THE 

NATURE AND TREATMENT 

OF THE 

EPIDEMIC OR ASIATIC 

CHOLERA ; 

WITH 

SIMPLE DIRECTIONS 

FOB THE 

SUPPRESSION AND PREVENTION OF THE DISEASE. 

By ROBERT VENABLES, A.M., M.8., Oxon, INCEPTOR CANDIDATE, KOTAL COLLEGE OF PHTSICIANS, LONDON, 

AND ONE OF THE GOVERNMENT PHTSICIANS ATTACHED IN 1832 TO THE CHOLERA HOSPITALS AT BETHNAL GREEN, WHITTLESEA, ISLE OF ELY, CAMBRIDGE- 

SHIRE, AND WICK, CAITHNESS, NORTH BRITAIN. 

"Disce docendus adhuc, quse censet amiculus, ut si Cuecus iter monstrare velit: tamen adapice, si quid Et nos, quod cures proprium fecisse, loquamur." PUBLISHED BY H. BAILLIERE, 219, REGENT STREET, 

AKl) 

H. HUGHES, ST. MARTINS-LE-GRAND, CITY. 

1848. 







WC 6 

P'lh; JJg-J J t^> J- 

WILLIAM HENRY COX, 

!>, Grkat Queen Street, Lincoln's Inn Fields, 



DEDICATION 

TO 

SIX WILLIAM PYM, M.D., Knight, 

ffiimlnnan, 

AND 

SIR DAVID BARRY, M.D., Knight, 

I3epitti> <rri)atnnau, 

CENTRAL BOARD OF HEALTH, LONDON, 

THIS ESSAY 

IS HESPECTFUIXX DEDICATED B% TH&lfi^ 

\ 

VERY FAITHFCL AND OBLIGED SERVANT, 

THE AUTHOR. 





PREFACE 

TO THE FOUETH EDITION. 

I had hoped when the Cholera of 1832, and 1833, took at last its departure, that it had quitted these shores for ever. The present apprehensions, however, by no means ill founded, or unnecessary, justify the suggestion of any means for controlling the spread, and limiting the ravages of this frightful malady; the efficacy of which, either experience has proved, or reflection warrants. I can only say, that the precautions laid down in this essay, were found eminently successful in preventing, to a very great extent, attacks of the disease; and when it did appear, its fatal progress was often arrested. I have endeavoured to lay down, all those rules and principles of public and domestic hygiene, which the most careful reflection could suggest, and also those, the efficacy of which, in controlling epidemic and pestilential diseases in general ; mitigating their seyerity, and disarming them of their malignancy experience has confirmed. Thus, those persons whose duty it may be to provide for the public health and safety, will be able probably to glean from these pages, hints which they may find useful in enabling them to pursue an efficient course, and perform in a more perfect manner their duties. 

It may be objected, that preparation is not only unnecessary, but injurious by creating alarm and exciting, possibly, groundless fears and apprehensions. "Principiis Obsta" is a good maxim ; it is better to prepare for an enemy than suffer incursions and spoliations to proceed whilst we are making preparations for defence. The Sanitary Commission, I find, object to hospital provision for the sick poor, and if certain of the grounds upon which the objections are founded, be valid, it would lead to the suppression of hospitals altogether. The mortality in an hospital must always be greater than the average of an equal number of sick under domestic treatment. The very worst cases go into hospitals, and many, after having been treated in vain at home. It would, then, be very imprudent to leave the poor to the privations and aggravating effects of poverty, cold, 

A 2 



6 

PREFACE. 

damp, bad diet, and all the causes which enervate the frame and increase the virulence of disease. It is to be hoped, therefore, that this subject will receive attentive reconsideration from the Sanitary Commission. 

At the particular solicitation of several, upon whose judgment and candour I rely, I have been induced to offer this fourth edition to the notice of the profession and the public. Persons in general will find a system of sanitary measures, which, if observed, will, I am satisfied, go a great way in securing from attacks of the disease should it again appear, but if not so far successful, will greatly lessen its malignity. 

The profession on the irruption of Cholera in 1832, were confounded by the rapidity and extraordinary features of the disease. The judgment was, as it were, bewildered by phenomena never before witnessed in this country. The younger practitioner, therefore, who has not yet seen the disease, will probably find sufficient in these pages to direct his judgment and settle his practice; while the principles inculcated will prove perhaps not altogether useless to the more experienced members of the profession. 

