MALIGNANT CHOLERA, •AS IT Al'l'l^ltE*) \y 

In the Summer of is:!;;. 

AKD VERSAILLES IN 183 C 

W£ ww* wm^ iP4iwiiiiisr(ft» 

I* » 

B. T. DURRETT, 

202 EAST CBSSTWJT ST. 

LOUISVILLE, KY, 

>¦ 

LEXINGTON, KY. 

tRIN'fJJD BY W. 1). SKILtMAN. 



1835. 



F S2-DF A T O II ..¥': :S^TICE. : $^T ICE. 

The substance *(>f. the follottidg rremJkrka jvsp written soon after the Cholera subsided' \ti tiiis city in the summefbf 1833. At that time, howevfir^ likad-no.intcntion of publishmg ttjewi, •JJlitjbding convinced, while oil au*tJisJffo, T v^orsai3lesJ a mpighbQjri«g\ village;, frlie.re the Cholera has recently appeared, that, notwithstanding all that has been said and written, the people are comparatively ignorant of the symptoms in the incipont stage of the disease, and are not sufficiently impressed with the importance of prompt and vigorous treatment at a period when it i 3 perfectly under the control of medicine, I am induced to lay before the public this short dissertation on the subject, with the hope that it will subserve the cause of humanity. 

The Cholear broke out in Versailles on Sunday, the 18th of August. I arrived there about one o'clock the next day, in company with Dr. Bell of this city. There had been up. yards of thirty deaths, and there were a considerable number of collapsed cases when we arrived. I remained at Versaiilas between tsvo and three days and nights, attending on the sick. So far as my observation extended, and from what f could learn of the history of the cases that proved fatal before my arrival, there was nothing peculiar in the type of the disease. Jt certainly was very malignant there, but not more so than it was here in 1833. It was very similar in its onset, progress, and termination. The forming" stage was marked by a white fur on the tongue, and a gentle diarrhoea continuing several hours before the violent symptoms came on. Dr. iiell and myself treated a number of cases in the first stage of the disease, which yielded readily to such remedies as are recommended in the following treatise. lam fully persuaded that the practice of administering large and repeated doses of calomel, to the exclusion of all other remedies, cannot be too strongly reprobated. It is too blow for the rapid cases. The diarrhoea must be checked; if we wait for the calomel alone to do i(, the patient will probably be collapsed before it is arrested. 

Lexington, August 22, 1835. 



S £4T*53 



MALIGNANT CHOLERA 

As to the remote cause of this disease, much difference of opinion 

exists among Physicians. Many of the Physicians of Europe, and a very few in the United States, contend for the contagious nature of Cholera; while a much larger number of the profession, both in Europe and America, agree, that it is not contagious, but they disagree as to the nature of the remote cause. Some contend that it is produced by what they denominate an epidemic constitution of the atmosphere, acting as a specific cause, while local circumstances act as exciting causes:— others, that it is produced entirely from marsh imasmata, or from the effluvia arising from the decomposition of vegetable matter — and that it is nothing more than a high grade, or a malignant form of the Cholera Morbus. 

The disease cannot be contagious, for the following reasons. First : If you remove a patient, laboring under this disease, to a healthy atmosphere, the disease will not be propagated. Second : It is spontaneous in its origin, springing up in places distant from each other, at the same time attacking individuals who have had no possible opportunity of taking it from the sick. Third: Persons are liable to have it more than once; but if contagious, and having had it once, being no security against a second attack, it could not be chocked or extinguished while there was a single individual remaining exposed to its ravages. Fourth: Contagious diseases travel slowly, but Cholera, like other epidemics, flics on the wings of the wind, frequently attacking a large number of persons at the same time, who are at a groat distance from each other, and who have not been exposed to any one laboring under 

the disease. 

