brooklyn, October 30, 1865. ASIATIC CHOLEEA. Mr. President : I deem it peculiarly appropriate and timely that the subject for this evening — Asiatic Chobra — should be discussed now. In the far off East the grim monster Death has been marshaling his mysterious and invisible forces for a fourth terribly grand march around the world, and already has he slain his thousands upon thousands and left desolation and anguish in all his course as he has taken up his line of march through India, Turkey, and the nations around about his more immediate homestead; passing westward he is now victoriously moving across Italy, and, planting his left wing upon the soil of proud France, is preparing his right for a devastating march over, all Europe. Even now he has numerous scouts in London and Paris, and if we but cast our eyes about us we cannot mistake the premonitions of his presence here among ourselves. In fact, the devastating scourge is almost upon us. 9 " The cruel and awful civil war which has cost this nation so much of blood and treasure — which has left so many widows desolate and made so many children fatherless, has but just ended, when we see the unmistakable evidence of the near and yet nearer approach of the " Pestilence that wulketh in darkness and wasteth at noonday !" * I desire here to contradict the canard that has been going the rounds of the newspapers that there has been a case of "Genuine Cholera in Brooklyn" and that / have so "proncunced" a late cast of sickness of a police sergeaat— the story ts aimply faUe. 6 Bat do we see our people preparing to avert, so far as possible, this calamity ? Are our Authorities making preparations to meet this terrible enemy in his onward march towards us ? Are our Quarantines more watchful than usual ? Do our Boards of Health more carefully watch for the causes of disease ? Do they boldly and fearlessly turn out the pestilential " fat-houses " and other like kind of nuisances from the thickly settled neighborhoods of incorporated towns and cities ? Do our City Authorities take more pains that the streets shall be made and kept clean and properly sewered ? And do they diligently see to the enforcement of the laws in regard to the over-crowding of tenement houses ? Is there in fact anything being done to prevent the Cholera doing its worst among us ? Alas, no, no ! Our streets are filthy — our tenements over-crowded — our sewerage, what there is of it, is but a miserable apology for the thing it should be, having a stinking reservoir for filth at every street corner, which, when it becomes too bad, is dipped out and carted off through the streets because the sewer pipes are not of sufficient size to allow anything but the strained water to run off through them.* And our olfactories meet the stench from pig styes, and goat pens, and hide tanneries, and fat and slaughter houses; and even the bone boiling establishments can hardly be said to be out of town, and one can scarcely tell in fact why it is that we have not always some Epidemic upon us. lam no alarmist, Mr. President, and yet had I the ears of the people I * I understand that some of the authorities of this city and their advisers have and will take exceptions to this paragraph. They assert that Brooklyn has the most " scientific system of Sewerage of any city in the world." This reminds me of the consolation said to have been given by a very pompous Surgeon to the wife of his patient, who had just died from 4he effects of an extremely "fine" surgioal operation — the patient's life having undoubtedly been shortened thereby—" Your husband has been treated very teientifically, Madame, very scientifically, indeed." Now, then, If we have such * splendid system of sewerage, let those whose business it is to watch to preserve the health of the community, eacourage complaints and turn them in their proper channel, and use every effort to wake up those who ought to see to it, that the sewers are in proper working order, and not come out before the publia and whiningly " deprecate the excitement in regard to Cholera as tending to do more harte than Sanitary measures can do good." The public will not keep still, and you cannot make them believe in the "sciencs" of your sewerage system— harp upou it as much as you maywhile they sniff in at every street oorner the disgusting and sickeniig stench arising from the decomposing mass of animal and vegetable debris in a basin some three feet i«i widtb by six in length and sunk four feet below any possible out-let and without any sort of disinfectant, and then know that such basins or culverts are only cleaned out once in lour to six mouths and sometimes less I—See1 — See Appendix. 7 would sound this note of terror with redoubled force, that they might compel the authorities to do what the history of former Cholera Epidemics plainly teaches is both feasible and useful in at least mitigating the severity of the scourge, and in many cases of preventing it altogether. And now, begging the par iof the Society for this long introduction, I come to the immediate consideration of the nature, cans* and treatment of THE CHOLERA. SYMPTOMS. If we are called in haste to a patient, and find he has had profuse and continued vomiting of a yellowish or dark and greenish liquid, with inordinate thirst, and great prostration of strength, and perhaps also cramping of the muscles of the legs and abdomen, with, it may be, great uneasiness, getting up and laying down, and perhaps rolling about the bed or floor ; with sometimes cold feet, and covered with cold perspiration, we at once conclude we have a case of what now is termed cholera morbus, or English cholera, but what, previous to 1831-2, was called cholera. We order the patient in bed, surround him with warm bricks and bottles, apply sinapisms to the spine and epigastrium, and give from a sixth to a half a grain of sulph. morph., with from a twelfth to a quarter of a grain of piperine, triturated with sugar, dry upon the tongue every hour or two, and forbid drinks almost entirely, perhaps allowing a lump of ice occasionally, and go on our way. We call again in a few hours and find the patient much improved, or recovering rapidly. The old term cholera, as applied to this disease, had reference to the flowing off by the mouth, and per anum of the bile, and of course the term thus applied was appropriate. Again we are called in great haste, very likely between three and six o'clock in the morning ; we find a patient vomiting and purging excessively, the fluid a milk and water looking substance gushing from his mouth suddenly, and with great force, even while he is attempting to answer our questions, and immediately there is a pouring off from the bowels of a liquid of the same flaky rice-water or milk-and-water character, entirely free from bile. The patient is 8 very thirsty, looking death-like, with eyes and cheeks sunken, features shrivelled, skin pale and purplish, and bathed with a cold perspiration ; hands and feet in a little time assuming a sliri veiled, cold and contracted appearance, like those of a drowned man, and as we watch him and notice the progress of the terrible complaint, we hear him shriek and call out in a faint, unearthly, husky voice, of the "cramps," as the gastrocnemii and other muscles of the legs, thighs and abdomen are contracted and contorted, causing severe suffering to the patient; when, finally, in the course of from two to three, to occasionally twenty-four or forty-eight hours, he stretches ont before us cold, calm, and unconcerned. He looks as if dead, and desires not to be disturbed, yet will, perhaps, speak rationally, and may explain how he was taken, give us a history of his case, and even talk of his present condition, and of his future intentions, and yet, his voice is sharp, husky, and feeble ; his wrists are pulseless ; his skin — yes, and his breath are cold and damp ; his breathing slow ; the pulsations of his heart scarcely perceptible, and we slowly realize the truth that the patient is dying — a few short moments, or a few hours at most, and he is dead. We make inquiries, and find that for a day or two, or three, the patient has had diarrhoea, which, though rather free, gave very little concern, as he suffered almost no pain ; he only complained of feeling a little weak and languid. From the time of the commencement of the severe symptoms, it was thought (and they might have been certain) that he had not voided urine, and if we had felt his pulse when first called, we should have found, if there was any, that it was very feeble, and very soon there would have been none at all ; the breath through all these severe symptoms would have felt, as he hurriedly breathed upon us, cold and death like, as also to the touch of the finger, his tongue and mouth, and skin generally; the tongue we might also have found of a deep purple or leaden color ; and if we had noticed, we should have discovered that the dejections had no smell of foecal matter, but that they, with the vomited matter, gave the apartment a peculiar cadaveric or dissecting-room odor. This disease, the symptoms of which I have endeavored briefly to give an outline, is called now-a-days — though miscalled — cholera. I would not be understood as saying, however, that it is always 9 as above described ; on the contrary, the disease in question assumes many different grades ; sometimes it is a simple and easily controlled diarrhoea ; in fact, as I have stated, it usually commences with a diarrhoea, and this, it should be remembered, is the stage during which remedial means are of most value. Again, it may occur suddenly, the first discharge somewhat consistent, but very free, as if the whole contents of the abdomen were passing away; then vomiting and purging of the rice-water fluid, followed with cramping, and collapse coming on almost instantly, and proceeding with fearful rapidity to a fatal termination ; or the patient may be suddenly seized with terrible prostration, cramping and collapse, without either vomiting or purging. This is said by some to be the worst form of the disease. We may yet have patients with moderate or sometimes severe vomiting and purging, who, notwithstanding, do not go on through the remaining symptoms which are designated collapse ; and yet again a patient may have all the severe symptoms with the collapse, and yet recover. Following all the forms or grades of the disorder, there is usually what is termed consecutive fever, continuing for from a few days to a week or more, and then resulting in death, very commonly, by coma and convulsions ; or the patient may slowly regain his usual health with many times a great liability to attacks of diarrhoea and kindred disorders, and I think (though I have never proven it so, nor have I found any record of it, ) that cholera patients are very liable to be left with chronic Bright's Kidney. Generally in those cases which recover, the early favorable symptoms are the cessation of the vomiting, purging