All these considerations, however, would hardly have induced me to send forth this edition had not the first been so favourably received in Scotland, and obtained tho very flattering approval of Sir William Pym, and the late Sir David Barry, -as attested, in the subjoined letter. 

London, 

5, St. Vincent Placr, Citf Road. 

January, 1848. 

(Copy.) 

SIE DAVID BARRY'S LETTER TO THE AUTHOR. 

" Council Office, 11th. Oct. 1832. 

"My dear Sir, — I have received your letter of the sth inst. with your excellent pamphlet on Cholera, which Sir W. and myself are now reading with much interest. We are both lettered by your having addressed your work to us. For myself, without flattery, I think it one of the very best and most praotioal essays yet published on the disease. 

" Very truly yours, 

" D. BARRY. 

" Dr. Venables. 

" Cholcru H'-'spitiU, Wick 



THE NATURE AND TREATMENT, 

SfC, Bfc. 

The progress of Cholera may be divided into the preliminary diarrhoea; 2d, The premonitory; 3d, The cold; 4th, The collapsed stage; and sth and lastly, The stage of typhoid re-action. 

The preliminary diarrhoea : — Consists in the passing off of the biliary and feculent matters from the intestines. The duration of this stage varies from one to ten days. Its continuance, however, is, generally speaking, determined by the violence of the purging. When the stools amount to only three or four in an hour, or perhaps six or eight in the twenty-four hours, the premonitory stage is proportionally deferred. I am not aware of anything in the character of the diarrhoea, which will enable us to determine whether it be the preliminary to an attack of Cholera, or diarrhoea from more ordinary causes. The history of the case and the actual prevalence of Cholera will probably furnish the best grounds for deciding this question. There is one circumstance, however, which, when it occurs, may be invariably looked upon as determining the nature of the diarrhoea — namely, the frequency of the motions; for instance, when the purging is repeated twenty or thirty times in an hour. When this is the case, a severe and immediate attack of Cholera may be anticipated, unless sanative measures be resorted to. 

The premonitory stage : — I regard as decisive of the system being under the influence of the causes of Cholera. This stage is characterised by the ricewater, serous,* or mucous character of the alvine dis- 

* Sinco the former editions I have examined the nature of the fluid discharged; it is distinctly serous. Coagulating by heat, by nitric and nitro muriatic acids and acidulated solution of yellow prussicitc of potass. 



8 

THE NATURE AND TREATMENT OP 

charges. It is truly at first a serous or mucous diarrhoea, or perhaps both ; but after some time all the mucous passes off, and further secretion being suspended, the evacuations are purely serous. The intestinal discharges are almost invariably alkaline. I have examined them in numerous instances, and cannot bring to my recollection a single occasion on which I found this character wanting. When the premonitory manifestations are once fully established, there is neither bile nor feculent matter to be detected in the discharges, by any of the usual chemical re-agencies. Indeed, I believe that the bile and foecal matters are discharged, or pass off, during the preliminary stage ; while in the premonitory, the serum of the blood is poured into the canal, as observed above, and is passed off from the intestines. There is seldom or never vomiting in either of the above stages ; but a severe degree of nausea, or even retching, frequently attends these stages, more particularly the latter. — Spasms of the abdominal muscles, with severe griping, frequently prevail during these stages, more particularly during the latter ; and the severity of the spasms and griping are greatly increased should flatulence be a concomitant. The tongue generally feels cold in this stage. 

The third stage : — I denominate the cold stage. Some, perhaps, may be inclined to look upon it as but a less severe form of collapse. Be this as it may, I have found it practically useful to distinguish it, and note its characters. In this stage, there is vomiting and purging of serous matters. The abdominal spasms increase in severity, and the cramps in the extremities are intolerable. The temperature of the body is reduced very much below the healthy standard, and the tongue feels moist and extremely cold, but is still clean. The pulse is feeble and weak, but perfectly sensible to the feel. A cold clammy sweat frequently bedews the surface. There is an anxious desponding expression of countenance — the features are so much altered, that it is difficult to recognise those with whom we have been but 



THE EPIDEMIC OR ASIATIC CHOLERA. 