The hypothesis that attributes its origin to an epidemic state, or to some general cause existing in the atmosphere, of the nature of which wo arc entirely ignorant, as the remote cause, while marsh miasmata, imprudence in diet, &c, &c. act as exciting causes, is, we think, most conformable to the history and phenomena of the disease . it cannot be accounted for from local causes only: for we find the disease has, 

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within a few years, travelled through almost every country on the g!ob>- ? marked with the same fatality, and characterized by the same general symptoms in every climate and country, attacking individuals in every condition of life, prevailing in large cities among its luxurious inhabitants, and in the wilderness among savages; in short, sweeping over cold, temperate and hot climates, and attacking communities entirely dissimilar in their pursuits and manner of living. It must, therefore, have some general and all-pervading cause. The malaria arising from the decomposition of vegetable matter may, and doubtless does act as a co-operating cause. But if it be the specific cause, why have we not had malignant Cholera in Europe and America before? London and Paris have existed for centuries, and has there never been a sufficient quantity of heat, moisture, and vegetable matter existing at the same time, to produce malignant Cholera, until within three years? Quebec, Montreal, and New York are among the oldest cities in North America, yet Malignant Cholera has never prevailed in those cities un^til very recently. If a combination of heat, moisture and vegetable matter were alone sufficient to produce the disease, why have they not had it before 1 These facts show conclusively? that there must be some agent besides marsh miasmata, and that this agent must be a general one. But the advocates for this doctrine contend, that the disease existed in Europe and America before, and that it is produced from the same cause, and, in fact, that it is nothing but an aggravated form of commou Cholera Morbus. 

What arc the principles on which we classify diseases? Such as have a general resemblance in their nature and symptoms, we arrange in the same class. The Phlegmasia, for instance, is one class. The Febrile diseases constitute another class. Why arc they thus arranged ? Because they have a general resemblance ; yet they have a specific difference. Inflammation of the lungs is a very different disease from imflammation of the stomach ; and the treatment, in a great many essential points, is very dissimilar. Yet they have been very properly arranged in the same class. Intermitting Fever and Yellow Fever differ widely in their symptoms and treatment; notwithstanding, they arc both arranged under the same head. Cholera Morbus and Malignant Cholera resemble each other in some particnlars, while they differ greatly in others. One striking difference is, that the one rarely ever produces death, While the other is the most fatal disease that we have any history of. The Cholera Morbus has prevailed in Europe and America, during the hot season o^ the year, for a"-es; yet it never 



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h;is been regarded as a formidable* or dangerous disease, while the Malignant Cholera has produced consternation and death wherever it has appeared, and has swept oft" more of the human nice in cue year, than, the other has in one thousand. 

But it may be urged that they attack tho same organ?, and that they exhibit similar symptom?. It is true that each effects the stomach and bowels, inducing purging and puking. Tartar Emetic taken into the stomach wiJl induce vomiting and purging, and if there is an over-dose takcny.it will probably produce spasm also. Yet the disease produced by the introduction of Emetic Tartar into the stomach, cannot be Malignant Cholera.. The resemblance between disease produced by taking Tartar Emetic and Malignant Cholera,, is as strong as it is between Cholera Morbus and Malignant Cholera; yet no one has ever pretended tosavthat Tartar Emetic was the cause of Cholera. 

We conclude,. therefore, First, from the history of Malignat Cholera, that it must have a different, remote cause from common Cholera Morbus: Secondly, that the two diseases differ in their symptoms and (i\tality; and, therefore, must have a different origin. Candor compels me to say, however, that t am .fir in! y convinced, that the malaria arising from the decomposition of vegetable matter, has an important agency in producing Cholera i for, so far as my own observations have extended, I have not known it to prevail in any place, town or country, that was not favorable to the production of marsh miasmata, though I cannot believe it is alone sufficient to account for the prevalence of the disease. 

As to the scat of this disease, there is but little room for a difference of opinion. Its primary scat, as well as its strong hold, is most certainly in the chylopoictic organs. It is in these organs that we discover the iirst deviation from health, and to them we address our most important remedial agents, and to them we look with intense anxiety for a change of action and secretion. It is mainly upon their condition that we form a favorable or unfavorable diagnosis. There is no doubt that the circulatory system, as well as the skin and kidneys, and probably every organ and tissue in the body, arc soon implicated in their diseased action. For it is true, as Dr. Rush has beautifully expressed it, that the organs of the human economy are "like the bells on the robe of the Jewish High Priest, if you touch one, they all ring together." 