and cramps, with a return of the pulse, of the voice, and of warmth to the surface ; a disappearance of the blueness of the skin, and of the hippocratic countenance ; the reappearance of bile in the alvine evacuations, and the restoration of the secretion of urine. But a fearful proportion of the cases prove fatal. PATHOLOGY. Now let us examine the dead body. Shortly after the breathing has ceased, we notice the blue color of the skin disappear, and see convulsive vermicular movements of the 2 10 limbs, — the mnscular contractions, — and the body become* warm on the surface, Tso that we are half inclined not to believe the patient dead after all ; but when all further doubt is dispelled we examine internally, and find the alimentary canal to contain a white liquid, having whiter flakes in it, just such as has previously issued from the bowels, and the mucus glands, both the solitary and agminated, are unusually large and conspicuous. The veins are loaded with thick, black, tar-like blood, and the urinary bladder is empty and contracted to a very small size ; the venous system is greatly congested ; the mesenteric veins full, and the vense cava distended to its utmost capacity. The heart we find full, and the blood grumous and half coagulated ; the brain and lungs are slightly congested ; the liver has no very marked abnormal appearance, except that it is slightly paler than usual, but notwithstanding there has not been before death, and is not now any bile in the alimentary canal, yet the gall bladder is full of bile — healthy bile. The contents of the bowels, the rice-water fluid, we find of an alkaline reaction, although Dr. Elliotson, in his work on Practice of Medicine, says :—": — " I examined that point, in several cases where no alkali had been taken, and so far from the observation being correct, I found them exceedingly acid.' 1 The kidneys we find much like the kidneys of a patient who has died of scarlet fever. The cortical substance is pale and turgid, and the tubuli uriniferi gorged with imperfectly developed epithelium, which are mostly loaded to an unusually extent with the oleo albuminous granules. Dr. W. T. Gardner, of the Royal Infirmary, London, says :—: — " Congestion is not at all an essential or universal appearance." He also says of the chemical constitution and microscopical appearances of the evacuations :—": — " These discharges separate by filtration, or on standing, into a colorless or slightly colored fluid,, of an alkaline reaction, and a flaky sediment. The former is usually of a specific gnfvity, from 1,005 to 1,010, and contains, therefore, a small proportion of solid matters ; these have been shown by Dr. Parkes to consist chiefly of salts. Repeated examinations of this fluid have shown ( Andral also exemplified the same 11 ¦thing) that albamen, as tested by heat and nitric acid, is not necessarily present in it. Indeed, the presence of albumen usually coincides with that of a small quantity of blood, which is frequently present. The fluid, however, constantly contains a small quantity of an organic substance which is precipitated by alcohol, by corrosive sublimate, and (when acidulated) by ferrocyanate of potash, and which presents, in other respects, the chemical reactions of mucous. The flakes which form the sediments of cholera stools, have likewise the ordinary chemical reactions and physical properties of mucous. They are, however, opaque and turbid, and when submitted to the microscope, show a hyaline finely-striated basis, involving numerous granules, nuclei, and cells. The granules and minuter molecules require no particular description. The nuclei are from 1-250 to 1-180 of a line in diameter, circular or slightly oval, and not affected by acetic acid The cells are comparatively few in number, mostly globular, seldom exceeding 1-150 of a line in diameter. Some of t\ em are but little affected by acetic acid, and single-neucleated ; others present all the appearances of pus cells, being two, three, or even four nucleated, and having the cell-wall rendered very transparent by acetic acid. The most common appearances, however, were the nuclei without cells above mentioned." Dr. F. Brittain and Dr. J. G. Swaine, of Bristol, England, claim to have seen in rice-water discharges, certain bodies which they regarded as peculiar and characteristic, but I propose to refer to this again when speaking of the causes of cholera. HISTORY. This dreadful disorder, the phenomena and pathology of which I have so imperfectly portrayed, is endemic in Southern Asia. In the year 181 T it broke out with fearful violence in the Delta of the Ganges, and Dr. Watson says, from its irruption in that year, it committed frightful devastation in the British f Armies in the northeastern districts of India. " From India," says Professor Watson, "it spread to Persia ; from thence to Russia, and across through Poland to Germany ; and at length it was found at Hamburgh ;" and so it passed on slow and halting in its course, to be sure, like the modes of travel at that time, yet with steady progress 12 / in a northwesterly direction until it reached Sunderland in England in the Fall of 1831. Its arrival there had been foreseen and foretold, and physicians had been sent to meet it and investigate its cause, course and treatment. It gradually spread over the British Isles, and was the most fearful and fatal in London during the months of August and September, 1832. It did not, however, stay its onward march while resting in the Metropolis of the Old World, but, Watson says : " crossing the Atlantic, it invaded America, turning at the same time in a southeasterly direction, it ravished France and Spain, and the north coast of Africa and Italy." As in London, so in New York, Philadelphia, and throughout the United States and Canadas, the first epidemic was most fearful in its ravages during the Summer and Autumn of 1832. Twice since then, in 1848-49 and in 1853-54, has it visited Europe and America, having taken less time in its journey from Southern A sin, just as human progress over the route has been more expeditious ; but the " general course and character of the three epidemics have manifested a strong mutual resemblance. Each had a period of invasion, then a pause, and then again a subsequent fiercer outbreak, determined, apparently, by atmospheric conditions."— (Watson.) Bach were noticed to be unequally severe in different parts of the country or countries, and the parts which suffered the most, and those which were the least affected were the same, or nearly the same in all three epidemics And again, as I said in the opening, it is, as heretofore, moving onward in " defiance of all natural or artificial barriers," continuing " under opposite extremes of season, temperature and climate, in the teeth of adverse winds, over lofty mountain chains, across wide seas, through hot, cold, moist and dry."* * " The attack of 1817, in India, was terribly fatal in its character. It broke out north of Calcutta, and in a month the city itself was attacked, and for a year was under its influence. Traveling southward, Madras, Ceylon and Malacca were successfully visited - r and in 1819, the Burmese Empire and the country eastward were reached. Bombay was next (1820) the chief seat of the disease, and no less than 150,000 persons fell victims. In this year, Borneo, China and the Philippine Islands became affected, and in 1821 Persia, Arabia and Asia Minor. After a brief lull it reappeared in Central Asia, with disastrous results. Europe began to suffer in 1829, first in Southern Russia and next in Moscow. In 1831, Central Europe was overspread, and Sunderland, England, began to be infectod in October of the same year. The next year, in January, Edinburgh, and in February, London, were overspread — the number of deaths being, however, comparatively small. One mouth later, Paris and the whole of France were visited. 13 CAUSES. And now comes the question as to its cause, and here is the mystery, and here the opportunity for theory. Like every other disease, the definite cause of which is not known, innumerable theories have been put forth ; contagion, miasm, electrical derangements, subtle atmospheric cells, absence of ozone, meteoric phenomena, scurvy, " visitation from God," &c, &c, &c. Each gentleman who promulgates a theory, proves it to the complete and thorough satisfaction of — himself. ; There are many strong names who are on the side of the theory of contagion. Braithwaite says :—": — " The theory which ascribes the production of cholera to a specific morbid poison, which is re-produced in the body of each person affected with the disease, involving as it does, the difficult and important questions of contagion and quarantine, has given rise to much discussion. Facts in great abundance are brought forward by both contagionists and non-contagionists, in support of their respective opinions. And both classes of facts force themselves, more or less, upon the notice of those who have no particular theory to support." Dr. James Copeland, F. R. S., says, in closing some remarks in 1849 :—": — " I must only add, that whatever twaddle may appear on the subject of ' non-contagion/ of ' non-infection,' of ' contingent contagion,' of ' contingent infection,' pestilential cholera will some day be acknowledged to be what I have long ago, and again more " The cholera paid this Gontinent its first visit on June 8, 1832, at Quebec, six months after its appearance at Sunderland. Thirteen days afterward this city began to suffer, losing, during the whole visitation, 3.513 lives, and the disease traveled in various directions, attacking Boston, Philadelphia, Washington, and many other towns — iv October spreading from Cincinnati to New Orleans. " We give the course traced by tho ravages of the cholera as showing its steady advance and apparent inevitability. The subsequent occasions upon which that course has taken, are, in the main, similar in Europe, and it will be remembered that cholera was distinctly present in India last year. The virulence of the attacks has varied considerably, both as to number and locality. Although there were relapses in Europe in 1835 and 1837 , the mortality on this side the Atlantic was hardly of an epidemic nature. The visitation of 1849 cost this city 5,071 lives, and that of 1854. 2,509 lives. In 1834, 971 persona died, and in 1852, 374. There may be added to time figures 137 deaths scattered over other periods. The total number of victims to cholera iv New York siace 1832, has been 12,575."— N. Y. Times, Nov. 4, 1865. 