5 

s lightly acquainted during their health. There is often a lividity of the toes and fingers ; the skin becomes shrivelled ; the eyes sunk into the orbits ; there is an expression of languor and despair, and they assume somewhat of a glassy appearance ; while the face appears elongated and sharpened, from the absorption of the adipose substance. There is a total suppression of urine in this stage ; and, in one or two instances, I have witnessed considerable irritation in the bladder, manifested by an urgent desire to void the urine ; while the introduction of the catheter proved that the bladder was empty. This I observed more frequently in women than in men ; but altogether it is rather of rare occurrence — being more frequently a concomitant of the febrile stage. — Recovery is frequent from this stage; and singultus or hiccup at this period promises a speedy convalescence. 

The fourth stage : — May be called the collapse. In this stage the vomiting and purging cease altogether, or they are but very trifling. Whatever discharge takes place from the bowels is involuntary, and the patient does not appear to be very sensible. Indeed they take no notice unless roused; but still when they can be roused, the faculties seem to be unimpaired. More frequently, however, there is a general torpor, particularly towards the advanced periods of the collapse. The respiration becomes laborious, and even stertorous; — the whole of the body assumes a livid, purple, black, or blue hue ; — the patient becomes deadly cold, and nearly senseless ; — the eyelids are but half closed, while the globe of the eye is reverted, so that the pupil is drawn up under the orbitar process of the frontal bone; — the pulse is not to be felt at the wrist, nor are even the carotid or femoral pulsations to be perceived. Indeed, the motions of the heart, if they exist at all, are so weak and feeble, that they are frequently not perceptible, even to stethoscopic exploration. The respiration becomes gradually slower 'and slower, and the intervals between each succeeding inspiration are often so prolonged, that the patient is considered as dead, until a subsequent deep sol) convinces the bystanders that the 



10 

THK NATURE AND TREATMENT OF 

) 

unhappy victim had not positively ceased to exist. At last, however, a long deep convulsive sob* puts a period to his existence. Recovery, under these circumstances, or indeed from this stage at all, is very rare, and can hardly be looked for: still, I must state, that I have witnessed three recoveries in this hospital under circumstances as hopeless as any in the above description. 

The fifth and last stage, or that of febrile re-action: — There is often a transition, from the cold stage to one of fever, assuming the typhoid character. It often happens that there is a transition from the premonitory to the typhoid stage, without the intervention of either the cold or the collapsed stage. The typhoid stage appears by a gradual diffusion of warmth over the entire surface ; the tongue gets dry and glossy; and in persons whose digestion is impaired, or in whom the alimentary organs are irritable or congested, the tongue assumes a dull reddish appearance, something like that of dried salmon. The thirst, which was insatiable in both the premonitory and the cold stages, but which disappears in collapse, re-appears during the febrile stage. The thirst, however, at this period is not so urgent as it was during the premonitory and the cold stages. The respiration is quickened ; the pulse becomes perceptible, and more frequent. It is always small, but often hard and thready. Sometimes it is softer and slower : whenever there is a transition to the febrile stage, there is always a dull languid expression of the eye, and it is invariably more or less suffused, or blood-snot. The degree of suffusion is one of the most unerring means of prognosis with which I am acquainted. The moment febrile re-action takes place, I watch the appearance of the eye with the most scrupulous attention ; for if suffusion to any extent or degree of severity set in, I look upon the case as lost. A fatal congestion in the brain is the result ; and although I have seen one or two recoveries in this hospital, under the circumstances above described, and as unpromising as it is well 

* The dyspuaja, or rather this peculiarity in the difficulty of breathing, is probably owing to pulmonary collapse and closure of the air cells. 



11 

THE EPIDEMIC OR ASIATIC CHOLERA. 

possible to imagine ; yet I am not inclined at present to set a high value upon the remedial means adopted, notwithstanding the success which attended the activity and decision with which they were employed. It still remains a doubt in my mind, whether the recovery was not owing as much to chance, or the powers of the system, known professionally as the " vis medicatrix naturae," as to the curative means instituted, however powerful, or well devised they may seem. However, as they will be detailed in a future part of this treatise, the reader will have an opportunity of forming his own judgment on the subject. 