Whether the deleterious agent acts primarily on the stomach and bowels, and involves, through the medium of sympathy, the whole system; or, whether it enters the circulation through the lungs, in respiration, 



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and aicts upon the stomach, bowels, and Ir T cr, through the medittn* of the blood, we will not stop here to inquire. We only wish to establish the fact, that the diseased action is primarily seated in the digestive organs: and this, we think,, the early symptoms abundantly prove.. 

SYMPTOMS AND TREATMENT. 

I have observed three distinct varieties of this disease. The first, which is the most common, as well as the most dangerous form of Cholera, is that which comes on with a diarrhoea. The second comes on with vomiting without diarrhoea; and the third makes its attack with spasm, without either vomiting or purging. The diarrhoeal form begins with a thin watery discharge from the bowels, unattended with cither pain or sickness. The first discharges resemble hard cider, or soap suds. From the fact, that the serum is colored by the contents of the rectum, so soon as the contents of the lower bowels are discharged, it assumes the appearance of rice water. If the patient is not well acquainted with the early symptoms of the disease, the diarrhoea produces no alarm, while it' goes on increasing in quantity and frequency, until there is a sudden explosion, and thepaticnt finds himself collapsed, almost before he is aware that he is the subject of disease. It is thus that I have seen a great number of persons, whose life seemed to slip away from them, without their knowledge, and without spasm, pain, or sickness: these were the worst kind of cases. The discharges arc sometimes consistent, of the color of ashes, showing that they are destitute of bile. In a cholera atmosphere, every case of looseness of the bowels, where the discharges show a want of bile, should be marked as cholera, and treated accordingly. My practice is, if the diarrhoea is not frequent or copious, simply to administer twenty grains of calomel,, and one grain of opium, which will generally arrest the disdase, in this stage. If, on the contrary, the diarrhoea is rapid and copious, and the disease seems to be hurrying through its stages to a fatal termination, I adopt a more energetic and decisive practice. If the pulse will bear it, I bleed,— if the stomach is sick or oppressed, 1 administer an emetic of mustard and salt. After the operation of the emetic, and after the stomach becomes perfectly calm, I give about 30 or 40 grains of calomel, with lor 2 grains of opium. If the calomel and opium should fail to arrest the diarrhoea, I direct a tea-spoonful of laudanum, mixed in a solution of starch, to be thrown up the rectum, after every watery discharge, until the diarrhoea is checked. This preparation scarcely over fails to arrest the discharge, after a few repetitions. If it should seem probable that the calomel had run off by the bowels, before the discharge 



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Irrcstcd, the calomel should be repeated. Eight or ten. hours after Jiarrhoeais cheeked, if the calomel has not operated, I direct a dosfl hubarb or castor oil. I have rarely ever known calomel to remain tor ten hours in the stomach, after the diarrhoea was cheeked, but the next operation was a bilious one, showing that it had produced pecific effect on the liver. I, therefore, administer rhubarb or oil, period when the calomel has had full time to act on the liver, beit has remained in the stomach long enough to. produce ptyalism, a result always to be most scrupulously guarded against, in the treatment liis disease* After bilious operations aro established, they should cpt up by the use of small doses of calomel, until the disease isre-3d. If We could rely on what has been written on cholera, wo d conclude, when we once succeeded in getting bilious operations )lished, that our patient was -safe; but the case was very different here — I mean in the most malignant cases. The physician may ha.ye succeeded in procuring consistent bilious discharges, and been cheered with the prospect of the speedy recovery of his patient, when suddenly the scene is changed, and he is doomed to encounter the keenest disappointment, by the recurrence of the fatal rice-water discharges. I havo known this take place in numberless instances, and in many of them, while calomel was in the stomach. It may be asked, if ptyalism is no immunity against a recurrence of the disease, and if the establishing of bilious operations affords no security against the return of the ricewater discharges, what arc we to rely on? 1 answer that the annals of medicine do not furnish us with an account of a disease so violent in its attack, so rapid in its progress, and yet so obstinate in its nature, requiring the most prompt and energetic treatment, and, at the same time, the most incessant and protracted vigilance. There is no safety except in constant and unwearying attention, until the disease is entirely removed. Every stool should be examined by night and by day, with positive injunctions to the nurse, to repeat the injections and the calomel, after every watery discharge. It is only by this course , I mean watching the change in the secretions, and meeting promptly every untoward symptom, that can ensure safety to our patient : for it is in vain to say that any one medicine is a specific in this disease : and it is equally preposterous to pronounce our patient safe, because we have salivated him, or succeeded in effecting bilious operations, for I have seen a number die in either condition. I have known watery operations to come on while the patient was salivated, and take him off suddenly : and I have known several persons to die while they were having bilious distfir.ifgcs-. 



