FOUNDED 1836 WASHINGTON, DC. — — ITS SEAT, NATURE, AND TREATMENT. \>.\ CHARLES SHRIMPTON, M.D., Chevalier de la Legion d' Honneur, XleJailte dv Cholera Decernte par la ville de Paris, 1532, &. Signs characteristic of Cholera lfi Pathological cold X; Impaired functions of hematosis and respiration. ... 17 Intestinal flux .¦ 18 Reaction -. , ? . . 19 CONTAGION 21 Dr. Briquet's report to the Academic de Me'decine ... 21 Paper read before the Acadeinie by Dr. Jules Worms 23 Report on the epidemic of Marseilles by Dr. Grimaud (de Caux) 25 N ON -CONTAGION 34 Paper read before the Academic de Me'decine by Dr. Cazalas 35 Quotations from English authors — James Annesley, William Twining, and Sir James Ronald Martin 36 Letter from Dr. rilerminier to the Academic de Me'decine 43 Extracts from Dr. Didiot's work on the epidemic- Cholera of Marseilles 45 Period of incubation , 52 Neither virus nor miasma 53 Dr. Guyon's experiments on rabbits, fowls, pigeons, and leeches 54 Seat and nature of the disease 57 Mode of propagation and etiology GO Cordons sanitaires 61 Quarantine Laws 61 Precautionary measures 72 Treatment 78 Pbopositioms 90 tENDix. — Dr. Beale's Microscopic Beaewrobet on Cholera 94 8 Cholera has been committing its fearful ravages, flying over the whole of Europe during the last thirty years, whilst all our efforts have been in vain to stay its course or mitigate its violence. This terrible disease, which appeared to be confined to India, began to invade other countries in 1817, and made its appearance amongst us in 1832. Since then it has never left us, and from time to time it bursts out in disastrous epidemics, without our having been able yet to discover by what means it is propagated. We have evidently here to contend with phenomena of a new character, and we must endeavour to study the nature of this unknown agent without allowing ourselves to be influenced by any preconceived notion. Cholera presents itself in a character so widely different from other diseases, that none of our former theories can assist us in our researches on its nature, its origin, and its seat : we must be guided by the established data of science only. B 2 I There can -be no doubt that this disease is probated. Are we obliged on this account to ;lare that it is contagious ? It is true that we dw at present only of two modes, contagion and ection, by which diseases are propagated ; but ! we justified in declaring that a disease is itagious merely because we know of no other ans by which it may be propagated? This yect has engaged much of our time and thought many years, and we have never yet been able discover any means by which it could possibly contagious. Another difficulty arises from the circumstance that Cholera has frequently been considered as an epidemic disease, and consequently, in giving faithful accounts of the different epidemics, it has been necessary to enter into all the details of complication, for Cholera associates itself easily with other diseases, and thus the efforts of some of our highest authorities have frequently been diverted from the proper channel in their search after the real nature of the disease. Our perception of this source of error has led us, in our study of the disease, carefully to isolate it from all its complications. We have at the same time avoided all speculations on the nature of epidemic influences, which we cannot fathom any more for Cholera than for many other diseases. Why then raise a problem which most probably we shall never be able to solve ? This 3 Ebe the barrier that human intellect is not to — the to Oeiov of Hippocrates. When visited, however, by such a devastating agent as Cholera, we cannot but inquire from whence such deadly power arises ; how it is propagated : and what measures we can take to protect ourselves from it. I Who can tell from what source the deadly uence comes ? By some it is affirmed that it ceeds from one cause, by others from another : t it comes to us sometimes from one direction, letimes from another ; even the very means by eh the disease was supposed to have reached on the appearance of each epidemic, has been esitatingly pointed out. All this is very doubt- We believe that we are nearer the truth in ing that Cholera has always remained with us in a sporadic state since 1832, and that it' frequently becomes epidemic. BThe practical questions to be solved are the two >wing :— Is Cholera a contagious disease, or is it not ? ¦What are the rational means to be employed he treatment of Cholera ? llt is urgent that the question of contagion ild be categorically brought before us in the tefold interest of science, of social economy, of individual security. We cannot admit that Cholera can be a contagious disease. This conviction has gradually grown upon us from all that we have witnessed during the epidemics of 1832, 1849, 1853-54, 1865, and from what is now passing around us. I The clinical and pathological observations we re had such ample opportunities of making : study of the works and opinions of our most rned men who, some of them, widely differ in nion from us, have only confirmed us more and re in continually bringing new proofs in support our conviction. I It is of the highest possible importance that s question of contagion should be solved, for in we find involved that of the nature of the disease elf. The solution of the question with regard social economy, will enlighten us as to the real lue of the quarantine laws, and as to the hygienic ;asures to be taken ; and with regard to indilual security, we shall learn whether there be y danger or not in contact with Cholera patients. I Such a question cannot be solved by the mere :umulation of facts which may be always brought contradict each other. It is from the study of 3 disease itself; by a careful examination of the uptoms, of the progress, of the pathology and ology of Cholera, that we may hope to throw ne light on this hitherto mysterious agent. We iieve that we shall find the same active principle 4 in all the elements of the disease, and be thus guided to its true nature and seat. Symptoms and Progress. — Frequent dejections of a liquid resembling rice-water, cramps, suspension of all the secretions, suppression of urine, vomitings, praecorclial oppression, breath cold and dry, tongue cold, weakness of voice, coldness of the surface of the body, particularly of the lower limbs, sunken eyes, and small pulse, form an assemblage of symptoms which cannot allow Cholera to be confounded with any other disease. It is not necessary that all these symptoms should be as characteristic as we have described them to allow us to recognise the presence of Cholera, for the disease exists really from the moment that a patient is attacked with the frequent dejections, intestinal flux, which has been called " cholerine," and which in a vast number of cases precedes the development of the other symptoms. This intestinal flux characterises the -first period of the disease, and is of a very insidious nature. It is unaccompanied by any pain, and without any other disturbance of the general health beyond a slight diminution of vital power, and a vague feeling of uneasiness. Intestinal flux, it will be seen, is quite of a different character from diarrhoea, with which it should not be confounded. An error of this kind would occasion 5 I loss of much precious time, and lead to a wrong tment. I Diarrhoea is characterised by frequent c vacuans of liquid stercoraceous matter, accompanied th more or less pain, and an increased action (irriion) of the whole system of the digestive organs. I In Cholera the stomach and intestines, instead being in a state of increased action, become the ssive recipient of almost all the serum of the :ly. This intestinal flux of which we are now making is the result of the more or less rapid abrption of the serum from the blood, and from the Lole of the organic structure. The first evacuans, which must naturally contain stercoraceous itter, soon become quite liquid and inodorous, and ye no longer any trace of the ordinary excrement, ese stools, which have been compared to rice,ter, are composed of serum, in which float small sees of coagulated albumen and epithelial cells. I Most frequently the intestinal flux is so slight •it persons do not pay any attention to it. A ght degree of weakness and general uneasiness, orexia, without disgust for food, a slight mbling feeling in the bowels, frequent liquid acuations, as if propelled by a syringe, without lesma, or even any irritation in the region of the us. Animal heat is diminished, the circulation d all the secretions are slightly impeded. A v;ist number of persons are affected in this 6 lay during the reign of an epidemic, and after a vv days' continuance of this slight disturbance a rtain feeling of comfort pervades the frame, lis is the sign that a kind of reaction has taken a,ce, and that all the functions have returned to eir natural state. Persons who have been thus Curbed are often not even aware that they have en under the influence of Cholera. But things not always go on so smoothly, and when tients suffer a little more it is already late, but idical advice should be obtained as quickly as ssible. This stage of the disease requires prompt d good management, for, if not subdued, the nptoms, after a few days, often after a few hours, assume the character of confirmed Cholera. This, the second period, which we have already described in giving the symptoms of confirmed Cholera, is most frequently of but short duration, merely a few hours, and the disease passes to the third, algide, period. Cholera does not always proceed from stage to stage as we have just said. The most serious cases generally begin at once, by this last period passing over the two others. This is often the case at the beginning of the most violent epidemics, IHematosis has ceased entirely, or nearly so ; pulse is no longer felt at the wrists, and the ith has become absolutely cold without any 7 vapour. The thirst is insatiable, with a sensation of burning heat in the epigastric and umbilical regions. Animal heat is no longer generated, and the characteristic cold of Cholera has seized the whole frame. The skin is cold, soft, and doughy, with a cold, viscous liquid filtering through its pores ; it has become flabby, and is shrivelled up, having lost the elasticity of living tissues ; it has a violet tint, with livid spots here and there. All the secretions are entirely suspended. The eyes are become dry, they appear to be diminished in volume, and are withdrawn to the back of the orbits. The tongue and the mucous membrane of the mouth are cold, with a bluish hue. The cramps which first attack the legs quickly extend to the arms, and from thence to the muscles of the abdomen and chest. The breathing is slow, and the action of the heart weaker. All the symptoms, cramps, vomitings, and intestinal flux, become more violent, and the patient suffers inexpressible anguish from the spasmodic contraction of the stomach and bowels ; he throws himself about in every direction, and complains of oppression, though air continues to enter the lungs abundantly. There is frequently delirium at this period. When the end is drawing near, the violence of all these symptoms is abated, the vomitings, dejections, and spasmodic contractions cease from the exhaustion of the vital powers, and the patieut 8 9 Period of Reaction. — When the disease is to Ea more favourable termination, all the sympi, instead of taking the more aggravated form, oie a milder character, and reaction takes place ually. The first sign of this favourable change is often the evacuation of a small quantity of urine, announcing the re-establishment of the other secretions. The skin loses its deadly coldness, becomes warmer by degrees, and is moistened with its natural perspiration. The animal heat returns, the pulse is developed, cyanosis gradually disappears. The breath becomes moist and warm. The stercoraceous evacuations re-appear. The secretion of the lachrymal glands is re-established, and the eyes are less sunken in the orbits. The voice recovers its tone. In a word, a total change has taken place. Reaction in Cholera is necessarily very slow, and when most promising it is mild and calm, the patient experiencing great comfort and desiring repose. llt rarely occurs that the transition is so easily unplished. Most frequently a febrile movement js place, which the patient overcomes after a days of care and good management. KChe disorder created in the whole system is, ever, frequently so great that the reaction canbe sufficiently supported, and the febrile state m an adynamic form with all the accompany ing symptoms of typhoid fever ; the tongue becomes red, dry, and fuliginous, with stupor, coma, or delirium. The intestines are inflated with gas, the abdomen distended and painful. Petechise appear on the skin, which becomes hot, dry, and is covered frequently with a kind of roseola, or a species of urticaria. Vomitings recommence, and bile is now abundantly rejected, frequently also diarrhoea with most offensive evacuations. I When the vital powers are thoroughly exmsted, and the patient has not strength to bear en the first efforts of reaction, the pulse, after a int development, quickly becomes weak and ready ; the skin does not keep up its warmth, d is again covered with a cold, clammy exuda>n; the general vitality gives way, and the tient sinks rapidly without any suffering. Thus Cholera has four modes of termination. 11st. By mild and regular reaction without any arent fever. 12nd. With fever, the patient retaining sufficient 1 power to overcome the commotion. 13rd. The fever takes an adynamic or ataxic •acter — Typhoid fever. 4th. Vitality gives way without the power of reaction. I We must now pass on to pathology, which account for all the symptoms we have been :ribing. 