14 recently, endeavored to show it to be, according to the most irrefragable evidence, a disease sui generis, which is propagated by a specific infectious emanation proceeding from the sick, as observed in respect of true typhus and scarlet fevers, whenever and wherever the predisposing and concurring causes are in operation." Watson, in the edition of his work on Practice, issued since the three cholera epidemics, says :—": — " Many converts have been made to the doctrine which I. have held from the beginning, that Epidemic Cholera is catching ; that it results from a material poison which is portable, capable of being conveyed from place to place, and communicated from person to person, or from inanimate substances to which it clings, such as articles of furniture or clothing. That the morbific matter floats also in the air, and may be wafted about by its currents, is a general and well founded belief. " I think," he says, " with Dr. Baly, that when it travels over great distances, as from one country or region to another, it ases the vehicle of human intercourse ; but that it may be, and often is, diffused over smaller spaces, as from one part of a town to another, or from a tainted port to a ship anchored to leeward, by the movements of the atmosphere. The long migrations of the disease are not made rapidly. Its rate of progress never exceeds, and is often slower than that of modern traveling. Its primary appearance in an island or kingdom is always on its outward boundary. In our country," he says, " for example, it first planted its foot in a seaport town on the east coast, over against the main land where cholera was raging, and whence ships had very recently arrived. The same is true of two subsequent visitations' On the other hand, the crews of vessels sailing from healthy places remain free from the disease until they have entered an infected port, or held intercourse with an infected shore." Dr. Snow has advanced a theory that the cholera poison is swallowed with the food we eat or the water we drink. And, says Dr. Watson again :—": — " The horribly disgusting fact has been made too certain by the unchangeable disclosures of the microscope, that the water which is supplied by the several water companies for domestic purposes to the great City of London does habitually contain visible particles of human ordure." Dr. Snow reasons that, 15 from the fact that the general symptoms of cholera appear in the alimentary canal, therefore it is proper to suppose that the effects which follow are only the results of what has occurred here. He says :—": — " The exudation of the watery part of the blood into the stomach and bowels, causes the faintness and sinking, and the remaining symptoms to collapse. How far," he says, " the cramps depend on irritation of the nerves of the alimentary canal, and how far on the want of fluidity and proper circulation of the blood, is not very evident ; but it is quite certain that they do not depend on any cholera poisoa circulating in the blood, for the cramps and all the symptoms of collapse disappear for a time on the injection of a weak saline solution into the veins, which merely replaces what has been lost by the bowels. It is evident from this circumstance that the blood is not poisoned by cholera, except in cases of secondary illness, when it becomes charged with urea and other excretory matters, owing to congestion of the kidneys. The primary and essential morbid actions of cholera being confined to the alimentary canal, it follows that the materies morbi of cholera must find a jcess to it by being swallowed, that it must increase and multiply there, and be discharged to be a source of danger to others. It has been observed," he says, " in all parts of the world that nothing assists the spread of cholera more than want of personal cleanliness, When we consider how free the evacuations from the stomachs and bowels of cholera patients often are, both from color and odor ; how suddenly and copiously, and with what force they are generally discharged, it is evident that the hands, both of the patient and his attendants, are liable to be soiled with them. Unless great care is taken to wash the hands frequently, and mo,fe especially before taking food, or handling and preparing the foodf ood of others, small quantities of the evacuations must necessarily be swallowed. The influence of dirty habits in aiding the sp ea^ of cholera is thus clearly accounted for. It is analogous to -^hat occurs among house painters in regard to lead poisoning. Those of cleanly habits escape ; while others constantly swallow a fittle paint with their food, and become affected with colic. T' fle scarcity of water, of course, is an obstacle to cleanliness, even -^en the inclination prevails ; and this has frequently been oV- /g(i jy e (i to be connected 16 nected with the unusual extension of cholera in a town.or neighbor* hood. The reason why medical men, and other persons of cleanly habits, who do not stay to eat and drink in a sick room, are scarcely rendered more liable to cholera by their avocations, while it often fares differently with the social visitor, is perfectly explained by the above views. It is evident, also, why the medical man can make inspections of the dead bodies of cholera patients with impunity ; while they who wash and lay out the bodies often suffer. The medical man is certain to wash his hands after the operation, while the persons who perform the other offices mentioned, especially among the poor, are almost as certain to neglect that duty. It is obvious that, where a whole family live, night and day, in one small room, in which the cooking is done and the meals are eaten, that the food is very liable to become contaminated, in the event of a case of cholera occurring ; and where several families live in one room, the risk amounts almost to a certainty. Dr. Snow presents some striking facts as proofs of his theory. It seems quite certain that a most fearful outbreak of cholera in Soho was fairly attributable to the water of a certain pump being contaminated from a neighboring sewer. As before intimated, Drs. Britton and Swayne, of Bristol, England, profess to have discovered certain peculiar bodies in the dejections and vomited matters of Cholera patients ; they are called by them " Annular bodies," or " Cholera cells," which they think they have seen with the microscope both in these discharges and in the atmosphere during the prevalence of a Cholera Epidemic; they believe them to be of a fungoid nature, and the cause of Cholera. Dr. Swayne published a very interesting account of these experiments and researches in the London Journal for November, 1849. But other observers, after careful investigations,' have not been able to arrive at the same conclusions. Some deny the presence of the " Cholera cells" altogether, and again others think they may be found, but are not always present; and reason that they must be therefore more an effect than a cause. A Mr. R. Hunt claims to have discovered that during a Cholera Epidemic in London there was less ozone in the atmosphere than usual, and therefore very naturally claims that the absence of ozone 17 is the cause of Cholera. Dr. T. K. Mitchell, of Philadelphia, claims and attempts to prove that the disease has a fungous origin, and says certain points in the history of Cholera cannot be explained, " but if we assume for Cholera a fungous origin, all difficulties vanish." Again, another theory is that the Cholera poison is an animal poison; for instance, the rice water discharges, by the same rule that cadaveric poisons are evolved during a certain stage of decomposition, become poisonous and capable of exciting the same disease as that of which they were the product. And yet again, it is claimed by M. Andraud, of Paris, that the cause of Cholera is the absence of electricity in the atmosphere. During the months of Aprii and May, 1849, he found it difficult to obtain a spark from his large electrical machine which usually gave large sparks at two or three turns of the wheel, he considered it an important fact but was not convinced, thinking it might possibly depend upon the weather and to the moisture of the air. " Thus I waited," he says, " with impatience the arrival of fine weather and heat, to continue my observations with certainty. At last fine weather, and to my astonishment, the machine, frequently consulted, far. from showing, as it ought -to have done, an augmentation of electricity, has given signs less and les* sensible, to such a degree, that during the days of the 4th, sth and Gth of June, it was impossible to obtain anything but slight cracklings, without sparks. On the 7th the machine remained quite dumb. This new decrease of the electric fluid has perfectly accorded, as is only too well known, with the renewed violence of the Cholera ; for my part I was not more alarmed than astonished — my conviction was complete. I saw only the consequence of the fact .already supposed. It may be imagined with what anxiety, in these moments of crisis I consulted the machine, the sad and faithful interpreter of a great calamity. At last, on the morning of the Bth, some feeble sparks re-appeared, and from hour to hour intensity increased. I felt with joy that the vivifying fluid was returning in the atmosphere. Towards evening a storm announced at Paris that electricity had re-entered its domain ; to my eyes it was the Cholera which disappeared with the cause which produced it. The next day, the 9th. I continued my observations ; the machine, at tbe least touch rendered with facility 3 16 with the unusual extension of cholera in a town. or neighbor* hood. The reason why medical men, and other persons of cleanly habits, who do not stay to eat and drink in a sick room, are scarcely rendered more liable to cholera by their avocations, while it often fares differently with the social visitor, is perfectly explained by the above views. It is evident, also, why the medical man can make inspections of the dead bodies of cholera patients with impunity ; while they who wash and lay oat the bodies often suffer. The medical man is certain to wash his hands after the operation, while the persons who perform the other offices mentioned, especially among the poor, are almost as certain to neglect that duty. It is obvious that, where a whole family live, night and day, in one small room, in which the cooking is done and the meals are eaten, that tke food is very liable to become contaminated, in the event of a case of cholera occurring ; and where several families live in one room, the risk amounts almost to a certainty. Dr. Snow presents some striking facts as proofs of his theory. It seems quite certain that a most fearful outbreak of cholera in Soho was fairly attributable to the water of a certain pump being contaminated from a neighboring sewer. As before intimated, Drs. Britton and Swatne, of Bristol, England, profess to have discovered certain peculiar bodies in the dejections and vomited matters of Cholera patients ; they are called by them " Annular bodies," or " Cholera cells," which they think they have seen with the microscope both in these discharges and in the atmosphere during the prevalence of a Cholera Epidemic; they believe them to be of a fungoid nature, and the cause of Cholera. Dr. Swayne published a very interesting