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For it is a fact, that I succeeded id procuring bilious discliar* 'gcs from patients that wore collapsed, yet they did not recover. I have known the pulse to revive, the skin to become warm, the secretions from the liver natural, and all the symptoms to appear favorable, yet it was like the flickering light of a lamp, when the oil was exhausted. These favorable appearances were delusive in their nature, and momentary in tkeii 1 duration-. The vital principle was too far exhausted, and in despite of every effort, the patient would soon sink back into his former 

state. 

Stimulants arc frequently indicated in this disease, of which French Brandy and Elixir Paregoric arc the best. They can be given in every stage and variety of the disease, after the bowels and liver have been acted on, and the strength is exhausted, and the pulse soft and weak. 

The second variety of cholera is where there is vomiting without di¦awheea. I always puke in these cases, and apply a blister plaster over Stho region of the stomach: and if the pulse is full and strong, or small and tense, I bleed and give calomel without opium, as I do not consider the opium indicated, where there is no diarrhoea. 

The third variety is where there is spasm, without vomiting or purging. These cases arc rare, but I have met with a few of them, and have found blood-letting a certain remedy. I always bleed, in such cases, ad dcliquum animi, which instantly relieves the spasm, and restores the circulation. After bleeding, I would give the calomel without opium. — I have found these the most manageable cases. 

Unfortunately, physicians differ widely in regard to the treatment of this truly formidable disease. We find some of them relying exclusively on bleeding and calomel, — others on calomel and opium, — others on emetics, and a few, on calomel alone. Cholera, like other epidemics, varies in every case. The practitioner, therefore, must adapt his remedies to the case. If the pulse is strong and full, or small and tense, he should bleed, and while the blood is running, he should have his fingers on the pulse, and as soon as there is an impression made on it, the orih'cc should be closed. Cholera patients are peculiarly liable to faint from bleeding. This circumstance has deterred a great number of practitioners from the use of the lancet in this disease, after the first trial. If, howover, they had given the remedy a fair trial, by waiting patiently until the system had time to react, they would have found the condition of the patient much improved by its use. I bled about sixty patients in this city, and in the town of Harrodsburg, and not one of the cases proved fatal. It is to be remarked, however, that I did not 



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ISrnploy the remedy in the worst cases. I used it generally, early \u disease, and never, where I was not convinced there was sufficient strength for the system to react. The first time that I used the lancet in this city, was in the case of Mr. George Timberiake. He was attacked in the market house on the Wednesday morning after the cholera broke out here. As soon a.3 I saw him, 1 gave him about forty grains of calomel, and two of opium. By evening it operated well on his bowolSj producing bilious discharges. The succeeding night he was attacked with severe cramps in his extremities — cold skin, and a strong bounding pulse. The pain was so severe, that he could not be kept in bed. I resolved to bleed him, and accordingly took between a pint and quart of blood. Before the biood was done running, I had the satisfaction of witnessing the entire ccsssation of the cramps and spasm. The warmth of ihc skin was restored, and the patient completely relieved. I]o did '.veil afterward?. I used the lancet in Messrs. Ilcrvey and Burrowes' cases, of this place, with a decidedly good effect, and a great many others, which I think unnecessary to mention. I was called to a case on the flili, near the ciuse of the disease in this city, where the lancet was clearly indicate;!, and where its effects were so decisive, that I think it important to notice if here. Miss Barnet, a young lady, was affacked with spasm, — she had neither puking nor purging, but was bound in an indissoluble spasm. She could not move a muscle in her body, ?hc skin was cold and purple, she complained of blindness. Her pulse, though small, was tense. I immediately bled her, — not getting enough out of one a-rrfc, I opened a vein in the other, and let the blood run until she. fainted. The moment she fainted, she was relieved from the spasm and blindness, the skin soon became warm, and of a natural color. She was sometime confined, but ultimately recovered. 