10 Our researches are necessarily confined to algide cases, that have succumbed without any reaction. All organic lesions which are produced * reaction cannot be the result of the influence Cholera, which no longer exists. They therefore belong to other categories of diseases, most frequently of a typhoid character. PATHOLOGY. General state of the Body. — The general appearance of the body differs little from what it was during life, much resembling a case of asphyxia in an emaciated subject. The blue tint of the skin, with livid spots formed in the parts on which the bodies lie, have quite the same character and appearance as in asphyxia. The cadaverous rigidity is very marked. The skin is flabby, forming almost folds in some parts. The body is shrivelled up, as it were, by the abstraction of its serum, and is thus protected for a short time from putrefaction. The muscular fibres continue twitching during an hour after death ; and the muscles contract, producing slight movements of a finger or a toe, or even of an arm or leg. The phenomenon which strikes us the most is that the body becomes warm soon after death. This increase of temperature is very perceptible to the hand, and the thermometer when applied to 11 12 I the groin rises one degree more after death than during life. This remarkable fact, which has ELick all medical men, will assist us very conerably in our study of the nature of this ease. It is the result of the vital reaction of the elementary cells of the body after the disparition of Cholera and after death. This reaction is necessarily very transitory. I Under the same circumstances of temperature id atmospheric influence, putrefaction takes place 3re slowly in the bodies of choleraic than of her cases. The abdomen does not become green d violet — first sign of putrefaction — until several ys after death. On opening the abdomen we not find that peculiar cadaverous taint so coniiitly present in other bodies. iThe peritoneum is covered with thick viscous sity ; the intestinal circonvolutions are aggluted by the contact of the surfaces of the us membrane, the parietes of these intestinal mvolutions are contracted and appear thick - l ; they are soft and doughy, presenting here there various colours, produced by the extrations and arborisations of blood-vessels in the ous membrane. There is no trace of stercoras matter or of bile in the intestines. The stomach and intestines are more or less distended by the quantities of liquid they may accidentally contain. This liquid is of the same 13 liture as the evacuations, mixed with the drinks c patient took before death. The pyloric orifice often contracted. The parietes of the stomach id intestines are thickened by infiltration and ntracted. The extravasated blood and the borised vessels of the mucous membrane generally occupy the lowest parts and disappear on compression, or on slight friction with the back of a scalpel, leaving the membrane perfectly white. The whole surface of the intestinal canal, particularly of the jegunum, is covered with a scattered kind of granular eruption, psorentery. The mucous membrane has the appearance of having been macerated. The supposed granulations are simply the effect of infiltration, for on dividing them with the scalpel, they almost disappear allowing a small quantity of serosity to escape. The mesentery and omentum are in their natural state ; the trunks of their veins gorged with black blood. The spleen is often smaller than usual and contains but little blood, whilst the liver is full of blood, particularly in the system of the vena porta. The pancreas has nothing to remark. The (/all-bladder is generally distended with inspissated bile. The kidneys are injected, and the papilla? are filled with a creamy white matter : the calices do tt contain any urine, the ureters are in their tural state. The bladder is healthy, empty, and contracted. I The lungs are sound and shrunken. They are lcli lighter than in other cases, from the circumnce that the blood-vessels are quite empty. pleura are glutinous and adhesive, like the toneum. tThe 'pulmonary arteries, as also the right caviofthe heart, are gorged with dark black, bloodjelly, in the midst of which some clots of blood may be found. I The pulmonary veins and the left cavities of heart contain scarcely any blood at all. The pericardium is dry and glutinous. I The heart is soft and friable. Some extra va;d blood is often found on the part on which it ines, as well as on the pericardium. The arteries are almost entirely empty, in a collapsed state, and the internal membrane stained here and there by blotches of blood — a post-mortem effect. A quantity of black, jelly-like looking blood is found in the larger ramifications. §AU the large trunks of the veins are gorged h black uncoagulated blood, but the capillary 3els are collapsed, and quite empty. Nervous system. — Head. — The sinuses of the dura-mater are full of black blood. Extravasations of blood are often found on the arachnoid, 14 tich is not so dry and glutinous as the other ous membranes. The substance of the brain appears to he healthy, but small drops of black blood appear on cutting it in slices. There is no perceptible change in the nerves of the cerebral or ganglionary system. What, now, are the pathological signs characteristic of Cholera ? The invincible cold which seizes the whole 7. 12nd. The development of animal heat, vi vita', soon as the choleraic influence has disappeared, en after death. (3rd. The kind of granular eruption 011 the ucoua membrane of the intestinal canal. 4th. The liquids contained in the stomach and intestines, with the exception of the drinks, medicines, &c, are composed of nothing but serosity, in which small pieces of coagulated albumen and epithelial cells float, with a little mucus. 5 th. The empty state of the arterial system whilst the venous trunks are gorged. 6th. The blood is much thicker and of a deeper colour than in its physiological state. It does not coagulate to form a clot which floats in the serum ; no buffy coat is formed. The fibrin e is dissolved, forming an homogeneous mass with the globules and the small quantity of remaining seisin. The 15 K)bules appear shrivelled up when examined by c microscope. 7th. There is no urine in the urinary organs. 18th. The surface of the body is of a bluish lour, cyanosis. There are extravasations of blood re and there on the skin, and on the mucous 3mbrane of the intestinal canal ; sometimes also the serous membranes, pleura, pericardium, ritoneum, and arachnoid. t9th. The expired air of Cholera patients has same chemical composition as that of the osphere, but it is four or five degrees below the ounding temperature. I In studying the ensemble of all these elements the disease with care we cannot fail to observe c connexion between the phenomena of the sease and the relation which the symptoms and thology of Cholera bear to each other. Let us pc that the deductions which follow may unveil c nature of the disease. The constant phenomena observed in the ensemble of symptoms and pathology which characterize Cholera are : the pathological cold ; the impaired state of the respiration, and the suspension of hematosis ; the intestinal flax. The pathological cold which suddenly seizes the whole frame is, without doubt, the prominent symptom of the disease. This is not simply a n< gative state, from the absence of animal heat, 16 but the effect of an active agent, and the temperature of the body is frequently four or five degrees below that of the surrounding atmosphere. This accounts for the difficulty encountered in warming a patient as long as the choleraic influence lasts. As soon as this influence ceases, even after decease, reaction takes place of itself. The morbid choleraic influence evidently seizes the elementary cells of the whole economy, and as each individual cell is endowed with its own independent vitality, it has the power of reaction in itself even after the cessation of all the other functions. Impaired State of the Functions of Respiration ami Hematosis. — In slight affections the change in these functions is scarcely perceptible, but in the more serious cases it becomes more | and more marked, with asphyxia as its highest I point. Organic vitality is then suspended ; the I air penetrates abundantly into the lungs, which are sound, but reduced to quite a passive state, as in a dead body. The cold breath exhaled from the lungs in this pathological state is quite characteristic. The blood, no longer oxygenated, becomes thick, like jelly, passes with difficulty through the vessels, and saturated with carbonic acid gas, strikes every organ with stupor. The capillary vessels are collapsed and empty. <¦ 17 I The Intestinal Flux is the first of all the symptoms we observe in slight cases of Cholera. This flux is necessarily more or less abundant in proportion to the rapidity of the absorption and the suspension of the secretions. With the appearance of this intestinal flux we can already discover the first dawning of all the other symptoms of the disease. The absorption of serosity appears to be the result of an altered state of the functions. All the secretions being impaired, hematosis and the generation of animal heat being diminished by the choleraic influence, which strikes with more or less violence the very elements of organic life, and decomposes all the liquids of the body just as blood decomposes when left in a basin. The serosity, thus separated from all the other elements, is promptly absorbed and carried to the intestinal canal, which becomes a mere recipient for the accu- tAll the morbid phenomena of Cholera are ounted for by the perversion of vitality which ades the entire organism, penetrating even to elementary cells. In the most serious cases, when patients are carried off in a few hours, the pathological phenomena we have described have not had sufficient time to be established, and consequently scarcely any pathological traces are left. From the moment the pathological cold begins 18 and hematosis is suspended, the vital functions of the whole frame are greatly impaired ; there is already a beginning of a kind of stasis of all the liquids, and a relaxed state of the tissues somewhat of the same character as we find with moribunds. Cholera is always declared at once, whatever may be the degree of invasion, consequently there can be no period of incubation. On the same ground the disease must be identical in all its periods, in its slightest as well as in its most severe form. Cholera does not necessarily go through all its periods, the disease may terminate after a slight invasion, it may pass at once from this to the period of asphyxia without having gone through any preliminary state. Reaction. — As soon as reaction frankly takes place, all signs of Cholera gradually disappear, and the disease assumes quite another character. There can be no cure for Cholera without reaction, and this reaction, though almost imperceptible in the mildest cases, is necessarily accompanied with more or less danger, in proportion to the violence of the attacks. In the most mild cases the general vitality suffers little, and the embarrassments are but slight, still they exist in degree, and in severe attacks the whole system is more radically affected. c 2 19 The enormous quantity of vitiated blood with which the viscera and the venous system arc gorged must be put in movement, and hematosis must be re-established before any permanent reaction can be accomplished. The viscera, when roused from their state of torpor, are exposed to be over-excited by the return of arterial blood, thence the febrile state which the patient is not always able to bear. iThe reaction, to be beneficial, must be mild, >w, and well supported. When the patients are o much exhausted they sink suddenly into a state adynamia, from which it is difficult to make em rally. I These observations are leading us away from ¦ subject, for the passive congestions and adynaj state which take place after reaction belong to te another pathological order. We could not howr pass them over in silence, for we are interested ye all in learning how a patient can recover n Cholera. The next part of the subject w r e c before us is that of contagion. Is Cholera a contagious disease, or is it not ? The question presents itself naturally in this form representing the two parties so absolutely opposed to each other — contagionists and noncontagionists. We place ourselves in the second category, and it appears to us strange that whilst our convictions are continually being strengthened 20 CHOLERA. 21 by diligent and impartial inquiry, we see the number of our learned brethren, believers in the doctrine of contagion, increase every day, though they cannot produce any proof on which they found their doctrine. If by contagion we are to understand the transmission of a disease from one person to another by any particular means, can it be by infection, by poison, or by any morbid production ? We will answer each of these questions, but it appears to us that the nature of the disease, its seat, and mode of propagation preclude Cholera from even the possibility of its being a contagious disease. Before we proceed to give the reasons on which we found our convictions, we think it right to give the opinions of the distinguished medical men who believe in the doctrine of contagion. CONTAGION. We place in the first rank the learned report of Dr. Briquet, which occupied many sittings of the Academy of Medicine. Dr. Briquet read this report in the name of a Commission appointed by the Academy to analyse the innumerable documents concentrated in the archives of the Academy. After giving a complete history of the disease, he passes in review all the different opinions on the Imptomatology of Cholera, and then says, "With gard to the propagation of the disease, our formation is extremely contradictory ; the result, •wever, after the analysis of an immense number facts, is that the disease spreads gradually, from use to house, from commune to commune, &c. c have examples of the most imposing character, th from their number and their authenticity, lich would make it appear that Cholera is msmissible from one individual to another, o wever the Commission abstains from giving iy opinion on a subject so difficult and so obscure, c place the facts before you, leaving every one form his own opinion. I" Inoculations of matter taken from Cholera bjects have been tried by several experimenlists without any success, from which we must nclude that Cholera is not a virulent disease." itting of the Academy of Medicine, March 27 th, I This report resumes the opinion of the Comsion on all the documents presented to the idemy. From this general opinion we must cend to details, and give more development to doctrine of contagion. We shall find all the uments usually employed in support of this trine in a paper read before the Academy by Jules Worms, at the sitting of November 1 7th, 22 CHOLERA. 23 t" Since 1817, starting from the Delta of the iges, Cholera has always followed the most vented lines of communication. I" The progress of the disease has always corponded with the rapidity of the means of traling. I" In a great number of cases the march of the ease has been in a direction quite contrary to most violent atmospheric currents. " There is not a single case on the records of science in which an island or a harbour had been primitively affected without its having been visited by a vessel coming from some infected I" When the disease reaches us by land, it is vays at the frontier that the first cases of Cholera pear. t" In an immense number of instances the ecting vessels had cases of Cholera on board, c same has always happened in large bodies of n who came from infected countries. t" It has never happened that a considerable iber of cases have appeared simultaneously in >dy of men, on a vessel, or in any place, without c isolated cases before. " In a considerable number of epidemics the disease has been imported by known individuals, who had the disease in a more or less confirmed state. 