account of these experiments and researches in the London Journal for November, 1849. But other observers, after careful investigations,' have not been able to arrive at the same conclusions. Some deny the presence of the " Cholera cells" altogether, and again others think they may be found, but are not always present; and reason that they must be therefore more an effect than a cause. A Mr. R. Hunt claims to have discovered that during a Cholera Epidemic in London there was less ozone in the atmosphere than usual, and therefore very naturally claims that the absence of ozone 17 Is the cause of Cholera. Dr. T. K. Mitchell, of Philadelphia, claims and attempts to prove that the disease has a fungous origin, and says certain points in the history of Cholera cannot be explained, " but if we assume for Cholera a fungous origin, all difficulties vanish." Again, another theory is that the Cholera poison is an animal poison; for instance, the rice water discharges, by the same rule that cadaveric poisons are evolved during a certain stage of decomposition, become poisonous and capable of exciting the same disease as that of which they were the product. And yet again, it is claimed by M. Andraud, of Paris, that the cause of Cholera is the absence of electricity in the atmosphere. During the months of April and May, 1849, he found it difficult to obtain a spark from his large electrical machine which usually gave large sparks at two or three turns of the wheel, he considered it an important fact but was not convinced, thinking it might possibly depend upon the weather and to the moisture of the air. " Thus I waited," he says, " with impatience the arrival of fine weather and heat, to continue my observations with certainty. At last fine weather, and to my astonishment, the machine, frequently consulted, far. from showing, as it ought -to have done, an augmentation of electricity, has given signs less and less sensible, to such a degree, that during the days of the 4th, sth and 6th of June, it was impossible to obtain anything but slight cracklings, without sparks. On the 7th the machine remained quite dumb. This new decrease of the electric fluid has perfectly accorded, as is only too well known, with the renewed violence of the Cholera ; for my part I was not more alarmed than astonished — my conviction was complete. I saw only the consequence of the fact .already supposed. It may be imagined with what anxiety, in these moments of crisis I consulted the machine, the sad and faithful interpreter of a great calamity. At last, on the morning of the t ίth, some feeble sparks re- appeared, and from hour to hour intensity increased. I felt with joy that the vivifying fluid was returning in the atmosphere. Towards evening a storm announced at Paris that electricity had re-entered its domain ; to my eyes it was the Cholera which disappeared with the cause which produced it. The next day, the 9th. I continued my observations. ; the machine, at tbe least touch rendered with facility 3 18 some lively sparks." It was stated that the six days following the Bth of Jane, the mortality in Paris fell gradually from 661 to 355. Another very curious circumstance in this connection is stated by Dr. Kidd, of Limerick. While the epidemic was raging in that city, a large magnet, capable of sustaining seventy pounds, was watched daily. No variation took place in it. But on the appearance of the disease in Dublin — 100 miles east of Limerick — the Cholera being quite gone from the laoter place, the magnet — quite suddenly — lost nearly all its power. Dr. Waldo Burnett, of Boston, Mass., has found vibriones in great abundance, not only in Cholera stools, but in the substance of the muscles. • Scientifically considered, the question of contagion or non- contagion, appears at present hardly susceptible of a rigorous solution. WHO WILL SUFFER. The people as a class who are most liable to suffer from a Cholera Epidemic are the poor, the inhabitants of tenement or crowded houses; those who are poorly fed; those of uncleanly habits; those who tipple or are drunken; those who live in filthy streets or alleys, and those who inhabit lower parts of towns or cities. Altitude is of paramount importance — "This law of altitude," says Watson, "so important and so practically valuable — is but an expression of the result of many concurrent circumstances. The material poison of Cholera will be likely to gravitate, as the marsh poison gravitates, with which it has many points of analogy, to the lowest part of the atmosphere; where the barometrical pressure is the greatest, and vaporous diffusions therefore the least; where unwholesome exhalations from the soil and from the water are the most abundant; where the dispersing and diluting influence of winds is least felt." It is &lso supposed that people of feeble constitutions, especially those inclined to bowel difficulties are particularly liable to attacks of Cholera. This, however, has been contradicted by Dr W. T. Gairdner, of London. PREVENTION. It must not be supposed that the rich, or more prosperous, or better situated of a community are exempt from attacks of thia malady; although pestilence, like war, falls heaviest upon the t» 19 poor, yet when the foul miasm, multiplying itself as it does while feeding upon the unfortunate, accumulates in a town, the whole atmosphere thereof necessarily becomes impregnated with the poison, and when the death damp gathers around the mansion of the opulent, no amount of money can then purchase a " substitute" to meet the unrelenting foe; and hence, it becomes important, and a matter of personal interest to us all, that we study to prevent the disease ; and here we cannnot do better than quote the rules of Dr. Snow, who says :—": — " The measures which can be taken beforehand to provide against a visitation of cholera are : " To effect good and sufficient drainage. " To provide the inhabitants with an ample supply of water, which is quite free from contamination with the contents of sewers, cesspools and house-drains, or the refuse of people who navigate the rivers. " To provide model lodging-houses for the vagrant class, and sufficient house-room for the poor generally. " To inculcate habits of personal and domestic cleanliness among the .people everywhere." Dr. Snow says, during the epidemic in 1849 : — "At a row of houses in Wandsworth, twenty persons of the middle class of life were successively cut off by cholera in a few days. As, by the bursting of some drains, owing to the heavy rains a few days before, the water used by the inhabitants had become contaminated by admixture with the cesspool water." Dr. Lloyd described two localities which, in 1849, came under his observation, the first being in Silver Street, Rotherhithe :—": — " The privies entered into a drain which had once had communication with the Thames ; but that had been cut off. All the privies then ran into the cesspool. There were eighty cases and thirty- eight deaths in the course of a fortnight. The water of the well from which the inhabitants derived their supplies, smelt of hydro-sulpburet of ammonia. No sooner had the communication of the sewer with the Thames been opened, the sewer cleaned out, and the people prevented from drinking the water of the well, which was filled up, than the cholera ceased." Facts like these might be multiplied almost without number. 20 * One great need in this city, especially in the poorer parts, is the connection of the privies with the sewers, and a much greater care and frequency in the cleaning of the miserable nuisances* at our street corners, heretofore casually referred to. In regard to quarantine, although with the mode of enforcing the quarantine laws usually resorted to, it seems almost ineffectual ; yet, if it were possible to prevent infected ships or persons from coming from the Eastern continent from the regions of the cholera, I do not believe the poison would ever reach us ; and hence I think the facts in the history of the epidemic warrant a careful observance of the quarantine laws, with a certainty that such enforcement is greatly effectual for good. The New York Times 1 correspondent, " Malakoff'," who, I understand, is an intelligent American physician, practicing in Paris, in a letter dated October ' 3, of this year, (1865,) says : " The cholera has appeared at Paris in an endemic form, aDd not by contact with the points where it is raging in the south of Erance. • The disease has appeared principally at Montmartre, La Chapelle, and the region around the Northern Railway Station. The hospital Lariboisiere, situated near this station, has contained from twenty to thirty cases daily for the last five or six days, most of which have been fatal, but the facts are not published otherwise than at the medical societies and in the medical journals. If the- weather continues as at present — for, with the exception of a few rainy days in August, we have had uninterrupted sunshine and heat for six months — the disease may spread ; but as it is almost impossible that the heat of Summer should continue many days longer, and as the endemic or sporadic cholera is a disease particularly of the Summer season, we may expect that the first cold days will extinguish it. So that, if the cold days only arrive soon, we will undoubtedly escape entirely this year, and perhaps altogether, the epidemic disease which is raging at Marseilles and Toulon with such intensity." Writing again, under date of October 6, (1865) "Malakoff" says : " It appears now, from further investigation, that the few cases of cholera we are having at Paris may be linked to a woman who came from Marseilles, and who died almost immediately after arriving at Paris. This woman served as a germ of infection in the neighborhood in which she died, and from this neighborhood; which is inhabited exclusively by the poorer * * In their present coadition , 21 classes, all the cases come which have so far entered the hospitals. Nearly all of the cases have been treated at the Hospital Lariboisiere, in the neighborhood in which the disease was developed, but a few cases were carried to the Hotel Dieu and to La Pitie. I have seen the cases at the Hospital Lariboisiere, and they do not appear to be of a malignant type. Not more than half of them prove fatal, and for the kind of cases which generally find their way into hospitals, this fact demonstrates the non-malignancy thus far of the disease. Moreover, but one case, as late as two days ago, had been communicated in the hospitals to patients ill with other diseases. Mo reports of the progress of the disease have yet been published, and nothing but vague references to the subject have been permitted by the authorities, but M. Husson, Director-General of the Hospitals of Paris, estimated the entire number of cases in the city and suburbs day before yesterday at seventy . This figure is but a bagatelle on a population of two millions ; and as the temperature has descended very materially the last two days, there is a reasonable hope that the disease is not going to become general." The measures for prevention during an epidemic are numerous, but may be epitomized as follows : The most careful observance of personal cleanliness, not only of the physician, but of the attendants, and so far as may be of the patients themselves. The attendants should never eat without the most careful washing of the hands, washing of the food before cooking, and the utmost care as to where the drinking water is procured ; and if there is any doubt about the purity of the water, always boil it before using it. The bed-clothing of the patients should be very often washed, and everything about the apartments kept scrupulously clean, and a free and frequent use of disinfectants should be advised. When the cholera appears among people living in crowded apartments, the patient should at once be removed ta cholera hospitals or cholera wards of established hospitals ; and well persons, who are not needed to take care of the sick, should never be allowed to remain in the same room, if possible to avoid it. TREATMENT. As to the treatment : — The first, and I might say the most important step in this direction, is to advise the people that they must not neglect, during an epidemic, even ordinary attacks of diarrhoea, which may generally be easily controlled by moderate doses of opium and camphor, and by many other forms of astringents. 