During the febrile stage, there is often vomiting and slight diarrhoea. Sometimes diarrhoea alone — sometimes vomiting alone. Sometimes there is merely nausea, or nausea with retching. The evacuations in these cases seem to consist of the water or fluids which the patient drinks, occasionally tinged with bile. They are frequently of a green colour, owing, apparently, to some acidulous re-action on the bile ; — the discharged fluids, in such circumstances, commonly giving a slight tinge of red to litmus paper. There is often headache, or a sense of weight in the back part of the head, or across the fore-head ; or there is a soreness of the proecordia, very sensible on slight pressure. The urine — if the patient is likely to do well — is generally secreted ; but in unfavourable cases, there is an urgent desire to pass water, though, on examination, there is none found in the bladder. More often, however, the urine is secreted and voided. This promises well. Where there is much congestion in the brain, the urine is frequently secreted, but retained in the bladder, producing a considerable degree of tumefaction in the hypogastrium. This is a fatal symptom. I saw three instances of thL at "Whittlesea, and two in this hospital. In one of the cases at Whittlesea — a woman of the name of Cox — the accumulation was so rapid and so great, that in one night the abdomen swelled so much, that it felt as if she was pregnant. I immediately sent notice to Mr. Boultbee, Surgeon, who drew off a considerable quantity of urine. 



12 

THE NATURE AND TREATMENT OF 

When death takes place in this stage, the patient mostly dies comatose, — sometimes with slight convulsions. Such appears to me a faithful picture of the disease. The ahove history, though concise, yet will, I helieve, be found to comprise the leading phenomena. The description has been furnished to me by much patient, but painful and laborious observation ; and I think it will be borne out and confirmed by those who have had much opportunity of experience. 

ON THE TRANSITIONS FROM THE ANTECEDING INTO THE CONSECUTIVE; STAGES. 

It almost invariably happens, that attacks of Cholera are preceded by diarrhoea, of greater or less severity. There are some few instances in which no such symptom could be clearly traced ; but, in the great bulk of cases, it was found, upon inquiry, that a " looseness " of the bowels, of more or less intensity, had ushered in the disease. The character of the discharges was always bilious and feculent; and it was the constant observation of this fact that determined me to regard it as a distinct stage. The transition from this stage is sometimes quite sudden and abrupt. Thus I have been frequently called to persons who had been labouring under diarrhoea — or, as it is more usually expressed in the North of Scotland, "the dysentery" — for many days without any apprehension, but who suddenly became alarmed, because the discharges assumed the appearance of pure water, rice-water, whey, or gruel. Such had always the alkaline re-action to a greater or less extent. In other cases, the diarrhoea becomes gradually less and less bilious or feculent, until at length the characters of the premonitory stage are clearly and unequivocally developed. When the diarrhoea is profuse, the transition is generally sudden ; but when mild and prolonged, then the transition is gradual — that is, serum or mucoserous 



THE EPIDEMIC OR ASIATIC CHOLERA. 

13 

fluids are discharged, intermixed with the bilious and foecal matters voided. 

With respect to the transition from the premonitory into the cold stage, I can offer but little satisfactory. — It is certainly not a stage of very long duration, nor are the transitions into the cold stage, in the majority of instances, abrupt or well characterized. In many cases, the pain in the prcecordia prevails from the beginning even of the preliminary diarrhoea ; in other instances, its appearance marks the commencement of the premonitory stage ; while, in others, it is not perceived till the formation of the cold stage. It may, however, be observed of the premonitory stage, that, generally speaking, it is not one of long duration, nor is the transition from it to the cold stage abrupt or well marked. 

The transition from the cold stage to collapse is still less sensible. The retching which prevailed at the termination of the premonitory stage, and which was superseded by vomiting on the transition into + he succeeding stage, will not serve to characterize the termination of the cold stage, nor the beginning of collapse. In most cases there is a gradual cessation of both the vomiting and purging during the collapse ; but then the collapse at this period, and its characters, are sufficiently well marked to determine its presence, and its intensity. However, a careful and vigilant observer will perceive the gradual accession of characters, which will enable him to anticipate what is approaching, and frequently to provide for the emergency. 

The transition from the cold stage, or from collapse — for this takes place from either — into fever, is better marked. Thus, a commencing warmth of the surface, a warmer feel of the tongue, a kind of fur on its dorsum, the moisture of the former stages, and the smoothness and softness of its feel, giving place to the dry rough harshness of fever, fully characterize the transition from the one stage to the other. Perhaps this is the best marked transition of the whole complaint. 

n 



14 

THE NATURE AND TREATMENT OF 

THE MORBID ANATOMY AND PATHOLOGY OF CHOLERA. 