24 I" Things soiled by the evacuations of Cholera tients during a voyage, when taken on shore, c passengers not having landed, have infected c persons who washed them. The power of infec>n lasts 20 days. t" The gastro-intestinal diseases which are said to 3cede Cholera have been wanting in three-fourths local epidemics. These diseases have very often o existed without having been followed by I" Most frequently the cases of Cholera which ye appeared in a place have been followed by a *tain number of others in the immediate vicinity me house, same street, same quarter). I" Cases which occur at a greater distance, and considerable numbers, have always been sepaed from the first cases by an appreciable lapse time. I" Persons affected with Cholerine may produce olera in their immediate neighbourhood. I" Elevated places are less affected than low und. I" The disease is more easily propagated in rshy ground and in buildings constructed on alluvial soil than on silicious ground. 1(i1 (i The proximity of animal and vegetable tters in a state of putrefaction has often been focus of Cli olera. " Absence of air and habitual filth have most 25 frequently coincided with the development of the foci of irradiation." I From this application of the theory of congion to all the different circumstances in which c disease is supposed to be transmitted, it will i interesting to see how the contagionists account r the appearance of epidemics. We have a good :ample in the last year's epidemic, of which we id a report in the sitting of April 23rd, ISGG, cademie ties Sciences. "On the Cholera of Egypt in its connection with the epidemic of Marseilles in 1865. by Dr. Grimaud (de Caux)." We here find the most precise account of the passage of Cholera through Egypt, and from thence to Marseilles. I" Cholera came by the fresh-water canal from 1 el Kebir by the market-women. " Such was the march of Cholera in Egypt. I" It appeared at Suez on May 20th, at Damaur, near Alexandria, on May 22nd. " It burst out at Alexandria on June 2nd. " It then goes up the railway, at Beni Lacel it takes the branch to Zagazig, and reaches, by Fell el Kebir, the salt-water canal, committing the greatest ravages at Isma'ilia, a place reputed to be one jf the most healthy in the world. " If we now go to Marseilles we shall see that the fate of the Stella discharging her cargo on 26 nearly as possible, the same as that of the English steamboat depositing its cargo on the shore at KWe find in this paper the following paragraph hich we transcribe as an example of the most -aphic description of contagion. " The Cholera of the Isthmus has all the demonstrative value of a most successful experiment in a laboratory. What laboratory, indeed, could be more appropriate for such an experiment than this part of Egypt with its isolating desert, its one single railway, its fresh-water and its saltwater canals, all passing through the desert, and these groupings of workmen forcibly confined to their limited circumscriptions ? Nothing could occur there to disturb a careful witness, in obliging him to have recourse to various hypotheses. The pestilence can be followed step by step. Wherever it may be found it may be discovered, not only from whence it came, but almost always by whom it came.'' i" Conclusion. — Patients affected with Cholera :re imported from Alexandria to Marseilles by 3 Stella and other vessels, as it had been ported from Djedda to Suez by the English at, and by other vessels accompanying it." I Dr. Grimaud (de Caux) continues his subject er the title " Propagation in the town of ¦settles after the arrival of the Arab pilgrims 27 June, 18G5." — (Academic dcs Sciences, May 7th, ISCG). " It is necessary that I should enter into some circumstantial details to be enabled to explain thoroughly the mode of propagation of the disease. These details will show the degree of guarantee which my researches may claim from science. " As soon as I arrived at Marseilles I made known publicly the special object which brought me there : I said it was connected with the circumstances which had driven a vast number of the inhabitants from the town. " A simple visit to the superior authorities opened every door to me, and prepared a sympathetic reception for me everywhere. I" An immense number of facts Avere comunicated to me, which I had to reduce to their 'oper value, to divest them of the exaggerations ith which the general alarm had coloured them, had to search out the most important of these cts, to go to their source, to appreciate the lmediate and further consequences. In a word, had to give to each fact its proper value. " From this ensemble of my first researches the result was my conviction that Cholera existed at Marseilles long before the 23rd of July. Date given by the first official declaration. " On the 20th of September the emigration had amounted to 104,000 persons, and the mortality 28 had reached its maximum since the 16th. Fright and despair were marked in every countenance ; sadness and mourning everywhere. I" Large fires were made in the streets, from liich two very good results were obtained for the sople : great amusement, which was visible from c animation which this sort of scene produced itil very late at night. In this respect they 3re really ( fevx de joie.' The other result was less important in the eyes of the hygienist. lese fires consumed the decayed wood, the filthy JB, receptacles of vermin and vehicles of bad lells, from which all the houses were thus oroughly cleansed. These fires were established cry where at Marseilles, and in the neighbourhood. " After having, with great danger, gone through all the quarters, visited the houses and the streets which were almost entirely depopulated by the emigration or death of the inhabitants, I had not yet discovered any fact which could prove that the disease came from without. " One thing I did know positively, which was that the disease first appeared in the old quarters, where the streets are narrow, opposite the fortifications of St. Jean and the new harbours. " I know, moreover, that in the night from the 14th to the 15th June two cases of Cholera had been found on the quay of the harbour of the Joliette, near the stairs of the Major. 29 I" Finally, I know, but only vaguely, and withit any precise detail which could allow me to nee it to its source, that a vessel had brought me pilgrims from Mecca, and that several of ese pilgrims had died. !" However, the fact that two bodies of Cholera tients, taken from the stairs of the Major, and B fact of the manifestation of the epidemic in c same quarter, were so blended together that all probability the decease of the Arabs, if the cease really did take place, had some relation to 311 other, perhaps even the relation of cause and I" I went to the municipality to examine the nsters of the month of June. It was necessary collect the deceases from the bulletins themves. I had before me 758 pieces of paper of Perent dimensions and various handwritings to xmine and decipher. I" I was looking for cases of death from Cholera, 1 naturally I fixed my attention on the causes death assigned to each individual. In the ;ater number of bulletins in which this cause s mentioned I found the one only indication, f ural death. At Marseilles those deaths only ich have been occasioned by some violent cause " The difficulty was very great. I thought at td neglecting the causes of death, I returned to c bulletins to read the names. t" This is how I discovered the Arab Ben Kadur : his certificate of death belongs to the 12th June, in which day there were twenty deaths. iis circumstance made me happy, for it was a il discovery. I" I had yet to learn whence this Ben Kaddour ne. The declaration of decease had been made two soldiers, Voltigeurs, of the 38th of the line, 1 the Aide-Major of the same regiment had ned the certificate of decease. The informai obtained from the Aide-Major, Dr. Renard, me to Captain Dol, the commander of the tification of St. Jean, and from Captain Dol to the timissariat of the harbour, where I learnt that i Stella, which brought the pilgrims, is also : vessel by which it was first known at Marles that there was Cholera at Alexandria. I" I could not confine my researches to this. I lied to see with my own eyes the name of the ib inscribed on the manifest of the Stella. t" This manifest was at the prefecture. I had examine bundles of papers to find it. When I d it in my hand, I there saw something more m the name of Hadj el arhi Ben Kaddour. jtead of one dead pilgrim, I had now three, d of which had been thrown into the sea on ne 9th. 30 I" From this moment I believed and could affirm at Cholera reached Marseilles by sea (see Comptes ndus, t. lxi, p. 591), and from this time no one aid deny it. I believed all the cases of Cholera which I had heard. I had no longer the right disbelieve any one of them without going to see em. I could believe the two sudden cases of c Major, the wife of the Genoa workman and his ild dead of Cholera in the Rue St. Catherine, c house painter on the Mcesis, after he had passed c day there, &c, &c, &c. I" Notwithstanding, I was careful not to accept ese facts without verification. They do not pear in my narration, because I did not verify em. They were not necessary. The turn that lolera took was then the same at Marseilles as in ifypt. At Marseilles, as in Egypt, the first cases 3re in the neighbourhood of the spot where ssels arrive. At Marseilles, as in Egypt, the sease remained confined to the same place for my days. At Marseilles, as in Egypt, the nditions of salubrity were no security for public " If we can trace the radiation of the disease better in Egypt than we can at Marseilles, it is because the means of communication are much more frequent in a populous city. The crowd moves in every direction ; the meetings, salutations, and contacts are infinite, and escape every kind of 31 supervision ; whilst in Egypt, with the limits of the desert, the railway, the canals, all is frontier, which can be watched with undoubted security." I We have made every effort to present the ise of the contagionists as favourably as posle, and we do not think it could be done more jctually than by choosing amongst their highest yhorities, those who officially represent the two idemies of science and medicine. I We have quoted from the conclusions only of 3 immense and learned report of Dr. Briquet, 3 of the most distinguished members of the ademy of Medicine, and we there find nothing b uncertainty and doubt. We first learn that, m the analysis of the greatest number of facts, } disease spreads gradually, from house to house, 1 that it is transmissible from one individual to )ther. " However the commission abstains from ing any opinion on a subject so difficult and so scure. We place the facts before you, leaving 3ry one to form his own opinion." We find the same hesitation in other members of the Academy. Thus Dr. J. Guerin, who, like his colleague Dr. Briquet, was for a very long time intrusted with all these materials from which we hoped we might obtain the solution of the long disputed question of contagion, says Gazette Medicate, June 28th, 1806, "For, we repeat it, the disease introduced into a family into a house,. 32 tads like a spot of oil, gradually attacking all nd it — everything that touches it." . . . continues in the next page, " All in the maniition and in the progress of Cholera is still a tery, and true observers would do well to cone to watch facts as they present themselves, ing the theorists to their absolute systems." Thus after having affirmed in the most positive and absolute manner that Cholera is a contagious disease, he tells us that everything in the manifestation and progress of the disease "is still a mystery.*' lln the paper we have quoted from Dr. Jules rms, we find the same confusion as in a great iber of authors who have confounded Cholera ti the diseases with which it is so frequently iplicated. Thus we find that all the proposils presented by Dr. J. Worms, except the third, eh annuls all the others, are explicative of the ins by which Typhoid, Yellow Fevers, the £ue, &c, are transmitted, but they are by no us applicable to the mode by which Cholera is {Finally, Dr. Grimaud (de Caux), in his account be arrival of the pilgrims at Marseilles, thinks las shown us contagion in the very act. He says msly, " Instead of one dead pilgrim, I now had c ; two of them had been thrown into the sea June Oth. From this moment I believed and i) 33 could affirm that Cholera readied Marseilles by sea." Dr. Grimaud (de Caux) forgets however to tell us that these Arabs died of Cholera. NON-CONTAGION. Quotations from the partisans of contagion might have been continued without end, showing by their own arguments not only how completely they fail in establishing their case, but how frequently they defeat their cause by the most involuntary inconsistencies and serious mistakes, which furnish us with the best possible arguments against the doctrine of contagion. We must now present the question in its other form, that of non-contagion, and not contenting ourselves with opinions, however respectable they may be, we must bring forward facts, and those ifacts only which have been observed by the most irrefutable authorities. All personal convictions and private opinions must bo laid aside, and our observations must be drawn from those immense foci in which all opinions arc concentrated, to be discussed and analysed by the officially established authorities. tit is principally in the military services, under c influence of discipline and hierarchy, that the thorities can demand from their subordinates it attention and precision which are so necessary obtain definite and satisfactory conclusions. 