22 A very convenient and effectual prescription, of which I think much, is as follows : R Spts. Lavend. comp., Tr. Opii, Tr. Cam ph., aa §j. Sig. Take from 10 drops to a teaspoonfull, (according to age of patient and severity of symptoms) in water, every hour or two. I am inclined here to quote again from "Malakoff" what is now being done in Paris. He says : ' ' Every necessary step has been taken in the way of precautionary measures, and if the disease should become general in Europe, there is no city where life will be so safe as Paris. An extensive system for treating the premonitory symptoms is to be adopted, and by such a system experience has shown that the epidemic may be cut short at any season and at any period of its duration. These precautionary measures, or at least the principal of them, consist in placing within the reach, or, in fact, forcing upon, the occupants of every house, a remedy for every case of diarrhoea as fast as it declares itself. In 1848 and 1854, the disease was thus extinguished in certain towns in England, with but a few deaths ; and yet in these towns there were an immense number of cases of diarrhoea, or commencements of cholera. The utility of thi» preventive mode of meeting an epidemic is at this moment so apparent that there is, in fact, no excuse for permitting the spread of the epidemic in any city so militarily governed as is Paris. But if the means for carrying out this system be not organized before the arrival of the epidemic, the disease can never be caught up with, for all the men and all the medicaments appropriated for the preventive measures will be required for the mortally sick. They will be obliged to follow the disease instead of preceding it. There is nothing better demonstrated at this moment than first, that the large majority of all cases of epidemic cholera is announced by the premonitory symptom of diarrhoea ; second, that this diarrhoea is easily cured, and third, that the very violent and malignant attacks which sometimes come on without premonitory symptoms are never cured. Bnt of these malignant and incurable attacks there would be but few or none if the epidemic were met in the start and modified in its intensity by preventive measures properly organized and vigorously applied. " So that hereafter, in order to finish wtth this terrible epidemic, it ought to be the rule of municipalities, besides adopting the ordinary measures for the cleansing of houses, streets and persons, and tha purification of the air, to distribute to each house, for a small sum of money, which all would gladly pay, a sufficient quantity of some well-known and well tried diarrhoea remedy, with ample directions for its use— a remedy and directions prepared by a council of physicians of high authority in their profession. 23 With such a remedy in the hands of every family, sanctioned and recommended by the highest scientific authorities, it would be strange indeed if nearly every case of cholera were not arrested while in its stage of incubation, and thus would be extinguished in a very short time this most terrible of epidemics. ' ' For the treatment of developed Cholera, I might give examples of the trial of nearly every article in the materia medica. The opium and stimulant treatment has probably been used, and no doubt abused, more than any other one plan. This treatment has been to give enormous doses of opium and pour down the brandy almost without limit, apply sinapisms, and rub the patient's limbs, and generally disturb him all we can until death ends the scene. If the patient does rally through, or in spite of, this treatment, there can be no doubt, I think, that much harm has been done by continuing the use of the opium after reaction had taken place ; and yet, opium, in connection with other remedies, there can be no doubt, is a valuable agent in the treatment of this disease, previous to the relapse. The treatment by calomel has many adherents. Dr. J. Ayer, of Hull, England, who had large experience in the care of cholera patients in the epidemics of 1832 — 1849 and 1853, came to rely exclusively upon this drug. He says, in 1849, " The mortality from the disease in this town has been very great under the stimalaat and opium treatment." He advises the commencement of the use of calomel early in the disease, and says often its failure is from the loss of time elapsed since the attack/ and, what is worse, he says, than the loss of time, is to find a patient upon whom " the opiate and stimulant treatment has been already tried, which, failing to restore the secretions, increases the congestion (of the brain and lungs) and puts in abeyance those vital sensibilities and sympathies which are needed to render the calomel treatment efficient. With respect," he says, "to the treatment pursued by us with calomel, I may here repeat that when a patient is entering the stage of collapse, as shown by the blue color, vomiting and purging, and weight at the prsecordia, and cramps, we begin our treatment by giving a mixed pill, containing two grains of calomel, every ten minutes, with one, or at most two drops of laudanum in a tea or table spoonfull of water ; we continue the calomel 24 at the same intervals for .five, six, or more hours, watching the coarse of the symptoms, and taking care to reduce the dose and widen the intervals of exhibiting the calomel as the coldness and lividness subside ; and when the surface has become of a natural temperature, and the pulse natural, it may be wholly discontinued." He sets no speoified time for giving the calomel ; his guide is the return of the natural symptoms ; he has no Tear of the constitutional symptoms from the drug, as he says, " Pending the duration of tke stage of collapse there is no absorption of the calomel into the system, and no benefit is to be obtained by aiming at such an effect ; and although no evil or inconvenience has been sustained by a slight tenderness of the gums, which is sometimes produced, yet it is not to be desired as a remedial means in the disease." Dr. Ayer insists that, with the calomel, he has better success than has ever been had with any other treatment. Dr. F. W. Richardson, of Woolwich, England, treats cholera with enormously large doses of calomel ; his object is, he says, " the elimination from the blood of the morbid materials which are interfering with its normal condition. We must therefore trust to calomel in large doses, uncombined with any other drug, to restore the secretions and cure the patient.'' In collapse he would " give an emetic composed of fifteen grains of sulphate of zinc, and fifteen grains of ipecac, and repeat it in ten minutes. In about twenty minutes place twenty or thirty grains of calomel on the tongue, and repeat from two to ten grains, or more, every ten, twenty, or thirty minutes, according to the severity of the symptoms. Support the vital powers by beef tea injections, administered every half hour or hour. Allay the thirst and vomiting by ice, or a teaspoonful of very cold water given ad libitum ; cautiously avoid all stimulants, for they have been shown to create positive mischief, and most alarming symptoms during the reaction. When the dejections again contain bile, continue small doses of calomel for a short time, and then give twenty grains of rhubarb, thirty grains of sulph. potassa in some peppermint- water, or a castor oil draught ; afterwards prescribe liq. ammon. acetatis every four hours, or some carb. soda and tartaric acid in a state of ellervesence." The calomel treatment, 25 -according to reports of those who have used it, whether in large or small doses, has produced better results than almost any other treatment, and it is said the patients are not apt to have the consecutive fever, and that they are generally well in from three to five days. The saline treatment of Dr. Stevens is said to have been used with great success, both in Norway and Sweden, as well as ia London. Braithwaite stated in 1850 that there was evidence that of 1,000 cases of cholera treated by Dr. Stevens' method in London, not more than six per cent, proved fatal. Dr. Stevens says : — " Acting under the belief that the premonitory bowel complaint is an effort of nature to expel th.c poison from the blood and body, on the first appearance of the premonitory symptoms, a seidlitz powder is to be administered ; but if the patient experiences a sinking without diarrhoea, more active saline purgatives must be employed. ¦" The aperient I have actually nsed is from one to three drachms of sulphate of magnesia, added to the seidlitz, and the whole taken in a state of effervesence ; when this commences to act on the bowels, the patient is to be encouraged to drink freely of thin beef tea, well seasoned with common salt. " If vomiting is present, a sinapism is to be applied to the epi* gastrium ; if the thirst is intense, seltzer, soda, or plain water is to be allowed ad libitum. 11 In the second stage or developed cholera the following powder : "R Sodaa sesquicarb, 9j. Sodii chlorid. 