The Morbid Anatomy of Diseases may be considered under three heads — namely, The morbid or diseased appearances which are essential, i. c. which are invariably observed. Secondly, Those which are accidental, that is no way necessary to constitute the complaint, but have arisen from the operation of previous or other causes, not essentially connected with the existing disease; and, thirdly, Those which follow in succession, and are, of course, consecutive. It will hardly be necessary for me to enter here at any great length upon these subjects, after the full consideration I have given to them in the Cholera Gazette, the Lancet, &c. I can only say, that my more matured experience has served to confirm me in the opinions which I have there advanced and maintained. I have now either opened myself, or assisted others, or have been present at the examination of between four and five hundred bodies* of persons who have died in the various stages of Cholera, and I must confess, that I have not met with anything to induce me to change the views — so far as they go — which I have already advanced and maintained, on the morbid anatomy and pathology of Cholera. I shall, therefore, here only briefly recapitulate the facts which I have elsewhere stated, and introduce a few others illustrative of the morbid anatomy of the stage of typhoid re-action. 

In Cholera, death happens only in two periods of the disease, — namely, in either the collapse or the fever. When a patient dies in collapse, the most obvious morbid characteristic is the altered condition of the blood. It is invariably of a pitchy black colour, and for the most part of the consistence of a liquid mixture of pitch and tar : it is of a rather thicker consistence than treacle. This is a very characteristic feature in the complaint. 

* I feel confident that I have understated the number. The opportunities which were presented to me as one of the government physicians were exceedingly numerous. 



15 

THE EPIDEMIC OB ASIATIC CHOLERA. 

The left, as well as the right cavities of the heart, contain blood of this description, and the same sort of blood is found in the aorta and great pulmonary vessels. In the cavities of the heart, clots of semi-coagulated blood, quite soft, and of a semi-fluid consistence, melting or dissolving down, as it were, under the pressure of the fingers, are found. The different structures — the organs and tissues, are pervaded to a greater or less extent with this blood. On incising the substance of the heart, lungs (these generally in a collapsed state) , and liver, dark or black fluid blood flows out in great abundance. This altered condition of the blood, I have observed in every dissection which I made or have myself witnessed after death during collapse. The blood never, in these cases, shows any traces of serum ; and when drawn during life in the cold stage, or immediately after reaction has commenced, never separates into serum and crassamentum, as in ordinary circumstances. The intestines nor their coverings present any unusual appearance ; but the internal surface and the mucous lining generally presents a blanched appearance. Sometimes the mucous lining seems of a muddy or gruelly-looking colour, but this arises entirely from the adhesion of the viscid secretion, which frequently characterizes the vomiting and purging in the disease : on washing the mucous lining, the coat seems blanched, as already described.* More frequently, however, the contents consist of a limpid colourless fluid, mostly possessing an alkaline re-action, particularly in the intestinal tube, although occasionally the fluid in the stomach presents a slightly acidulous one. There is one thing also observable, that although the gall-bladder is full, and frequently very much distended with bile, yet the usual re-agents will not indicate the presence of a single particle of bile in the gastro- enteric contents. 

The bladder is invariably contracted and corrugated on its internal surface, at least so far as my observation 

* Hoίmorrhagic congestions, and vascular patches have been occasionally observed ; but may not these have been established by previous disease? 



16 

THE NATURE AND TREATMENT OF 

and experience go. It now and then contains a small quantity, about from half a drachm to a drachm of liquid mucus, sometimes closely resembling pus, but more frequently it is perfectly empty. In those instances in which mucus was found in the bladder, there was a desire during life, without the ability, to pass off the urine. 

The brain, like the other viscera, seems to have its substance darkened by the quality of the circulating fluid. The veins and sinuses contain very dark coloured blood, and, on incision, it flows out abundantly. 

The accidental morbid appearances would, in fact, comprise those of all the diseases to which we are subject. Although these conditions do not constitute an essential of the disease ; yet as frequently giving a character to the morbid phenomena, it is right that we should keep the fact in view, that we be not deceived, or consider as anomalies, manifestations which are perfectly intelligible, and readily explained. These states, too, will frequently give a decided character to what otherwise would not amount to more than suspicious symptoms, and indeed often greatly aggravate the complaint, and increase its severity. 

The consecutive appearances properly belong to the typhoid stage. They are almost wholly of a vascular character. I have, however, upon several occasions in London, observed a contracted state of the colon, more particularly of the descending. This possibly may be the consequence of spasm, and may perhaps take place during the cold stage, when the cramps and spasms, &c. prove most severe. During the febrile stage, the spasmodic contraction probably becomes, as it were, permanently confirmed. It is not, however, a constant appearance, and can only be looked for in occasional instances. 