34 I The medical inspectors, members of the Board ' Health of Armies, who have before them the ports and opinions of all the medical officers in ief of the army and the hospitals are, above all hers, competent to form an opinion on a question such vast importance and so controversed. I Dr. Cazalas, one of the members of the Board Health of the French army, read a most admible paper on this subject before the Academy of edicine on the 3rd of April, 18G6, in which the ictrine of non-contagion of Cholera is most ably pported. After proving that Cholera existed in the Crimea before the arrival of the troops, which are accused of having imported the disease, and after having given us numerous examples of the appearance of the disease in many regiments which had never had any communications with each other, &c, Dr. Cazalas tells us that, " From January 27th, 1855, to January 13th, 1856, the Hospital of the Military School of Constantinople specially appointed to receive Cholera cases from every quarter, received 1,488 cases, of which 658 died. AH the worst cases were treated in the special wards of my personal service. The slight cases, and those which were not almost hopeless were dispersed, the first on their arrival, and the others as soon as convalescence began, in the wards of the ordinary patients, Well ! Cholera was not only not pro- D 2 35 could affirm that Cholera reached Marseilles by sea." Dr. Grimaud (de Caux) forgets however t<> tell us that these Arabs died of Cholera. NON-CONTAGION. Quotations from the partisans of contagion might have been continued without end, showing by their own arguments not only how completely they fail in establishing their case, but how frequently they defeat their cause by the most involuntary inconsistencies and serious mistakes, which furnish us with the best possible arguments against the doctrine of contagion. We must now present the question in its other form, that of non-contagion, and not contenting ourselves with opinions, however respectable they may be, we must bring forward facts, and those facts only which have been observed by the most irrefutable authorities. All personal convictions and private opinions must be laid aside, and our observations must be drawn from those immense foci in which all opinions are concentrated, to be discussed and analysed by the officially established authorities. I It is principally in the military services, under c influence of discipline and hierarchy, that the thorities can demand from their subordinates it attention and precision which are so necessary obtain definite and satisfactory conclusions. The medical inspectors, members of the Board of Health of Armies, who have before them the reports and opinions of all the medical officers in chief of the army and the hospitals are, above all others, competent to form an opinion on a question of such vast importance and so controversed. I Dr. Cazalas, one of the members of the Board Health of the French army, read a most admible paper on this subject before the Academy of edicine on the 3rd of April, 1866, in which the ictrine of non-contagion of Cholera is most ably After proving that Cholera existed in the Crimea before the arrival of the troops, which are accused of having imported the disease, and after having given us numerous examples of the appearance of the disease in many regiments which had never had any communications with each other, &c, Dr. Cazalas tells us that, " From January 27th, 1855, to January 13th, 1856, the Hospital of the Military School of Constantinople specially . appointed to receive Cholera cases from every quarter, received 1,488 cases, of which 658 died. AU the worst cases were treated in the special wards of my personal service. The slight cases, and those which were not almost hopeless were dispersed, the first on their arrival, and the others as soon as convalescence began, in the wards of the ordinary patients. Well ! Cholera was not only not pro- D 2 I gated in the wards of the ordinary patients, or the populous neighbourhood of the establishment, t not one of the persons belonging to the hos:al (physicians, nurses, sisters of charity, priests, othecaries, and officers of administration) living ily in the midst of these cases of Cholera, ever esented, during the whole of this long lapse of ac, one single symptom of Cholera, or of infection >m the disease." !We shall have occasion to return to this import/ paper, in which we shall find information of i highest value relative to the invasion of the demic at Marseilles, &c, &c. But before enteron this part of our question, we must answer propositions of our adversaries, and we cannot this more effectually than by placing before our ders some citations from the works of James lesley, 1831, of William Twining, 1855, and Sir nes Ronald Martin, 1861. These physicians of the Indian army and hospitals speak with authority on the subject, from the fact of their having made these observations on the spot where the disease first appeared, and where it is endemical. The following are the citations alluded to :—: — I" Without disputing the possibility of contagion Cholera, even in the midst of and notwithstand; the thorough ventilations prevalent throughout lia, I am bound t<> Bay that, althowh I m;iv be 36 said to have lived in the midst of the disease during many years, I have never seen anything which, in my opinion, warranted the belief, nor have I ever communicated with any Indian medical officer who believed in the contagiousness of epidemic Cholera in India." I" The Cholera epidemics have never, in any stance within my knowledge, been even supposed have been imported into any of the ports of dia, by ships from infected countries, or through y other manner of human intercourse." — Influence Tropical Climates, by Sir J. R. Martin, p. 513. "If the disease were contagious, the persons most exposed to contract Cholera in the General Hospital at Calcutta, would be those having charge of the bedding and clothing, and those employed in personal attendance on the patients. The man who has charge of the hospital clothing, and his assistant, both attend in the wards every morning, changing the bedding of one ward each day on ordinary occasions. But when Cholera exists, these people are obliged, in the majority of cases, to change some of the bedding of the patients having that disease daily, or oftener when soiled ; for which purpose they come to the bedside, taking away with them the dirty bedding, which is given to the head washerman. " Two clothes-keepers have been employed at this hospital in twenty-five years, and three head 37 none of these men have had Cholera, neither have any of the subordinate washermen or people employed about the clothing and bedding stores ever had the disease. I" The native dressers have daily the most unrerved communication with the sick, changing the plications over leech-bites, and the bandages to c arms of such as are bled, dressing blisters, and plying sinapisms ; not one of these has ever ffered from the disease. Buctourie, the head tive dresser, who instructs the subordinates, d attends with them alternately while at their ty, has been constantly employed at the hospital ¦ twenty-six years. He is a clever man, of good iracter, and asserts that he has never known one the hospital servants to be attacked with the lease. " The sweepers who clean and change the closestools, as well as the pans in which the matter vomited is received, and who wash such patients as may be helpless, have never been known to suffer from Cholera. It may be supposed that the occupations of the sweepers are usually such as might be expected to blunt their susceptibility to disease, or to the effects of any ordinary exposure ; but this will not be urged respecting the Hindoo coolies, who are employed in attendance on the sick, and are obliged to be much in contact with all bad cases of Cholera, to keep the blankets from being 38 39 when in the worst stages of the disease, and Buffering much from jactitation and restlessness. These coolies are also employed to rub and shampoo the extemities of the Cholera patients, and often cannot avoid inhaling the breath, as well as the exhalations from the bodies of patients in the most deplorable stages of the disease. Not one of these men has ever suffered an attack of Cholera. The young students, who are under a course of medical instruction, at the H. C. School for Native Doctors, are usually in attendance, and assisting at the hospital when Cholera is prevailing in a severe form, and when great numbers of patients are admitted with that disease. In March and April, 1827, when the hospital was unusually crowded with Cholera cases, and all the attendants much distressed and exhausted by the severe duty, a number of the young students from the school were brought to the hospital, and placed in attendance over the worst cases, being relieved regularly day and night. These young Asiatics performed their duties with great diligence, assiduity, and humanity for many days and nights, and none of them suffered by this constant exposure to whatever may be contagious in the emanations from Cholera patients, as well as the frequent contact of their persons. I publish these statements, after having made the most careful observations on this subject, when the disease has been prevailing most diligent inquiry relative to the same points during the last fourteen years." A remarkable instance of exposure, with impunity, to any morbific causes arising from the person during Cholera is recorded at page 146 of I" By Mr. Henderson's account of the disease lich raged on board the H. C. ship Berwick- Irt, in Bombay Harbour, in June, 1830, it pears that 94 men were taken ill of Cholera thin a few days, of whom 38 died. A large oportion of the sick was landed and treated at c Bombay European Hospital, and 16 of the aths occurred in that hospital, where there were the time more than 100 patients and attendants, t one of whom contracted the disease." " More than a hundred such instances may easily be collected by any one who will take the trouble to make critical inquiries respecting the history of Cholera for the last fifteen years." — Twining, vol. ii, pp. 181-186. " The lapse of time between the existence of perfect health and of the full manifestation of disease was so short, that no such evidence of the intermediate changes as exists in contagious diseases generally could be detected in this malady. Very many also of those who were seized with the epidemic Cholera, neither saw nor came within the sphere of any other individual affected with the- rli r rrlor * * 40 I" The sudden occurrence of the epidemic olera, in particular stations and districts, the onishing violence with which it appeared, the tat numbers which were immediately and mltaneously seized with it, its very unexpected 1 quick decline, and its total disappearance after umitting unheard-of ravages during a few days y, are circumstances wholly incompatible with 3 belief that it either originated in, or was dified by means of contagion." * * I" In illustration of the above statements, I may duce what occurred in the hospital under my arge. Indeed, both in that hospital, and during c course of my whole experience of the disease ewhere, no more than two cases occurred to ), which the most strenuous supporters of con- in this disease could adduce in aid of their iws ; and these oased evidently appear to have isen from a very different source than from con- " These patients were in a ward with between eighty and ninety persons, many of whom collected around their beds, and yet not one of that number was attacked with Cholera." * * t u As the non-contagious nature of the disease very generally admitted by the medical authoies of India who have had sufficient experience the disease, and as this property is generally lieved in by the community at large, I should J JO 7 41 42 not have thought it necessary to advert to a contrary opinion, had not that opinion received the support of some distinguished medical authorities. I cannot, however, but tliink it unfortunate that the idea was ever suggested, because the dread of contagion may lead to serious consequences, inasmuch as it may withhold from the sick that assistance which they so much require. The strongest proof which I can adduce in opposition to it, came fully under my own experience, which has not been inconsiderable, and was derived chiefly from what I observed in the general hospital at Madras, whilst it was under my charge. This hospital generally contained from 170 to 200 patients, natives and Europeans ; the wards were open, and a free communication existed between them ; and yet, although patients were daily brought into them suffering under the epidemic Cholera, although these patients were indifferently distributed throughout the hospital, and consequently not secluded from the rest of its inmates, no more than five or six persons. exclusive of the two already noticed, were seized with the disease while patients in the hospital, during a period of five years ; and certainly tl use cases could not be imputed in any degree to contagion. I can view them merely as cases of Cholera, occurring under circumstances of predisposition, during the prevalence of an epidemic cause, and as showing even a much diminished ratio of attack to that observed where the disease prevailed."— A nnesley, pp. 208, 209, 212, 213, 215, These citations might be considered quite ifficient to annul all the affirmations of the congionists. But why should we go so far back in arch of facts in support of our convictions, when c have them before us every day. We find a etter in the Comptes rendus of the sitting of the cademy of Medicine of the 28th of November. )r. Fee, Member of the Academy, informs his olleagues that he has received a letter from r. FHerminier, senior, dated November Bth, aiimncing that Cholera rages with great violence at juadaloupe. Dr. Fee gives the following extract ' his letter. " We have Cholera amongst us since October o 22nd, without knowing whence it came. No suspected vessels have arrived in our harbour, no caravan from Mecca, no railroad to bring it to us. It originated in the marshes, and in sixteen days 150 persons have died ; 50 of whom were negroes, the others half-cast, besides four white Creoles, three men and one woman, who were all in bad health and living in bad hygienic conditions. Here we have an introduction without any introductor — a most clearly proved case of spontaneous origin. The disease which was at first confined to the spot 43 44 h, Pitre) which is in the best possible condition of salubrity." iWe now proceed to answer Dr. Grimaud (de ux) and we have chosen the words of Dr. Didiot the Cholera at Marseilles, because Dr. Didiot is lilitary man, Medecin Principal dcs Tlospitaux, 1 as such he is subject to the control of his )erior officers — the Inspectors, members of the tny Medical Board. He, in his military capacity, 1 to give an official report on the epidemic at Maries which he afterwards published, and from ich we shall quote extensively, because it is ;m [uiry into the very facts reported by Dr. Grimaud. I" The official acknowledgment of the existence the epidemic at Marseilles dates from the 23rd July only, but it is undoubted that the disease peared sporadically in the month of June ; even the first week of that month cases occurred at :ervals of a few days from each other. These ses were either not recognised at the time as 3es of Cholera, or they were kept silent from ir of creating public alarm. " Thus as early as June 6th, a drayman was attacked with algide Cholera from which he recovered : June 9th, there was a decease