3j- Potassa chloratis grs. vij. Misce. '" Dissolve in half a tumbler of water, and administer, in severe cases, every half hour ; some malignant cases, every fifteen minutes ; while in those cases which are not very severe, it is to be given every hoar. The frequency with which the dose is to be repeated in each particular case varies according to its circumstances. la every instance the saline must be continued until the circulation is fairly restored ; when once that point is gained, the intervals be- 4 26 tween the doses may be lengthened ; when reaction is completely established, it is to be left off by degrees. " In extreme cases the dose of the chloride of sodium is to be increased to two drachms, and in some cases to even more than this.. "In those cases where the stomach is very irritable, a dilute solution of chloride of sodium is to be thrown up into the intestines ; the temperature of this saline enema being as high as the patient can easily bear, which, as a general rule, is about 100 degrees Fahrenheit. When properly used, this is a means of great value. "When the stomach is very irritable, the use of the saline powder may be occasionally suspended, and common effervescing mixtures, or small doses of common soda powders, with an excess of the carbonates used until the vomiting abates, and then the carbonate of soda, with larger doses of the chlorate of potash, may be given without the chloride of sodium, or the chlorate of potash may be given by itself, in doses of ten grains each. A large mustard poultice is to be applied in such cases to the epigastric region the moment the patient comes under treatment. When the saline powders are used at the time the stomach is very irritable, it is deemed advisable to dissolve them in a very small quantity of water. "When cramps supervene, the extremities must be rubbed with hot flannel. The pain produced by the spasms in the muscles is not only relieved by frictions, but by this, and by the application of sinapisms to various parts of the body, the temperature is increased, an object of no trifling importance in the treatment of cholera. In this stage of the disease, as in the premonitory symptoms, seltzer, or cold water, may be allowed the patients ad libitum. A strong infusion of green tea may also occasionally be used in severe cases with advantage. " The patients must, invariably, be placed in a room, in which a large fire is kept day and night. ' ' The ejections, and all other impurities, must be removed immediately from the patient's room. No solid food must be allowed 27 the patients for, at least, five days after their recovery from a state of collapse. "In extremely malignant cases, or when the patient has not been seen till late in the disease, and especially when neither vomiting nor purging are present, the stage of collapse being well marked, more active measures must be adopted. An ounce of the chloride of sodium, with half a drachm of the chlorate of potash, or chloride of potassium, is immediately to be given in cold water, and repeated, if necessary, every half hour, until the patient has taken about three doses of this strong solution. If reaction ensues, it is to be kept up by the common saline powders ; and if the strong saline given by the mouth fails, as a last resource, & saline fluid must be injected either into the intestines or into the veins." Dr. Stevens would not allow any opium, galvanic shocks, or anything of the kind to be used, and exhorts to depend entirely upon the saline treatment. I did anticipate giving an outline of the treatment of many other gentlemen, but I fear of wearying your patience. A Mr. G. H. Heath strongly recommends inhalation of chloroform to keep the stomach quiet until some powerful anti-emetic may be absorbed, and seems to have had success. Dr. G. 0. Rees would inject into the veins a substance as nearly as he can like what the blood has lost, and recommends chloride of sodium, three ounces ; phosphate of soda, one ounce ; carbonate of soda, one ounce and a half ; sulphate of soda, half an ounce. This powder should be dissolved in water until the fluid has si specific gravity of 1030, and heated to 98 degrees Fahrenheit. It is then ready for injection into the blood. Mr. T. M. Gbeenhow recommends the brandy blister which was used in India — a rag dipped in brandy and laid on the abdomen, and set on fire, to produce reaction by external stimulation. The actual cautury has also been used for the same reason and with success. And again, the cold water bath has been used by Mr. Mc- Pherson, in India, to produce a reaction. The patient ia placed in a hip bath and water poured over him, while 26 tween the doses may be lengthened ; when reaction is completely established, it is to be left off by degrees. " In extreme cases the dose of the chloride of sodium is to be increased to two drachms, and in some cases to even more than this. "In those cases where the stomach is very irritable, a dilute solution of chloride of sodium is to be thrown up into the intestines ; the temperature of this saline enema being as high as the patient can easily bear, which, as a general rule, is about 100 degrees Fahrenheit. When properly used, this is a means of great value. "When the stomach is very irritable, the use of the saline powder may be occasionally suspended, and common effervescing mixtures, or small doses of common soda powders, with an excess of the carbonates used until the vomiting abates, and then the carbonate of soda, with larger doses of the chlorate of potash, may be given without the chloride of sodium, or the chlorate of potash may be given by itself, in doses of ten grains each. A large mustard poultice is to be applied in such cases to the epigastric region the moment the patient comes under treatment. When the saline powders are used at the time the stomach is very irritable, it is deemed advisable to dissolve them in a very small quantity of water. " When cramps supervene, the extremities must be rubbed with hot flannel. The pain produced by the spasms in the muscles is not only relieved by frictions, but by this, and by the application of sinapisms to various parts of the body, the temperature is increased, an object of no trifling importance in the treatment of cholera. Iv this stage of the disease, as in the premonitory symptoms, seltzer, or cold water, may be allowed the patients ad libitum. A strong infusion of green tea may also occasionally be used in severe cases with advantage. " The patients must, invariably, be placed in a room, in which a large fire is kept day and night. ' ' The ejections, and all other impurities, must be removed immediately from the patient's room. No solid food must be allowed 27 the patients for, at least, five days after their recovery from a state of collapse. " In extremely malignant cases, or when the patient has not been seen till late in the disease, and especially when neither vomiting nor purging are present, the stage of collapse being well marked, more active measures must be adopted. An ounce of the chloride of sodium, with half a drachm of the chlorate of potash, or chloride of potassium, is immediately to be given in cold water, and repeated, if necessary, every half hour, until the patient has taken about three doses of this strong solution. If reaction ensues, it is to be kept up by the common saline powders ; and if the strong saline given by the mouth fails, as a last resource, a- saline fluid must be injected either into the intestines or into the veins." Dr. Stevens would not allow any opium, galvanic shocks, or anything of the kind to be used, and exhorts to depend entirely upon the saline treatment. I did anticipate giving an outline of the treatment of many other gentlemen, but I fear of wearying your patience. A Mr. Q. H. Heath strongly recommends inhalation of chloroform to keep the stomach quiet until some powerful anti-emetic may be absorbed, and seems to have had success. Dr. G. O. Rees would inject into the veins a substance as nearly as he can like what the blood has lost, and recommends chloride of sodium, three ounces ; phosphate of soda, one ounce ; carbonate of soda, one ounce and a half ; sulphate of soda, half an ounce. This powder should be dissolved in water until the fluid has a specific gravity of 1030, and heated to 98 degrees Fahrenheit. It is then ready for injection into the blood. Mr. T. M. Greenhow recommends the brandy blister which was used in India — a rag dipped in brandy and laid on the abdomen, and set on fire, to produce reaction by external stimulation. The actual cautury has also been used for the same reason and with success. And again, the cold water bath has been used by Mr. Mo- Pherson, in India, to produce a reaction. The patient is placed in a hip bath and water poured over him, while 28 attendants 'rub his limbs and body — when? he 1 begins'to shiver *nd fed chilly,ihe is taken out and put to bed and dry-rubbed. If he relapses when the warmth returns to the surface the operation is repeated until a relapse does not take place. He is given water to drink and little or no medicine is used. The beneficial effects of this douche plan are believed to arise from the stimulation given to the respiratory, and secondarily thereby, to the circulatory functions. Dr. Hancox gives croton oil two drops every two or three hours;: it seems not to^ act as a purgative in this condition of system, but the opposite. Mr. Gove, of England, Blacklock, of India, and Dr. Bird, of America, believe sulphur to be almost a specific for Cholera; they give the precipitated with carb. soda and tr. lavender; twenty grains each of sulphur and soda, and two drachms of lavender every quarter of an hour until it stays upon the stomach. The somewhat notorious " Maxwell's remedy," is — R Soda Besqui carb. 9j. Opii, grs. iij. Miίce. Ft. Pil. S. To be washed down with another scruple of soda in a wine glass full of water as hot as the patient can swallow it. Mr. Chittt, of the 31th British Regiment in Ceylon, in 184T, found the most successful plan to be the administration by the mouth, and by injection per rectmn, of a strong decoction of catechu conjoined with laudanum, tnrpentine, ether, or ammonia. Other gentlemen both in Europe and in this country have resorted to stimulant or irritating or astringent injections. Dr. McGregor, of Glasgow, has thus used corrosive sublimate. Brandy injections, either alone or with water, or with astringent decoctions as of green tea; or with beef tea, as used in St. Bartholomew's Hospital in 1849, have been used with variable success. Dr. Condie, of Philadelphia, confidently recommends acetate of lead in pill combined with opium and camphor to be taken by the mouth, at the same time that he uses injections into the rectum of the same substance in solution, 29 Dr. H. W. Fuller, of London, depends entirely upon sulphuric acid and believes it a complete specific for cholerine and thinks it the remedy in Cholera of more value than all others combined. I have myself had some experience with the sulph. acid, and reported some cases in the Buffalo Medical Journal in 1854, showing the power of this remedy infcholeraic diarrhoea when inflammatory action was not present. Its action as observed by Dr. Ohittt is as a stimulant and astringent to the capillaries. Dr. C. A. Chavasse who has had an extensive experience with the disease, says: " I have seen every plan tried — counter-irritation, brandy and laudanum, brandy and capsicum, cold