Another appearance has, I believe, heen observed in some few cases, although it has only occurred to my observation three times ; I mean intus-susception of the bowels. In one man there were three ; but in the case of a child that died in the Cholera Hospital at Bethnal 



17 

THE EPIDEMIC OR ASIATIC CHOLERA. 

Green, during the typhoid stage, the intestines were intus-suscepted in thirteen different places. This arose, no doubt, from the violence of the spasms during the Cholera ; but the whole of the foeces having been voided, the inconvenience which, under more ordinary circumstances would have been experienced, was not felt. That they resulted from the spasms, I concluded from the shrivelled corrugated appearance of the canal at these places, and throughout different portions of its length. 

However, the true consecutive appearances, as already observed, are of a vascular description. Now, in all fevers, as well as in the typhoid stage of Cholera, the morbid, vascularity presents two very remarkable differences. In both there is an apparent accession of vessel — that is, parts which are naturally colourless, assume a colour from distension of the vessels, with a coloured, instead of their naturally limpid fluids. Now, there is a very marked difference in the colour ; in one case, it is of a red hue, approaching to vermillion ; in the other, it is of a dark purple. The former may be considered as approaching in its nature to inflammation, and perhaps has its seat in the capillary arteries, while the latter, no doubt, is seated in the lymphatic or colourless veins.* In the former, the blood is possibly true arterial ; in the latter, most likely venous. The former, perhaps, may be designated sub-acute inflammation; the latter, veno-congestive inflammation. 

What has been termed congestion in fevers, may perhaps be considered as reducible to the two varieties of morbid vascularity, now described. It will not here be necessary to enter upon the phenomena, according to the organ which may be the seat of this morbid vascularity, but merely to consider it with regard to the brain, for the patients that die in the typhoid form of fever, 

* Whether this be the true solution or not, there can be no doubt of the facts. In the Dublin Hospital Reports, the characters of these morbid vascularities are noticed, and in Christison on Poisons, the errors which some have fallen into, by designation every species of morbid vascularity inflammation, are pointed out. 

B 2 



18 

THE NATURE AND TREATMENT OP 

consecutive to the collapse of Cholera, seem invariably to perish from cerebral derangement, of one description or other. It has been asserted, that the mental faculties are no way disturbed from the commencement to the fatal termination in Cholera. This, however, is far from being in accordance with my observation. Delirium, coma, and stertortous breathing, have frequently appeared during the typhoid stage ; and whenever this form of fever was well marked, delirium or coma to some extent, greater or less, generally prevailed. In enumerating the symptoms, retention of urine has been noted as a symptom in the latter stages of the fever ; and this no doubt arises from a kind of vesical paralysis from nervous torpor. A man, a fish-curer, named Calder, having been admitted into the hospital at Wick, died in the typhoid stage. He suffered from coma, slow laborious stertortous breathing. On examination, the bladder was found full of urine, though not remarkably distended. 

In the coma there are two states of the eye to which lam anxious to direct the attention. The eye is dull and suffused in both ; but in one the pupil is contracted; in the other it is dilated : in both there is a total insensibility to the stimulus of light. The contracted pupil marks a sub-acute inflammatory action of the capillary arteries j while the dilated infers veno-congestive inflammation. The former is the more speedily and certainly fatal, and of course warrants the most unfavourable prognosis. 

Although the same order of consecutive phenomena presents itself in the other organs and tissues, it will not be necessary to consider them in this place ; because, although they may to a certain extent aggravate the symp . Toms, yet they seldom, if ever, prove the cause of death. At all events, what has been already observed upon the general question, can be easily applied by the competent practitioner to particular cases. 

Pathology: — With respect to the pathology or theory of the disease, it may be observed, that the cause, whatever it may bo, exerts its influence primarily 



THE EPIDEMIC OR ASIATIC CHOLERA. 

19 

upon the nervous system. This influence at first causes the discharge of the bile and feculent matters from the intestines. This is followed by a discharge of the serum of the blood.* Hence, the blood t being deprived of its watery and saline principles, becomes thick and black, and incapable of preserving the healthy excitability of the different organs. The heart being the first supplied, of course its substance is first injected with unhealthy blood, and its excitability is the first impaired, and proportionably to the morbid condition of the blood. Thus, if the blood be only partially deprived of its serum, what I have designated the cold stage takes place ; but if the blood be wholly deprived of this principle, then perfect collapse, from which recovery is very rare, supervenes. 