from Cholera in the Church of St. Laurent. Now the Arab pilgrims, accused of having imported the disease from Egypt, had not yet arrived at Marseilles. It is also remarkable that it was not (the 2nd of June that the first case of Cholera >eared at Alexandria, and from the 12th of ie that the disease took an epidemic character 1 penetrated to the interior of Egypt." — {Report M. Aubert Roche on the Cholera of the Isthmus Suez). But it was well known that there were cases of Cholerine, Cholera, as early as May 2Gth at Marseilles, and these cases increased considerably in number during the month following. The disease reigned there as an epidemic from May 2Gth to November Ist. As it is not our wish to write a history of the epidemic, but merely to produce Dr. Didiot's work in comparison with Dr. Grimaud's report, we will at once come to the point which interests us .it lli is moment. After some details concerning the soldiers who passed through Marseilles, 2,000 per diem, and on those that sojourned in the fortifications of St. Jean, Dr. Didiot says : " Well ! this fortification of St. Jean so terribly accused by the contagionists, as were also the quays near the Juliette, had not one case of confirmed Cholera in this considerable population until September Bth, when a soldier of the 3rd batallion of African Infantry was attacked, and even this one case was in consequence of drunkenness." t' Dr. Henard adds : amongst all the men passthrough and lodged in the town, I was never 45 but once called to a case of Cholerine, which was on August the 27th, in the Eve d'Estelle for a soldier of the 63rd Infantry, a man of weak and exhausted constitution." I" From the simple statement of facts it is iarly shown that Cholera appeared at the same ne at Marseilles and Alexandria : in the first of ese two towns before the arrival of the pilgrims cused of having imported it, and in the second, ter they had embarked for Europe."' t" Moreover, truth obliges us to put some of facts presented to the Academic ties Sciences] Dr. Grimaud in their correct light and it will easily seen that these facts are not only in•ect, but the interpretation which has been m them is completely forced." " After diligent enquiry we learn the history of this wonderful Stella to which they have wrongfully imputed the importation of the pretended germ of Cholera from Alexandria to Marseilles. "Sailed from Alexandria on June Ist, with 100 passengers, of whom 70 were pilgrims. She had two perfectly clean bills of health, and on the 7th was permitted to enter the harbour of Messina. On the 9th there were two deaths on board, one E Letter from the captain of tlio Stella by M. E. Regnier, phore m east to west, in every direction, and often to mense distances without touching the inter. :diate country. I It is impossible to establish the filiation of the sease when it declares itself suddenly in a city, the centre of a country, where there has not been c single case of Cholera. Cases occur at the same jtant in places not only the most distant from other, but also without any possible communi:ion between the patients ; in the cells of prisons, convents, in hospitals, &c.,&c, in the most healthy well as in the most unhealthy places ; amongst classes of society, the rich and poor ; the valid 61 and invalid. Thus this terrible disease appears to us to break through all the laws that contagious diseases are subject to. Is it not then most unreasonable to inflict the rigours of quarantine laws on nations, to interrupt the intercourse between people, and to create terror, which never fails to spread the disease ? A cordon sanitaire was established at Dantzic, in 1831, outside the fortifications, and another in the harbour, and with a lazaret. In a word, all the measures of the quarantine laws were put in force. The disease appeared in the place notwithstanding all these restrictions, and then every house in which a Cholera case occurred was sequestered ; the disease continued to spread more rapidly, and to rage more violently ; of 1,387 patients, 1,010 died. Without doubt we shall be told, " You give us only one example ;it is not always so." We answer that examples of this kind are but too frequent, and that the same causes will always be followed by the same effects. We have here to deal with a sea-port, where every vessel can be rigorously inspected before it enters the harbour. Can these cordons sanitaires, these inspections, &c, be applied with any security to protection by land ? We unhesitatingly say they cannot, for every measure that can be taken must be absolutely powerless in preventing communications between neighbouring countries. Since then Cholera cannot be stayed, either by land or by sea, of what use are the quarantine laws ? Again, if these laws and restrictions were effectual, could they always be applied ? The International Congress, which is still sitting at Constantinople to prevent the return of Cholera, has decided by a slight majority to cut off all communications between Egypt and the coasts of Arabia as soon as Cholera might appear again in this latter country. I The representatives of the Ottoman Empire and F Persia opposed this resolution, vigorously pointig out the serious consequences that must result om such a decision, if it were ever carried out. heir argument is irresistible. They say, "If you •event the pilgrims from going to and fro on the a, there will inevitably be a revolt, or a most mgerous commotion amongst the people. If the lgrims are prevented from returning to their untry, they will not be able to find food in Arabia, us famine will be added to the epidemic, a foridable insurrection will follow, and the Porte will ye to bear the consequences." This resolution of the Congress cannot therefore be put into execution. It is evident that the most rigorous measures offer us no security against the invasion of Cholera. We do not yet know by what means the disease is propagated. It is very amusing then to watch the ingenuity of the mosl 62 tssionate contagionists when they are put to the al, and are obliged to account in some way or ler for the inefficacy of the quarantines they pose on us. In the Gazette Medicale de Paris, March 17th, 1866, under the head " Cholera-Morbus," by Dr. Eissen, editor of the Gazette Medicate de Strasbourg, we find the following paragraph :—: — "We have now learnt, without the possibility of any contestation, by the most patient and conscientious investigations, that these prodromic diarrhoeas, these cholerines, are the most active means by which Cholera is propagated. Patients travel with perfect ease, and often recover "spontaneously from these affections. The propagation of Cholera is thus principally to be attributed to these travellers who deposit their dejections here and there, everyvfoere, unknown to any one. These are the means by which the cordons sanitaires are deluded on land." (When we find our adversaries driven to such explanation as this, we cannot help thinking t they speak without conviction. Their irantines are always, and will always be iblished, either too soon or too late, for )lera has always deluded them, and always will tinue to do so. We have already seen that though the Congress sitting at Constantinople had proclaimed 63 ILe necessity of quarantine laws, they found that Lese laws and restrictions could not always be )plied. They now avow that quarantine is not ways necessary for "it is very true," says the Dngress, " that the steam-boats which have for any years been employed in the Indian service, Lye never imported Cholera to Suez, so that it ay be said without entering into more par-3ulars, that everything coming from a country Pected with Cholera is not capable of transmitig the disease." We presume to think that a disease must be contagious or not. Surely the example we have here quoted from the parti zans of contagion cannot be suspected, and it is of itself quite sufficient to guarantee us against every idea of contagion in Cholera. I The quarantine laws, the last remains of the rbarous institutions of the middle ages, are still wever maintained in all their rigour even in is our time of progress and civilization. These ws serve only for the protection of parasitical rporations, which prey on the vitals of society, crificing their victims to the remorseless fear of norant and timid populations. Every one must admit that quarantines and cordons sanitaires are quite absurd when the disease exists already throughout an entire country as is always the case in epidemic Cholera 64 65 What kind of protection or security do we obtain from quarantine even in epidemics of contagious diseases ? Why should they be established at any I The lazarets are nothing more nor less than >i of infection for contagious diseases, which en political reasons should not tolerate. I When the yellow fever raged at New York in )58, the Americans understood so well that the fection came from the quarantine that they rushed i the hospital of the Lazaret and set fire to it ter having taken the patients from the building. he epidemic ceased immediately. !It is clearly demonstrated that the only certainty which we can be protected from epidemics of itagioufi diseases is by the destruction of the ans by which these diseases themselves are oured, for contagions diseases are propagated re only, where they find the elements of their I We have another convincing example in favour our argument in the great fire of London in G6, which destroyed the greater part of the y. The houses were at that time built of wood 1 projected, almost touching each other, over 5 streets, so that the atmosphere of the dwell[s could never be thoroughly changed, and the igue was quite an endemic disease, becoming demic two or three times every century. The F louses were rebuilt on better hygienic principles, nd since then the Plague has never appeared in ondon, although the communications with infected mntries are very much more frequent now than •rmerly. The question of the application of quarantine laws to Cholera has led us to make these few observations on the quarantine laws in general. To return to our subject, Cholera, we must admit that although it is true, as we have already seen. that infection, poisons, miasmata, virus, &c., &c. (the means by which contagious diseases are propagated) have no influence whatever in the production of Cholera itself; these contagious, zymotic diseases, are often, however, associated with Cholera. There is no antagonism between Typhoid Fevers and Cholera, though they are of such a different nature, they often co-exist, and the typhoid character even predisposes to Cholera. The etiology of Cholera is still veiled in great obscurity which we may hope to dissipate only by the close observation of all that passes in a patient affected with this disease. I We have already seen that the morbific action sudden : the symptoms are those of collapse of 3 whole organism with an altered state of ality and suspension of the functions of assimiion and disassimilation. We know of nothing t electricity which could strike so suddenly and 66 67 so deeply through the whole economy, without leaving any trace of organic lesion. This electric influence hovers over us, occupying certain zones, attacking isolated vessels, even at sea. This opinion, far from being new, has been frequently enounced by the most learned physicians and the most scientific men of the day, particularly since the appearance of Cholera — d'Alambert, P. Brydon, Faraday, Lake, Oersted, O'Shaugnessey, Atkinson, Sir James Murray, Dr. Castle, of Boston, Mr. M'Cormach, &c, &c. Electricity pervades everything in nature, organic as well as inorganic matter. As we have already established an analogy between the affinity of atoms and the vitality of the cells, so may we now inquire if this analogy may not be continued in the composition and decomposition of mineral substances, and in the assimilation and disaflsimilation of organic tissue. There is a development of heat and electricity in both cases, subject to the laws of chemistry in the first case, and to the laws of vitality in the other. The vital action, which is incessant in the healthy frame, must then cause a proportionate development of electricity. To how many changes is this development of electricity exposed ? Innumerable causes from without and from within must affect this vital action : the milieu in which an individual lives ; the moral, intellectual, healthy, or morbid state, must inevitably produce 68 CHOLERA. corresponding changes in the electric state of the elements of the whole economy. I We are more or less affected by a change of mosphere, independently of its pressure, its teniirature, its dryness, or its humidity. Are we >t continually passing from a state of languor, •ostration, sadness, and depression, to a state of gour, strength, joy, and courage, with a feeling elasticity of body and mind, and an inward coniousness of indescribable happiness. All this ider the influence of a sudden change which has ken place in the electric state of the atmoslere. (Assuredly, as long as we remain in a state of ?pression, we are exposed to all the morbid fluences which may affect us, but when a favour)le change takes place we feel a kind, of reaction liich gives us the power of resistance witli a nsation of relief. This general influence is undoubted, but still we are very far from being able to define the action of electricity on the economy. We are perfectly conscious, however, of its existence and of its power. It is well known that the influence of the magnetic pole was considerably disturbed in Russia, and that a magnet which attracted a weight of 75 pounds, lost so much of its power during the height of an epidemic, that it could no longer CHOLERA. 