affusion, transfusion ; Stevens' Saline with soda, chloride of sodium, and chloride of potash ; the Australian sulphuric plan, mustard emetics, salt emetics, calomel and opium, opium and astringents, acetate of lead inclusive, calomel in large doses of one drachm every hour, and small doses of one grain every quarter of an hour, and many others too numerous to mention; some, certainly, with partial success, but all infinitely inferior in efficacy to the one I am about to recommend, and which I first saw put in practice in India on a very large scale. I have seen many cases successfully treated by it, and several times forty or fifty successively. The proportion of recoveries to deaths was, I believe, about eight of the former to one of the latter; and to show the great malignancy of the disease before it was adopted, nearly all the cases died, often in two or three hours." This is his plan :—": — " Warm turpentine epithegms, or mustard poultices, applied to the abdomen frequently. Take of calomel, prepared chalk, of each ten grains — make a powder — to be taken every hour in treacle, with half an ounce of the following mixture : Take of compound powder of chalk and opium, powdered acacia, white sugar, of each two drachms; sesqui carbonate of ammonia, one drachm and a half; cajeput oil, twenty minims; tincture catechu, three drachms ; camphor mixture eight ounces — mix. The above to be given until the evacuations become feculant— generally from twelve, sixteen, or twenty doses — and then the following substituted until the purging be quite stopped. Take of acetate of lead, half a drachm; strong acetic acid, half a drachm; Battley's Sedative Solution of Opium, fourteen minims to one 30 drachm ; oil of cinnamon, four minims; tincture of ginger three drachms; infusion quassia to eight ounces — mix. An ounce to be given every two hours. Afterwards decoction of bark, with dilute sulphuric acid may be given. It is of the greatest importance that the calomel be of the lightest description, and triturated for a long time with chalk. The strength of the patient must be supported by giving alternately, strong beef-tea spiced with pepper-corns and seasoned with salt and arrow-root and brandy and nutmeg between each dose of medicine. Cold water may be allowed ad libitum. Flannel should be worn next the skin." Now, gentlemen, I shall have done when I have expressed to you my own opinion of the nature and requisite treatment of Cholera. It is based upon the little experience I had during my studentship and during the first year of my practice, together with considerable careful reading and the comparison of the many different opinions and modes of treatment extant. In March of the year 1854, in my graduating thesis, I expressed the opinion that the process of inflammation, to quote myself, may be divided into — irritative, formative, and resulting stages. The irritative, or first stage, takes place through the medium of the nerves, extending their influence to the capillary blood vessels ; and is caused by anything which disturbs the nerves, ' either whether it weaken, to a certain extent, and thus irritate, or whether it strengthen beyond normal, so as to produce strong action, or whether it unduly act upon the normal excitability. In either case the nervous system is on the gui vive, so to speak, and there is a general action of the minute nerve ramifications of the part, affecting, either directly, or by reflex action, the muscular fibres of the minute or capillary blood vessels — arousing them to action — causing what is commonly noticed as the first phenomena of inflammation, viz., a change in the condition of the blood vessels ; usually at first a contraction, then an opening of the capillaries, or an enlargement both of the calibre aid diameter of these vessels ; and here we have the commencement of the second, or formative stage. This opening of the capillaries forms in the tissues affected, a kind of spongy mass — analogous to spongy platinum — which inherently absorbs gases, particularly the oxygen of atmospheric air, and as the 31 blood, by its attraction for such gas, and from its tendency to fill the partial vacuums, rushes into these capillaries, it not only becomes'purified,'as in the lungs, but other changes, chemical in their nature, result, as the formation of fibrin, &c, &c, and thus are developed the usual phenomena of pain, redness, heat and swelling; and in the third, or resulting stage, we have the effusion, formation of false membrane, suppuration, &c, &c. Without in this paper (which is already too long) offering any proofs as to the correctness of this theory of inflammation, I desire to say that I deem the process of nutrition to be analagous to what I have already described as the formative stage of inflammation, namely, a chemical action — the capillary blood vessels being used in health as the retorts and chemical apparatus, presided over by the nerves, and, through the vito electric, or nerve fluid, made to assume just such shapes and sizes as may be necessary, or as this vital chemistry may require for the production of the peculiar substance of the particular part acting or named. Inflammation is thus a deranged nutrition — a hyper-nutrition, defeating itself by, more or less, destroying the part. Passive congestion is a deranged nutrition — a filling up of the blood vessels without the nerve action, or vital chemistry ; and thus we may have many forms of this deranged nutrition from causes within or from without the system : from derangement of the mind, or weariness of the body, from material, or miasmatic, or other subtle atmospheric poisons — from improper surroundings — from too great an amount of atmospheric electricity — as from a ' stroke of lightning' — or, it may be, from a deficiency in the atmosphere of that peculiar fluid — withdrawing the usual stimulus to the vital actions. • Now I would offer the proposition that this failure of the vital chemistry, to a greater or less extent, according to the severity of the disease, is the proximate cause of Asiatic Cholera. It may result from the fact that the powers of the system are prostrated by a subtle poison — miasmatic or atmospheric — which paralyzes the nervous system, and thus the exciting cause and controlling power ef the vito chemical action is wanting, Ajid again, from the fact which has been demonstrated by M. Andraud, that the atmospheric 32 electricity, during a Cholera Epidemic, is greatly deficient,* and thus the external stimulant to the nervous system — which is like, if not identical with, the nerve fluid itself, is almost or entirely wanting — then again the very absence of this usual atmospheric electricity would work a continuance and increase of miasmatic effluvia, from the fact that the exciting cause of the normal chemical changes which destroy animal and vegetable debris, is itself wanting. Now this failure of the vital chemistry, the extent of which, as we have said, is indicated by the violence of the symptoms, leaves the blood vessels, especially the capillaries, in a state of inactivity, inducing passive congestion, and, as a consequence, the fluid portion of the blood is exuded or strained off, and with it the albumen and albumenoid, as also the arrested or partially developed ceil formations (leading to the theory of Britton and Swatne) and thus we have the ' rice-water discharges' and the ' thick grumous or tar-like blood' so often spoken of, and hence the general derangement of the system and peculiar symptoms which follow. The blood is alkaline, because the usual acid generated within it through the chemical actions — as the changing of albumen to fibrin, &c. — is not produced. And the albumen is strained off with the serum in consequence of its solubility in an alkaline liquid. As to my treatment, I should, of course, vary it according to the nature of the case, and circumstances, and surroundings of the patient. I have already given a favorite prescription for the initiatory diarrhoea. I migbt also add that I have great faith in aromatic sulphuric acid, given in doses of from ten drops to a drachm, properly diluted with pure water. I believe with Fuller, that in pure choleraic diarrhoea, or cholerine, it is as nearly a specific as any thing we can find ; but we must make sure our diagnosis, or we do Tiarm, as, in a diarrhoea from the presence of bile, or other irritation, ¦or if there be an inflammatory tendency — cholera being exactly the •opposite condition — it will always do harm. Had I charge of a •cholera hospital, I should pursue a general plan of treatment something like the following in all cases of developed cholera. I would put the patient in bed, surround him with warm applications, or ar- * And of necessity the ozone— ozoue being a certain electrical state of oxygen peculiarly fitting it for chemical affinities— is deficient also. 33 range the clothing so as to throw hot air nnder them to surround the body with that; apply pure, strong mustard poultices along the Tvhole course of the spine, spreading out over the region of kidney, and over the whole epigastric region, but particularly over the right epigastrum. I would prescribe as follows : R Hyd. chloride mite, 9ij. Morph. sulph., gr. j. Piperine pulv., gr. j. Pulv. sacch. alb., 9j. Misce. Ft. pulv. No. xx. S. One powder to be given dry upon the tongue every ten, twenty to thirty minutes, until vomiting ceased. And then continue the calomel with sugar or chalk every hour, until symptoms were much improved. I would also order, as soon after the entrance of the patient as possible, an enema composed of five ounces of brandy, with ten ounces of beef tea, to be repeated every half hour, or hour, according to the severity of the attack. I would also, from the first, apply electro galvanism to be passed along the spine, and have it occasionally — being attached to a sponge — brushed over the lumber and epigastric regions. Should allow the patient to drink cold water moderately during the severe symptoms, and freely afterwards; nourish with beef tea, soup 3 and gruels. After the secretions of bile and urine have returned, should give mild tonics, perhaps using sulphuric acid, liquor ammonia acetatis, or sweet spirits of nitre, as symptoms might indicate. " If this treatment — varied according to circumstances — should not prove satisfactory, I should next give preference to the plan recommended by Dr. C. A. Chavasse, heretofore given. Whatever the plan, or mode of treatment adopted, I cannot but think that more general satisfaction would result, should the physician think less of some sort of "elimination" of a real or supposed poison from the system ; and direct his attention more thoroughly to the rousing of the overpowered and prostrated nervous system,, and thereby hope to obtain a better capillary and general circulation of the blood. 