The dyspuoea which prevails in collapse probably is caused by the influence of the impure blood upon the brain and nervous system. The muscular energy is greatly reduced, and the respiratory efforts are prolonged and inefficient. Thus the air cells undergo no dilatation, and pulmonary collapse at length succeeds. 

It has been asserted that the intellectual faculties are never disturbed in Cholera, not even within an instant of dissolution ; and it has been objected to me, that if the pathology I support were true, the intellectual functions should suffer as all the others. In the first place, the history of the cases in this hospital, and generally throughout Wick, and which will be published in one of the Journals, by my friend and colleague, Dr. Miller, will show that coma and stertor frequently attend the termination of the collapsed stage when fatal, and that sub-delirium and stupor supervene the advanced period of the typhoid stage. But still, allowing otherwise, the fact would not be at variance with my views ; because, 

* This has been unequivocally proved by the satisfactory experiments of Dr. O'Shaughnessy, and his conclusions, &c, have been fully confirmed by Rose and others, and also by myself. 

f Some imagine that the malarious agent, whatever its nature, is inspired with the air into the lungs, and the blood is thus directly affected by tho poison. 



20 

THE NATURE AND TREATMENT OF 

I 

as the excitability of the heart is impaired, its powers become enfeebled, and consequently the impetus given to the blood is inadequate to its complete propulsion, and the vessels of the ¦ more distant organs and tissues are not so forcibly injected ; therefore, they suffer from an imperfect stagnation, rather than injection with a poisonous fluid. 

When the patient survives the cold stage or collapse, unless some critical termination supervene, he gradually enters into a stage of typhoid re-action. I have witnessed petechiae in one or two instances, and in several desquamation of the cuticle to succeed. It is unnecessary here to enter further into the typhoid pathology. The reader, anxious for further information, is referred to the Cholera Gazette, Lancet, and other works upon the subject. 

ON THE CAUSES OF CHOLEEA. 

The predisposing are starvation, a poor, watery, of otherwise unwholesome diet ; bad water, impure air, the consequence of densely populated localities, and crowded, ill-ventilated habitations; these are aggravated by grief, anxiety, fear, drunkenness, and all sorts of intemperance, &c. In short, anything which tends to emaciate the body, enfeeble the frame, or depress the spirits. However, there is no one of these capable of itself of producing the disease, and therefore we must look for some more immediate exciting cause. There are but two which have been looked upon as capable of producing this disease — namely, malaria and contagion. The doctrine of contagion* is in the present day rather unpopular ; and malaria, or an epidemic or pestilential 

* There seem to be very subtle and nice distinctions drawn between contagion and infection. Thus we are told a disease may be infectious but not contagious. By contagion, however, I understand an emanation, generated by the human body under disease— which will produce in susceptible individuals a disease similar to that from which it originated. 



THE EPIDEMIC OU ASIATIC CHOLERA. 

21 

state of atmosphere is now the favourite theory. The Sanitary Commission have decided against the contagiousness of Asiatic Cholera. My opinions and views upon these important questions have been now some years before the profession and the public, and I need, therefore, hardly again enter at any length upon the subject. Suffice it to say that a very extensive experience has only served to confirm the views which I have already advocated. The evidence which has in many instances traced the disease, is as perfectly convincing to my mind, and proves the contagious character of the disease (probably in the cold and collapsed), but certainly in the typhoid stages, as it appeared in 1 832, as fully as such a subject will permit. 

However, I do not believe that either the preliminary diarrhoea, or the premonitory stages are, generally speaking, contagious. In fact, contagion is not an original integrant of even febrile disease ; but an accessory — the product of the diseased actions and morbid operations of the animal economy under the prolonged influence of fever. Thus, if a person be exposed to the contagion of typhus, he is attacked by a similar fever, but this fever is not at its commencement contagious, although it may become so during the diseased actions going on in the system, and the contagion so generated, emanating from the body, will produce, if applied to the body of a susceptible person, a disease similar to that from which it derived its origin. Therefore, contagion, according to this view, is not a primary or essential element, but an acquired and generated principle, and purely animal in its generation, origin, and development. 