69 attract more than 15 pounds. This disturbed influence of the magnetic pole was recovered, and the power ot the magnet restored, by degrees, as the violence of the epidemic abated. We know then that there is correlation between the electromagnetic power and the cause of Cholera. I We may also attribute'all epidemics, whatever j disease may be, to this cosmic influence. In demio Cholera, then, this influence cannot be lied, and from the nature, the seat of the disease, well as from its peculiar character and sympqf, we feel authorized to recognise the same luence as the cause of Cholera. I Have we not also had epizootics and diseases the vegetable kingdom within the last few rs, which we never had before ; the cattle the potato rot, and the oidium, which are attributable to the same cause ? We have seen that a modified state of th electro-magnetic power appears with, and accon panics the progress of, an epidemic ; that to i action also may be attributed the cause of Choler We shall now see that Sir James Murray, who ha made the influence of electricity in the productio of different diseases his special study for the las 40 years, attributes epidemics of an inflammator character — rheumatisms, inflammatory fevers, broi chitis, ophthalmia, &c. ; &c. — to positive electricity whilst he considers, Cholera, influenza* diarrhea 70 CHOLEIiA. dysentery, yellow fever, typhoid and intermittent fevers, to be under the influence of negative electncity. Dr. Castle most ingeniously represents by diagrams the choleraic action passing like lightning rom one country to another over the whole urface of the globe, and in his remarkable work lys " that climate and soil have nothing to do vith the epidemic only in their respective pro)erties as electric conductors, it being altogether produced by an electro-magnetic action and thermo [ectrical or telluric influences Avithin and upon le crust of the earth." He attributes the cause nd march of Cholera to these two influences. It cannot be denied that such influences must produce their effect on organic life. Their special action, in producing Cholera has not yet been demonstrated. The effects, however, on the system are such that none but the subtle and powerful influences we have described could produce then). We see the effects of these influences extending over vast continents and zones. Dr. Castle, as an example, tells us that " H. B. M. S. Undaunted left Canton for the purpose of conveying the Govenior- General of India to England. On her passage a mv nber of her crew were attacked with Choleraic asphyxia. This continued for several days. The surgeon recommended the captain to change the vessel's course into another latitude, which being I ne the malady immediately ceased. It is here >rthy of remark that the ship was, previous to is, perfectly healthy, nor had the disease been in it part of the world for a considerable period 3vious to the Undaunted 's visit. The ship Anne, Newhaven, crossed the same line of latitude, len the Cholera appeared on board. The captain mediately bore away to a more southern latitude, 1 it immediately disappeared/ Every individual who is exposed to these influences does not contract the disease. There must be an individual predisposition. We have already said that " the moral, intellectual, healthy, or morbid state must inevitably produce corresponding changes in the electric state of the elements of the whole economy." Exhaustion, prostration, and fear must expose those persons who are under the general influence to be affected by the morbific action. Fear furnishes us with the most constant examples of this predisposition in every epidemic. Probably people were never more alarmed than in 1832, when Cholera first made its appearance in Para During the first few days the patients were carried off in two or three hours. The panic took a frightful form, and certainly caused the greater number of victims. Everything became an object of dread. The people were persuaded at one moment that the water, the provisions, the wine, everything was poisoned 71 Amongst many other incidents of the time we ill relate the following as an example : — A man was suddenly taken with Cholera in a wine-shop. 'he persons present, in a state of frenzy and with ireats, obliged the unfortunate marchand de yin ,o drink a glass of his own wine. Overcome with 'ear he drank, and was immediately struck with Cholera. The mob rushed at once into the shop, emolished everything, and emptied all the wine 'rom the cellar into the gutter. We give only one more example of the effect of fear, which will furnish us at the same time with the most striking proof of non-contagion of the disease. !Fhe English Government sent Sir William sell to St. Petersburg when the Cholera fifiri «red there. Sir William states that the authos ordered a certain number of condemned inals to be placed in beds from which the es of Cholera patients had just been taken, criminals were carefully kept in ignorance of circumstance and were immediately afterwards to considerable distances from each other. Ie of them were then told what had happened lem, all of these men died ; whilst the others, to n this communication was not made, were not ie least affected. Precautionary Measure*. - From all that Wf know of the nature of Cholera, its etiology, &c, we 72 73 Id persuaded that every effort should be made to event the population from becoming alarmed, and gienic measures should be anxiously attended to soon as an epidemic is to be feared. Cholera is t a contagious disease ; every one should be coniced of this. It would be advisable that persons bued with this conviction should gain admittance every house, through some pretext or other, so to give confidence and security to families, and the same time to seek for those slight cases in lich simple, but prompt, measures are so highly I The house-to-house visiting which has been practice for several years, with the greatest aditage, in England, is, we believe, confided almost ilusively to medical men. These gentlemen mot possibly suffice for this duty, and, moreover, ;ir uncalled-for presence in families is objectione during an epidemic — it is a legitimate cause alarm. The visits of non-professional persons uld, on the contrary, give strength and courage lply by this mark of sympathy and kindness. EWe do not speak of those families who have r own medical men to guide and advise them dl times. We allude only to the poor, with r isolated families, amongst whom it is so ditfito establish those hygienic measures which, by r position, are rendered more particularly It is not necessary to repeat the arguments we have established against the appellations " Cholerine," " Premonitory Diarrhoea." Every one should be warned of the insidious nature of this intestinal flux, and of the treatment it requires. I The dispensaries and public places from which xlical assistance may be obtained, cannot render c services required during an epidemic. Medical distance is never sought by the poor until it is j late, and the visit of a medical man cannot ffice under such circumstances. It is not so ich the science and skill of a medical man that required as a perfect change in the habits and 3 of the poor. They huddle together in one room, "a fully closing up everything, papering up the inks of the windows, and Hating the doors, stoplg up the chimneys, &c, perhaps with a stove ¦ their little cooking. I This is how every room is, as it were, scientifily converted into a perfect laboratory of fer;ntatio — a terrible focus of infection. All the Iding, all the clothes are saturated with the mense quantity of vapour continually seethinir in their bodies — perspiration, breath, gases, &c. is this fermentation, putrefaction of animal /tter, which gives that peculiar odour to the thes which is called " the poor smell." I The atmosphere which these unhappy creatures athe is thus .-iliimst entirely composed of this 74 75 lisonous vapour, with carbonic acid, and sulphured hydrogen, gases, &c. Their vitality is so reced that they 3hiver as soon as they are exposed the least contact of pure air, and they quickly ;ep back again to their dens of infection. They mot be persuaded by any argument, for they are vev satisfied except when they are in this state intoxicating asphyxia, produced by their fright- I These are the foci of all contagious diseases licli are continually being kept up. How are jy to be destroyed ? Arguments and persuans are of no use, for the poor will always huddle 'ether in the same way. The poor, moreover, ) the most susceptible of all classes of society ; ly can be approached only by acts of sympathy :1 active charity, by assisting them in their ilillities and attending to their sufferings, practically mging their mode of life, without any explanan or attempt to persuade. I Authority has no power here. All the impro vents which may be made in the dwellings of the >r are necessarily very limited — whatever they y be, they can be but very temporary, for these lappy creatures will immediately relapse into ir former habits. No hope can be entertained any radical reform, any permanent good, by any er means than by frequent visits amongst them, iging them, imperceptibly, to change their mode 76 I' living. They require to be roused from their olation — to be made feel that they are not abanjned and rejected. This is the object of true ;tive charity which raises the moral, so differently om the negligent and indifferent alms-giving, liich serves only to degrade the poor, to encourje vice and misery. The most favourable time, the real opportunity, for the exercise of this active charity, is in the time of sickness, by attending patients in their own homes. An intelligent nurse, under the direction of the noble Sisters of Charity, by attending to all the wants of the sick, making the different members of the family assist in cleaning the rooms, lighting the fires, opening the doors and windows, destroys those foci of infection so much to be dreaded by the community. A permanent change will thus be obtained in the besotted habits of the poor, whilst at the same time there is every advantage to be gained by the attendance on the sick in their own homes. This is demonstrated by the fact that the mortality is much less with patients thus treated than in the hospitals. (In their homes 33 per cent., and 53 per cent, in the hospitals.) tin times of great visitations, the presence of highest personages amongst the sick raises the al courage, gives life and energy to the poor, i assuaging the violence of epidemics. 77 IWe have just witnessed the most admirable tcts of this powerful influence from the visits of M. the Emperor Napoleon to the Hotel Dieu, 1 of H. M. the Empress to the Beaujon, Larisiere, and St. Antoine Hospitals in Paris, and the hospital at Amiens. There is no doubt t many patients whose cases were absolutely paired of, were roused to a state of reaction, I their recovery was wholly attributable to the :ct of the presence of these august personages. I The effect produced by the presence of their ijesties was so great that we could scarcely ml citing it as an example of immense moral t ver which might be imitated on similar oceans ; also, the observations we have made on the lefit to be derived from attending the sick poor their homes are, we are persuaded, of such im•tance, that our digression lias been almost sessary though bearing only indirectly on our I The sick poor are not, however, attended in 'ir own homes ; in fact they never can be ; the ater part of them, always the worst cases, must sent to-the hospitals. The hospitals are overwtled immediately on the appearance of an demic, and become foci of infection for contaus diseases. We would suggest, then, that in&d of putting in additional beds, their number uld be diminished, in each ward, and that soparate 78 houses should be prej:>ared in every district for the reception of patients. By this means all the epidemics of contagious diseases would cease, and, in Cholera cases, the patients would be in a much more favourable condition for their treatment. With regard to disinfectants, as a preventive measure, we reject them altogether. All the experiments which have been abundantly tried have sufficiently proved their thorough inefficacy. The fumigations of chlorine would appear to be not only inefficacious, but really injurious, " all the men employed in some laboratories in the preparation of this substance (chloride of lime) died." (Cholera Morbus, Fabre, p. 222). The enormous quantity of chlorate of lime which is found in every corner of the streets of Paris, serve only to infect the atmosphere and frighten the people. There is nothing in Cholera to disinfect, and under all iicumstanoes, there is but one absolute disinfectant, and this is cleanliness. Treatment. — Every rational treatment must be based on the knowledge of the seat and nature of the disease. From the sketch we have presented of the symptoms and pathology of Cholera, it appears to us evident that the seat of the disease is in the elementary cells of the whole economy, and that its nature is derived from the vitiated state of these cells. The treatment then must consist in 79 Bloyed will always be at hand when we have a net object in view. IWe shall abstain from naming the immense nber of medicines and prescriptions which have n employed in the treatment of Cholera. They ild fill a large volume. The Materia Medica offers us two great classes of medicines : those which act directly on the system, and those which produce no effect until they have undergone an elaboration in the economy. The medicines of this last class can have no power of action in cases of Cholera, from the fact that all the functions are suspended, and they cannot be clnborated. Those medicines only can be rationally employed which produce a direct and immediate action on the system. It is simply a delusion to depend on the dynamic power of medicine in cases of Cholera : c. g. in the administration of mercury, not one atom, in the form of calomel or otherwise, was ever absorbed by a Cholera patient after the first period of the In confirmed Cholera the intestinal canal quite in a passive state ; there is no longer an abeorptdonj so that all the medicines which requii to be assimilated before they can act on the systen must necessarily pass through the bowels, withou produciLg any effect. This is how we can accoun for the immense quantity of sub-acetate of lea< 80 to li is patients, without producing any deleterious effect. Our remedies must then of necessity be those of the first class, which act immediately on the system, and every effort must be made to obtain a reaction as promptly as possible. t There are a great number of medicines of this it class, amongst which we find ethers the most werful and applicable in Cholera, from their Dmpt and penetrating action, which rapidly sses off, allowing the dose to be repeated freently, and that without the least injurious effect the system. I The ethers, ammonia, alcohol, the tinctures and usions of aromatic plants, camphor, coffee, tea, tie, brandy, liquors, ipecacuanha, the sulphuric and drochloric acids, furnish us with all that we may [uire ; opium and its preparations should never lie ployed except in the first period of the disease. First Period. — All the inhabitants of any region over which the choleraic influence hangs must in some degree be affected by it. This choleraic influence is in general so slight that the derangement of the functions may not be observed. This insidious nature of the affection renders it the more necessary, however, that the first symptoms should be attended to as promptly as possible : the habits of life should be regulated, the hygiene should be Erich exhausts the vital powers should be avoided, ople should live well, and their spirits should be pt up. No time should be lost when the first symptoms become more marked : warm drinks, infusions of