5 APPENDIX. Williamsburgii, N. V., October 30, 1865. Da. E. N. Com, Chairman Committee of Publication Med. Ass'n, E. D. Brooklyn, Dkar Sir, — I understand the remark upon the Sewerage of our city, made by me in the paper read before the Association on the 19th inst. has created considerable feeling, and has been pronounced by certain parties as uncalled-for and unwarrantable. I would therefore request, if it meet your approval, that the following voluntary communications, just received by me, be published as an Appendix to my paper in our forthcoming transactions. Very respectfully, &c., N. L. NORTH. Brooklyn, E. D., October 24, 1865. N. L. North, M. D. : Dear Doctor,— As I had the pleasure of hearing your Essay on Cholera read at our Association, and as I gave my assent to its main points, so now I deem it no more than fair that I should encourage you to persevere in pointing out the measures to be adopted, if not to ward off this fell destroyer, at least to mitigate its baleful ravages. The subject is one which ought to receive the earnest consideration of every good citizen, and the public will demand of the authorities to carry out those hygienic measures which have been approved of and recommended by the medical profession of this and the old world. 36 It is almost universally conceded that epidemics most freqnently begin and have their habitats where filth and wretchedness abound. The impurity of the atmosphere is acknowledged to be one of the chief causes of disease ; and when you call attention to the culverts at the corners of our streets as engendering a vitiated and unwholesome atmosphere, I believe you have the approving testimony of every enlightened citizen. You are right when you attribute great influence to the impurity of the air produced by its vitiation from these cesspools, and when you sound the alarm in order that the attention and care which such a state of things demands be speedily remedied. And although the divinum quid of Hippocrates — that something which escapes our senses — may be the prime cause of Cholera, yet all wise concurrent testimony calls for cleanliness as the great safe guard for the community. Tours, with respect, . J. J. ACHESON, Si. D. Brooklyn, E. D., N. V., October 26, 1865. Dr. N. L. Nokth : Dear Sir, — Allow me to express to you my appreciation of your Essay on Cholera, which I had the pleasure of listening to, before the medical Society ¦of the Eastern District. I was particularly impressed, however, with the remarks concerning the filthy streets and culverts, and concur with you that they are nusiauces which ought at once to be suppressed. I will not say that the sewerage system is imperfect, as that is a matter for Engineers ta consider, but it is apparent to all who walk the streets of the Eastern District, that the system of cleaning, if indeed any system exists, is very defective. And I doubt if any more inviting locations exist in our city where the anticipated epidemic might take up its abode than in the foul culverts and filthy gutters. Your obedient servant, N. W. LEIGHTON, M. D. Brooklyn, E. D., October 30, 1865. Dr. North: Dear Sir, — In regard to your Paper on Cholera Asiatica, which comprises the whole American and English literature on this subject in the shortest form, richly interspersed with your own suggestions, I might add a few remarks to which the perusal of the German literature leads me. In the most cases the dejections of individuals who are infected with the ¦cholera poison, are the cause of further infection, as universally admitted by 37 the profession, without contesting the fact of infection 'by contact or swallowing, peculiarly spoken of in your paper . After the latest appearance of Asiatic Cholera in Europe and America, Professor Pettenzoffer, in Munich, published a monograph on the modes of infection of this sickness after his investigation, which gained the approval of the profession on the European Continent. He agrees fully in the above adopted views, and further states, footed on a series of most carefully investigated facts, that the poison is not so efifective, or so developed for further infection in freshly dejected cholera stools, as it gets formed later by the aiding process of decomposition of organic masses. Particularly it has been proved by his investigations that the contact of cholera stools with putrescebt animal substances, has a prominent tendency to produce the infective cholera poison. A process which reminds the influence of decomposing animal substances on tho formation of the typhus poison, or of decomposing vegetable matters on tho production of the malaria miasma. It is out of question, that the carelessness with which cholera stools and ejections through vomiting are poured into privies, used by the inhabitants of tenant houses promiscuously, where organic masses are constantly in a state of decomposition, carries the infection from individual to individual, and that even the wind carries this poison sometimes over long distances without abating its infective force. It is, further, no longer doubted, that stools or ejections of cholera patients poured on the ground of streets in highly populated cities, where the accumulation of vegetable or animal substances, already in all phases of decomposition,, is spread over a sandy and porous ground, furnish a formidable source of this poison when carried into the air with the other gases, which are necessarily disengaged by the process of dissolution. And yet how few people ever thought that a pestilential smell be anything else but a bad smell, which might be avoided by living in another street ? It is long known, especially by the inhabitants of Long Island, how the malaria poison is carried by the east wind from swampy valleys to the airiest ridge of very distant hills ; how narrow-sighted must it appear to dream of immunity from this subtle poison in a quarter that is, perhaps, a few blocks distant from the laboratory of death ! In regard to the above stated mode of infection, I am naturally led to additional remarks concerning some of your recommendations to the dignitaries of public health. The plan of our sewers is based, without doubt, on the right and only practicable principle — to place the heavier substances into cesspools, with the water running over them, so as to lead on the process of putrefaction under water, as this process of putrefaction is far less dangerous to health, and is quite a different one from that in which air is admitted. If we take in view the slight and irregular inclination of the planum of our city ground ; the many already existing underminings by the aqueduct and gas leading in a ground at different places obstructed by rocks, we are 38 certainly obliged rather to admire the plan, and technical execution of this underground work, than to find fault, although it could not be denied that one essential improvement could yet be made, an improvement for which the present occasion (the prevention of an epidemic infecting peculiarly by sewers and privies) time and technical difficulty perhaps lay in their veto, but which appears important enough to be at least taken into consideration. Before rain sets in, and particularly when there is a want of electricity in the air, these cesspools or culverts disengage a most odious smell of hydrothion and other gases. These effluvia could be prevented by placing a layer of charcoals on a grating inside of the culverts over their contents, as this is the case in Paris, to my knowledge. You will, perhaps, doubt that the effect of charcoals will be of long lasting, but though I do not know exactly the time, I am sure that it will last for about one year at least, considering the enormous absorbing capacity which charcoal has for gases." But you will ask what should we advise when technical difficulties prevent this improvement ? The answer is very simple : the same what we would advise for disinfecting of privies and cesspools without sewers — vitriol of iron. It is mixed to the contents of the culverts in sufficient quantities as to take away the ammoniacal smell, and has to be renewed at least every week. «It has been found, experimentally and scientifically, the best disinfecting material for this purpose. The mode of its acting explains itself by recollecting that sulphuric acid gets bound by the" disengaging ammonia, and that iron gets bound to sulphur, abundantly present in the organic contents of culverts, and that the rest of vitriol of iron will form double salts, so far as ammoniacal salts are present in proportional quantity. For disinfecting of the street gutters, the old method with chloride of lime seems to be the best and only practicable. I do not doubt that your paper will find its appreciation to the best of the public ; and I am so far from any apprehension of alarming, that I might express the opinion that an enlightened public, as that of Brooklyn, will be rather satisfied to see her officials busy in their duty of protecting her, than in fear of alarming, or of being alarmed. Tours truly, CARL WHITTMANN, M. D. Dr. T. Moffatt, in a letter dated Hawarden, September Ist, 1865, published in the London Lancet, recommends phosphorus as a disinfectant. He seems to believe in the theory that the absence of ozone in the atmosphere is the cause of cholera. He says: — "I beg to state that for upwards of seventeen years I have used phosphorus for producing ozone, and for five years I have used it as a disinfectant." Further on he states that it is effective only during its luminous condition, and that ozone is formed onlj~ 39 -when it is luminous, and that " the luminosity or non-luminosity of phosphorus are influenced by atmospheric conditions. High pressure, a low degree of temperature, and wind from the north points of the compass are the conditions of non-luminosity ; and low pressure, high temperature, and wind from the south points of the compass, are the conditions of luminosity. The former atmospheric conditions are those of cholera periods, and cholera disappears with the setting in of the latter. eoooe«oo» a " For purifying apartments I use phosphorus in the following way : — I take a quart bottle with a wide mouth, into which I put rather more than a pint of water ; a piece of cork, carrying a flat piece of phosphorus, with a clean cut surface, floats upon the water. The mouth of the bottle is loosely covered with a cork. The bottle is then placed first in one part and then in another of the apartment to be purified, until the peculiar smell of ozone is detected. " The process of purifying may be performed night and morning, or oftener. 11 For purifying air in the neighborhood of street gratings, or sewers, I simply suspend a piece of phosphorus from the grating. " In apartments the temperature may be sufficiently high to keep phos* phorus luminouί under all atmospheric conditions ; but in sewere it will be luminous and non-luminous, according to the height of the barometer, thetemperature of the surrounding air, and the direction of the wind, ana ozone will be produced only when it is luminous."