In Harrodsburg, the disease was not so malignant in its type generally, as in this city, I consequently used the lancet there with more freedom, because I usually reached the patient in the early stages of the disease. I used the lancet in at least forty cases there, and in every instance I was satisfied with its effects. There was one case in which its effects were so striking, that I must give it. Gen. Atlair, aged about 75 years, naturally of a robust constitution, was attacked with vertigo and vomiting of serous fluid, with a singular feelimi all over the body, which he called a creeping sensation. I have noticed E)eculiar sensation in others to precede an attack of spasm. His was strong and full, the functions of the brain very much ¦'•^"jri- Notwithstanding his great age, I djd not hesitate to bleed him. I 

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took more than a pint oi' blood from his arm. It immediately relieved the vertigo, and partially restored the functions of fhc brain. 1 directed an emetic and a dose of calomel. I visited him next morning, and found him much relieved; but his vertigo was yet so great, that ho could not raise his head from the pillow. His pulse being yet strong. I bled him freely, with most complete success. The calomel had operated well, and the dose was repeated. lie soon recovered. 

Emetics. — Though there is much difference of opinion about the use of this remedy, I am thoroughly convinced of their efficacy in a particular class of cases. Wherever the stomach is oppressed or overloaded, emetics arc particularly demanded. In fact, I have found them beneficial in every variety of the disease, where they were used in tho early stages. I saw a few cases, where they were administered, after the disease had progressed too far, with obviously bad effect. They seemed to increase the discharges from the bowels, and prostrate the strength of the patient. It is a fact that but few cases recovered in this place until emetics came into general use. The first cases that occurred here, were peculiarly violent in their onset, and progressed rapidly through their stages. They were so violent and rapid, that calomel was too slow for them : and few were saved, unless the disease was first arrested by emetics or opium. 

Opium. — The use of this article is much extolled by some practitioners, and as strongly condemned by others. That it has been used with top much profusion and indiscretion by some physicians, I am frcn to acknowledge; but that it is an indispensable medicine in the treatment of cholera, the experience of the profession abundantly proves. I have used it in a great number of cases, both by the stomach, and in the form of a suppository, introduced into the rectum, also in a liquid form in a solution of starch, as an enema. lam convinced that I saved more desperate cases by its use, than by any other remedy, cases where neither bleeding nor emetics were applicable, and where calomel alone was insufficient to arrest the fatal rice-water discharges. Theeo cases were verging on the stage of collapse. The pulse almost imperceptible, skin cold and purple, and the discharges from the bowels rapid and copious. The strength was too far gone for bleeding or emetics. Calomel, though administered freely, was too slow — the patient* ,s strength rapidly exhausting. What was to be done? After loosing several ca«C5 in this condition, I determined, at length) to try the introduction of ¦ium up thfl f ecium. The first case in which I used it, the diarrhoea is suddenly checked, and did not return until the calomel operated. 



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T afterwards auminisicved the article sparingly by (he stomacli, Lu^ t'rcoiy cither by introducing it up the rectum in a solid form, or by injoclion with starch, and, I can say, with the most decided success. Ido not believe that opium alone will cure, the disease, but Ido believe that it will serve apurposc hat no other medicine will, it will arrest the diarrhoea, and suspend the serous discharges until the calomel oporates on the? liver and bowels. 

But there is another remedy which I have not noticed, not inferior, in point of importance, to any I have mentioned. Perhaps, if all the other exciting causes were combined, they would not be equal to fear alone. It behoves the practitioner, therefore, while he is prescribing for (he body, not to neglect the mind. He should) by all means, encourage, and cheer his patient. This is a matter of the first j importance. It is useless for him to give medicine, while his patient is in despair. He should exhort him to have resolution, and infuse hope into him, or his remedies will do no good: and it is impossible to effect his purpose, unless he is himself composed and resolute.