camomile, tea, violets, some camphor julep, a little brandy, rum, or any other kind of spirituous liquor in hot water, heated flannel applied to the abdomen — such remedies, with a little repose, are r orally sufficient to obtain the desired effect. The tongue is in general clean, far from being linn and dry, it is disposed to be cool, and the dilation is already rather languid. The system ist be supported, and a certain degree of reaction tamed. If the means already employed do not ffice, it would be advisable to produce a slight neral commotion by the administration of one two scruples of ipecacuanha ; and if after this 3 intestinal flux should continue, eight or ten >ps of chlorodyne, with three or four drops of phuric or hydrochloric acid in an ounce of water, be given with advantage every two hours, or after each evacuation. Our usual prescription is as follows Ji> Tineturse cardamonii eomp : Syrupi cortieis aurantii .... aa. ... $i. Vini opii (Sydenham) s' BB - Acidi hydrochlorici gttas xx Chloroformyli 3'i 88 - it mistum ciijus capiat cochleare ummi minimum cum aqiuc uneia un&, post sinrmous quantity of morbid blood in the large ions trunks constitutes those passive congesns, which are often the insuperable obstacle to ) continued reaction. I The peculiar nature of these passive congeslis appears to us so patent that it seems im- to attribute them to the effect of the inulants which the patient had taken to produce .ction. The collapsed state of the patient occaued by the presence of blood saturated with bonic acid, could scarcely be mistaken for in:ication produced by alcohol. It is evident that ) organs must remain insensible, and that no nuknt could reach them until they were freed 87 88 torn the accumulated quantity of black blood hich keeps them in a state of asphyxia. The great argument, then, employed against stimulants, on the supposition that these passive congestions are the consequences of their administration, is without foundation. As soon as organic sensibility is roused, great care and caution must be observed in the use of stimulants of all kinds. The patient should be kept quiet and sustained by small quantities of light food, broths, &c, so that the reaction may be as gentle and mild as possible, thus allowing the organs time to become habituated again to their natural stimulant — arterial blood. Tea, coffee, the infusions of warm aromatic plants, camphor julep, the acetate of ammonia, &c, are the principle medicines to be employed under such circum- I Notwithstanding every precaution, sometimes 3al inflammation, accompanied with some degree fever, sets in. when it has been thought necesrv to moderate the reaction by small bleedings. lis is an extremely difficult question, requiring c greatest medical tact. We have, however, nerally seen this accidental kind of inflammation by the application of large, dry, cuppingisses, and perhaps the administration of some ght purgative medicine — a seidlitz powder, or lf-an-ounce of castor oil We abstain as much as 89 Ijsible from the abstraction of blood, even under s3e circumstances, for this apparently too violent ction is quite ephemeral, and the patient easily ses into an adynamic state. With reaction olera disappears, and the adynamic state, the Lsequence of reaction, assumes a typhoid chater. We must therefore have recourse to quinna, and all the means usually employed in the ious forms of typhoid fever. lln the midst of the most favourable reaction, n when everything appears most promising, a ipse of Cholera often takes place. Unhappily i cannot be foreseen or guarded against. It •ears to us more like a second attack than a ipse, which seizes the patient under the most avourable circumstances. We have no other mrce than to endeavour to obtain a reaction in, by the means already employed — our efforts almost always in vain. I Convalescence is always long and difficult after second and third periods of Cholera, but there no particular indications to be attended to, ess from some organic predisposition, or acciital illness, which would then place the patient ler treatment for some other disease quite of ifferent nature from Cholera. »In concluding this short treatise, we venture to r the following propositions, in which we hope convey, in as clear and concise a manner as possible, the principles which have directed us in our researches on this difficult subject. tl. The symptoms of Cholera are the expression a disturbed state of the vitality of the whole nomy. (11. The invasion is sudden ; there is no period incubation or precursory symptom. I 111. The intestinal flux is the first, and often c only appreciable sign of the disease in light ses. This intestinal flux has no relation wliater to diarrhoea. IV. Diarrhoea is the result of increased action of the intestinal canal. The evacuations always contain stercoraceous matter. iV. The intestinal flux is nothing more than c evacuation of the accumulated serum from the testinal canal, which is become a p assive reCi ~ ent under the influence of Cholera — no stercoraous matter. VI. Cholera is divided into three periods ; the first is the intestinal flux ; the second is that of confirmed Cholera ; and the third of asphyxia, algide Cholera ; the fourth, that of reaction, does not in reality belong to the disease. VII. All the functions are affected at once ; organic action ceases, and all the secretions are suspended ; slightly in the first period, in a marked manner in the second, and in the highest degree in 90 91 reaction, which is almost imperceptible after the first period, accompanied by fever after the second, and this fever of reaction is almost always adynamic IX. There is no organic lesion. The whole economy is reduced to a passive state, stagnation, and decomposition of the blood in the large vessels, even before death, ecchymosis, and psorentery. !X. The blood has lost its physiological chapter. It does not coagulate, forming a clot, lich floats in the serum ; it does not become ffy ; the fibrine is dissolved, and forms a kind of ly with the globules and the small quantity of •urn which remains. The red globules are dvelled from the loss of their serum by exos- IXI. The air expired by Cholera patients is not the least changed ; it has the same chemical nposition as the atmosphere, but it is at 4° or below the temperature of a warm room. I XII. The pathological cold which seizes patients (appears after the cessation of the choleraic inence. The animal heat returns for a shoit time, vitee, even after the decease. XIII. The suspension of all the secretions and of all organic action renders the process of elaboration impossible. There cannot then be any period of incubation ; no virus, no miasma, consequently no contagion nor infection. 92 XIV. The suspension of organic life, more or ess violently arrested by choleraic influence, and le reaction which follows after the cessation of iis influence, even after the functions of the brain, ie heart, and of the whole economy have ceased, iow that the elementary cells are the seat of the isease. XV. The irregular course which Cholera takes, passing through immense space like lightning, renders all quarantine measures against this disease perfectly illusory. !XVI. Contagious diseases are propagated there ly where they find the elements of their existce. Protection against epidemics of these disses must consist then in the destruction of the ;i of infection, rather than in the establishment quarantines. XVII. The morbific action producing the more or less collapsed state of the whole economy appears to be the effect of electric action. XVIII. There exists some correlation between the electro-magnetic and the choleraic influence. The magnetic pole loses its influence, and the magnet its power, during the reign of epidemic Cholera. I XIX. It is probable that inflammatory diseases -c developed under the influence of positive ectricity.. and that adynamic affections, amongst Inch is Cholera, are under the control of negative I XX. A very great resemblance exists between c effect of fear and Cholera : sudden seizure of Id, intestinal flux, and collapsed state of organic c. I XXI. The only means of precaution at present own, after the execution of all the ordinary gienic measures, is to support the moral courage the people in establishing the conviction that idera is not a contagious disease. With regard disinfectants, there is nothing to disinfect in olera, and under all circumstances there is only 3 disinfectant, which is cleanliness. tXXII. There is no other cure for Cholera ients than by reaction. The rational treatment sists, therefore, in obtaining and in supporting ; reaction. Stimulants of all kinds and warmth our great resources. t XXIII. Opium and its preparations are counteruded, except only in the first period of the 3ase. The accidental presence of a large quan' of opium in the system is often the cause of th by absorption as soon as reaction has taken 96. I XXIV. Mustard poultices and blisters are ntermanded, as well as all revulsives. They srrupt the action of warmth by exposing the ient, and the vesications are often the source of at embarrassment and danger after reaction has 93 APPENDIX. I [Extracts from the Medical Times of Dr. Boale's most foresting researches, which so fully establish the pathogical character of the disease.] f Microscopical Researches on the Cholera. By Lionel S. Beale, M.8., F.R.S., Fellow of the Royal College of Physicians, etc. " Every one who has seen Cholera has been struck by the remarkable characters of the matter discharged from the intestinal tube, and those who have made post-mortems are familiar with the fact that the small intestines almost always contain a considerable quantity of pale, almost colourless gruel-, rice-, or cream-like matter. This has been proved to consist almost entirely of oolumnar epithelium, and in very many cases large flakes can be found, consisting of several uninjured epithelial sheaths of the villi. I have often found such sheaths in the stools in previous epidemics, and probably, every one who has carefully observed the disease will have inclined towards the opinion that in bad cases it is probable that almost every villus, from the pylorus to the ileo-c;ucal valve, has been stripped of its epithelial coating during life. 94 95 " This alteration in the apparatus concerned in the absorption of all nutrient matters from the intestinal canal, and the changes accompanying it and preceding it, are probably sufficient to account for death by collapse. Most important, therefore, is it to ascertain, if possible, the several phenomena of which this denudation of epithelium is the climax, and the order in which they occur. These important organs, the villi, are, in a very bad case, all, or nearly all, left bare, and a very essential part of what constitutes the absorbing apparatus is completely destroyed. If only a considerable portion of a villus was denuded, reparation might doubtless occur by new growth from the cells which remained, but if the villus was entirely stripped, it is more probable that it would waste, and its place be at length occupied by a new one, which would grow from its base, than that epithelium would grow anew from its bare surface. It is probable that the extent of this process of denudation determines the severity or mildness of the attack. If the great majority of the villi have suffered, it is scarcely reasonable to consider recovery more probable than it would be after a very extensive burn or scald. We shall have to inquire what is the proximate cause of the denuding process ? Why does the epithelium drop off ? What circumstances cause it to become detached ? The process may be due to violent contraction of the muscular fibres of the villi and the retraction of the villus within its lieath ; but although, no doubt, contraction occurs, is scarcely probable that the villi would be bo merally and completely stripped as they are in vere cases. It seems more probable that the ithelium may become detached in consequence of c almost complete cessation of the circulation in c capillaries beneath, but the death of the cells ly occur in consequence of their being exposed the influence of certain matters in the intestine in the blood, in which case they would simply .1 off. These and many more hypotheses will ye to be considered in the hope of finding the le explanation of the fact. " It ought not, I think, to be too hastily concluded that this abundant removal of epithelium is an indication of the occurrence of active elimination from the intestinal surface. For, in the first place, it must be remembered that the villi are not, in their normal state, organs of secretion or elimination, but active organs of absorption ; while, on the other hand, Lieberkuhn'w follicles, which open in the intervals between the bases of the villi, are secreting organs. Now these follicles, so far from being denuded, are choked with epithelium. It is possible, however, that there may have been a tendency upon the part of these cells to separate matter from the blood, but it seems improbable that the columnar cells which form the bulk of the 96 97 cellular elements of the contents of the small inestine, and which unquestionably come from the villi, should have been engaged in such an office. Secondly, I would remark that the pabulum passes through the columnar cell in a direction from its free towards its attached surface, or from the intestine towards the blood. If, therefore, it eliminates or separates anything from the blood, the flow must take place through it in a direction the very opposite of that which is constant during its life. Is it not improbable that this should be the case ? In short, it seems to me that evidence in favour of the view that the removal of the epithelium from the villi is an eliminative act is still wanting. By the denudation a raw surface becomes exposed, just as in the case of the cutaneous surface after a burn or scald, except that the villi are completely bared, which is not the case with the skin. No one would argue that the elevation of the superficial layers of the cuticle and the effusion of serum beneath consequent upon a burn resulted from elimination. We are to some extent acquainted with the several steps of the latter process, but we have not as yet learned much concerning the former. I" The removal of the columnar epithelium from villi, and the consequent destruction of the nanism connected with absorption, are broad s in Cholera which deserve the most minute ii 98 and careful study. We might well consider how this denudation may be prevented or retarded, and, having taken place, what fluids should be brought into contact with the naked surface — oily fluids, fluids containing salt, syrup or glycerine, bo as to make them of about the specific gravity of the serum, or ordinary serum itself, which last would probably be most efficacious — or whether it would not be better, until we know more of the matter, to let the denuded villi remain perfectly quiet, and allow the small intestine to rest, in the hope that the damage may be repaired. But is Jt not reasonable to hope that a thoroughly minute investigation into the circumstances which probably immediately precede this denudation of epithelium would enable us to form a notion of its nature, and to adopt means which were likely to restrain it ! A knowledge of the changes occurring after the denudation and destruction of many villi will probably teach us much concerning the nature of " secondary fever," and enable us to place the patient under conditions most favourable to his recovery. The consideration of the mere fact of there being a raw denuded surface throughout a considerable extent of the alimentary canal suggests the propriety of not introducing anything into the intestines. The question concerning the alteration in the villi is a most interesting one, and it is worth while to spend time in searching for new 99 E;ts, and in trying new experiments which m;i\ lp us to answer it. But the subject is a very tensive one, and has many ramifications, each which must be carefully considered in detail. I" Remarkable changes have occurred in the nailer vessels, especially in the capillaries and nail veins of the villi and submucous tissue, and lese changes can be readily demonstrated. The ood- corpuscles appear to have, in great measure, 'en destroyed in the smaller vessels, and in their ace are seen clots containing blood-colouring atter, minute granules, and small masses of gerinal matter evidently undergoing active multiication, but the nature of which has yet to be Lidied. Some of the arteries are contracted, but re and there small clots, destitute of blood-coriscles, may be seen at intervals. Drawings of ese will be published. I" On the other hand, the nerves and the gani, so numerous between the muscular and cons coats of the small intestine, exhibit a ural appearance, so that I should not be able distinguish a ganglion taken from a Cholera :im from one taken from a perfectly healthy son of the same age whose life was destroyed accident. The nerves and ganglia, and the ues for a short distance around the smaller Kiels, are, in many situations, stained with red and dissolved blood-colouring matter. 100 I" I propose to give an account of what I have bserved in the villi in Cholera, and institute a areful comparison between these and perfect I v ealthy villi. I shall have illustrations made, and hese will be published as soon as they can be n graved. The results of the examination of the ver, lungs, and other organs will follow as soon =5 the investigation can be completed . Of the Columnar Epithelial Cells detached from the Vitti. The columnar epithelial cells found in givnt number in the rice-water evacuations and small intestine after death from Cholera do not always exhibit the same characters, nor are they of the same size in every case. In the accompanying drawings (Figs. 1, 2, 3, and 4) cells of the smallest and largest dimensions and cells of medium size, taken from the first four cases I have examined, are represented. All these specimens are magnified with the same power. Case 3 was a child fifteen months old ; and it will be observed not only that the epithelial cells are much larger than in the three other cases, but that the nuclei are larger in proportion. See also Fig. 6, in which these cells are seen under a power of 700 diameters. In almost all the cases of Cholera f have yd Fig. 3. Fig. 3. | . I 1. Figs. 11l tnajnil Fie(. 6. i columnar epithelial oaUa nnd until c«!K from a 1 '¦¦ ¦ ¦ ¦ • ¦ ¦¦ ¦ ¦ ¦ ¦ I . a«d 700. | 7 — iumrait of columnar •pithel | .!,;„ ji^,, .< '; which nut i /, .100. 101 examined there is evidence of chronic structural change in the tissues of the intestines, and I think we shall be led to conclude that in most of the Cholera victims important morbid alterations have been going on for months, and in some instances for years before death. In some cases it is probable that, had the individual escaped Cholera, he must have succumbed to some other malady within a short period of time.""" The columnar epithelial cells often exhibit evidence of chronic change ; they seem to be stunted, and in many instances the nuclei are much smaller than in health. In the intervals between their attached extremities one fails to find those smaller and younger cells which in the healthy state gradually grow up to take the place of those cells which are removed and give origin to new cells, which in their turn become developed. So also it is to be observed that the masses of germinal matter so numerous near the surface of the healthy villus are almost absent in many of these cases of Cholera, And there are other and very striking changes in the iWe venture to differ from Dr. Bcale on this one point : pears evident to us that this structural change, without ence to any other morbid condition, must depend on the cc of asphyxia with which the cells are struck, and that altered state m;iy be accounted for by the violence of the en attack. This will also account for all the phenomena rved i i Cholera- the detached epithelium, the stunted the diminished volume of the nuclei, &c. 102 rrare of the affected villi which I shall describe in other communications. The specimens, however, from Case 3 afford an exception to the above remarks ; but until I have had further opportunities of examining the epithelium in fatal cases of children at the same age, I cannot venture to draw conclusions. For the present, therefore, I content myself with publishing the drawings. In this Case 3 the epithelial sheaths of the villi were very distinct ;n id perfect (Fig. 5), but the cells did not exhibit the characters seen in the other three cases. They contained numerous oil globules, some of which were of considerable size — a fact which perhaps justifies the inference that these particular cells were active and concerned in absorption shortly before death, which certainly is not usually the case in Cholera. The above inference is confirmed by the characters of the villi existing in this particular instance. In most cases the fresh cells seem to be almost destitute of oil globules, and many present a shrivelled appearance, as if they had not been very active for a long time before death. There seems, indeed, to be the same sort of difference between some of these cells in Cholera and healthy columnar epithelial cells, that is observed between the epithelium of a cirrhose and that of a healthy liver or kidney. CHOLERA. 103 rthe Bacteria in the Stools, Vomit, and in the Small Intestine in Cholera. Amongst the epithelial cells and upon their surfaces, if not in their substance, are multitudes of bacteria. Bacteria are found in the dejections during life, in the vomit, and in every part of the alimentary canal two hours after death. It is probable that these organisms are developed in the intestine in vast numbers during life. In Fig. 7 some of the smallest are represented as they appeared under the <^ 5 object glass. The bodies seen near the summit of the columnar epithelial cell are either germs of the same kind of bacteria or altered oil-globules. I The falling off of the epithelial cells cannot attributed to the influence of bacteria, nor it probable that these organisms are concerned the production of Cholera. Bacteria are found en enough in undigested or in imperfectly jested food. In dyspeptic infants they occur in st numbers in every part of the alimentary lal ; and in temporary stomach derangement i matters rejected by the stomach or passed p anum contain them in enormous quantity, ey have been observed by Dr. Gibb even in Ik immediately it was removed from the breast the mother, and must have been developed while the milk yet remained in the mammary gland They are always present in the fluids of the mouth, and are not uncommon in the contents of the stomach, though it is doubtful if they multiply in a perfectly healthy condition of the gastric mucous membrane. It is not very surprising that bacteria should be present in the cells of columnar epithelium in certain cases, seeing that their germs are always present in the old cells of squamous epithelium in the mouth. They invade these columnar cells from without, and live at their expense, just as they invade the epithelial cells of the tongue, and as simple fungi invade the cells of higher plants and animals when these cells begin to decay or lose through disease their healthy power of resisting invasion. Bacteria are constantly found in every part of the living body where a tissue is no longer permeated by the fluids, whose office it is to maint iin it in a state of integrity. Soon after the currents of fluid have ceased, especially where the organic material is soft and easily decomposed, bacteria make their appearance, and grow and multiply rapidly. Nor is there a tissue or organ in the inmost parts of the body in which these organisms may not within the course of a few hours make their appearance. The germs are there ; but so long as the normal state of things continues, these germs are prevented from being developed. 104 105 I These simple living organisms are without doubt stroyed in the healthy condition, although their rms may resist destruction. If the latter were to t into the healthy blood they would not multiply, t towards the close of many exhausting diseases, th in animals and man, after the blood has underlie important changes, they are found in great mbers. It is, however, doubtful if in any case ey can be regarded as the cause of the disease, or B materies morbi, and it is far more probable that change takes place before these organisms can iltiply in the blood, and that a condition of things comes established which is favourable to their owth and multiplication. There is then, I think, no good reason for supposing that the bacteria in such numbers in the alimentary canal in Cholera have anything to do with this disease, or with the falling off of epithelium from the intestinal or other mucous membranes. Bacteria are developed in organic matter which is not traversed and protected by the normal fluids of the body, and they invade the cells and textures in Cholera after these cells and textures have undergone serious prior changes, just as they would invade textures removed from the body altogether. Nor would it be in accordance with known facts to infer that Cholera was due to the invasion of some peculiar form or species of bao- 106 Such hypotheses as this I believe to be absolutely untenable, and think they may be positively dismissed as mere fancies likely to mislead us in searching for the true cause of the disease. The idea of "fermentation" in the present day is so different from that generally entertained five-andtwenty years ago, that the word ought never to be used in modern scientific writings without being defined. The mere multiplication of particles is not peculiar to ferments. It is an attribute possessed by yeast in common with everything that has life, and therefore in this sense the word may be applied to every kind of cell-multiplication in nature. If the act of multiplication of the virus of small-pox or scarlatina be termed "fermentation ," surely the multiplication of pus or mucus must be an example of fermentation, and if so every kind of cell-increase may be called "fermentation." if, however, this word is to be applied to the process in which carbonic acid and alcohol are evolved during the multiplication of a fungus in a saccharine solution, it is utterly inapplicable to the changes occurring in any disease affecting man or the higher animals. To speak of small-pox, or fever, or Cholera, &c, as due to ferments, conveys no real information whatever. By giving such pretended explanations of phenomena of which little or nothing is really known, inquiry is terribly discouraged, and real progress effectually checked. 107 [3 explanation offered requires explanation as eh as the phenomenon itself. The explanation not an explanation. It is a mere word, the \ning of which requires to be explained. Cholera seems to be so constantly associated with the removal of columnar epithelium from the villi, that we have been led to look upon this as one of the essential phenomena of the disease. Although there may be no actual diarrhoea, this epithelium is found in quantity in the intestine after death. It may be said that this removal of epithelium occurs immediately after or only just before death, but the great number of columnar epithelial cells and entire sheaths of the villi so frequently found in the rice-water evacuation, giving to it its peculiar character, proves that such a notion is not tenable. Can Cholera exist without the villi being denuded of their epithelium, — is a question which, as far as I know, has not yet been answered, but which must be answered before we can form a correct notion of the nature of this most wonderful disease. I do not think there is any other morbid condition in which this striking change is observed — at any rate, to the extent or with the frequency it is met with in Cholera. It seems, however, likely that where those changes in the blood occur very quickly indeed, so as to cause death by sudden stagnation of the blood in the capillaries of important organs, there might not be time even for 108 the removal of the epithelium from the vi Hi, just as we may have death from small-pox or scarlatina without any eruption. With reference to the denudation of the villi, it must be borne in mind that the throwing off of epithelium is not confined to the villi of the intestine, or to that of the intestinal mucous membrane generally. The process affects the mucous membrane of the gall-bladder and larger gall-ducts; that of the bladder, ureters, and pelvis of the kidneys, as well as that of the Fellopian tubes, uterus, and vagina. In short, there seems a tendency to the removal of epithelium from the surface of all the soft, moist mucous membranes ; not, it must be remembered, of the epithelium which is specially concerned in elimination, but rather of that which lines the ducts of glands and cavities which may be included in the category of the ductal portion of the different secreting glands. I On the other hand, there is no evidence of the ;reased formation or more rapid removal of the jreting epithelium in the various glandular organs, c follicles of the mucous membrane of the unacli and intestine, those of the salivary glands il pancreas, the tubes of the liver, kidney, and ler glands still retain their epithelium ; nor ye I been able to demonstrate in these varieties glandular epithelium any appearances peculiar Cholera, [ndeed, so far as I have yet been able 109 I observe, it would be extremely difficult to