That Cholera is endemic in certain situations is a fact that none will deny. That it originates in pestilential impregnations of the atmosphere caused by the decomposition of vegetable and other organic matters, under peculiar influences, is equally true. But if the sick accumulate, and are congregated in close, damp, and crowded habitations, uncleanly, and badly ventilated, fever of the typhoid character will be the result. Nor will this fever be a simple typhus, but a compound 



22 

THE NATURE AND TREATMENT OF 

disease, consisting of both cholera and typhus. Let us not, therefore, in the confidence of wow-contagion, forget that an epidemic simple, and in itself not contagious, may, and probably will under the above circumstances, become so. 

Diagnosis and Prognosis. — The Diagnosis or detection of Cholera is not very difficult in either the cold or collapsed stages, and, unfortunately, here it is not of that material importance. A diagnosis in the preliminary diarrhoea and in the premonitory stage would be of infinitely greater utility. I know of no means of determining whether the diarrhoea be the preliminary to an attack of Cholera or not ; unless, indeed, it be the frequency and severity of the purging.* There is in some cases a most anxious expression of countenance, and not unfrequently in very severe cases the voice is much affected, so that the intonations are in a whisper, and scarcely audible. However, the vox cholerica, as it is called, is not to be looked upon as an invariable symptom, as frequently it never appears at all, even in fatal cases. However, when it does, it may be taken advantage of as a very characteristic diagnostic. 

The premonitory stage is easily determined by the appearance and alkaline re-agency of the dejections from the bowels, t They are limpid like water, and a curdy shreddy rice-looking matter subsides. This frequently consists of fibrine and albumen. These principles may be readily detected by solution of yellow prussiate of potass, acidulated with acetic acid, or by any of the other tests for albumen. I have seen several instances here, in which the dejected fluid resembled the washings of beef. It depended entirely upon a slight intermixture of the red particles of the blood with the dejected matters. I at first supposed this appearance might have been caused by menstruation or 

* Should Cholera be rife, or prevalent in any locality, then any diarrhoea, however trivial, should be looked upon with suspicion, and receive immediate attention. 

f I purposely omit all reference to the English form ; the two can hardly be confounded. 



23 

THE EPIDEMIC OB ASIATIC CHOLERA. 

hoemorrhoids ; but careful inquiry soon satisfied me that it depended upon neither one or the other of these causes. The cold and collapsed stages require nothing in the way of comment. Their diagnosis is sufficiently characteristic, and admits of neither doubt nor ambiguity. The vox cholerica, though often wanting, yet is, generally speaking, an attendant upon these stages. 

It has been said that the typhoid stage of Cholera presents nothing characteristic whereby it may be distinguished from the more ordinary forms of typhus ; and if we except the duration of the disease, this may be considered true. However, this typhus proceeds more rapidly to a termination, whether fatal or to convalescence. The vox cholerica too frequently remains throughout this fever ; and the patient, with the dull glassy suffused eye, the dry brown or black tongue, and the leading symptoms of typhus, yet frequently continues cold. The burning sensation in the stomach is often severe, and frequently vomiting, and even purging of bilious serum, rendered green by some acidulous re-agency, prevails throughout. On the whole, the previous history, when it can be depended on, affords the most unerring means of diagnosis.* 

Prognosis : — With respect to the prognosis, I can say but little. It must generally be guarded, and but seldom too favourable. In the preliminary diarrhoea, unless the patient be a most inveterate drunkard, the prognosis is favourable. In the premonitory stage, though not quite so good, still it is not unfavourable ; in the cold stage it is doubtful ; but in collapse, hopeless. In the typhoid stage, we must be guarded. The suffusion or injection of the conjunctiva of the eye of itself betokens danger; with dilated pupil still more so ; with contracted pupil, the case is hopeless. 

Hiccup prevails occasionally and indifferently during the last three stages. In the cold and collapsed stages it 

* In a practical point of view, the diagnosis is matter of little moment ; but as it frequently happens, cases in this stage are referred to the physician to settle any doubt as to their nature, it is requisite to know the means of distinguishing them. 



24 

TIIE NATURE AND TREATMENT OF 

i 

may be considered as favourable, though not universally so. During the transition from the cold or collapsed stages into the typhoid, it also augurs well, certainly not unfavourably, but in the advanced periods of the typhoid stage, I do not like it. I have not witnessed many recoveries in such circumstances. 

The general habits, temperament, and other conditions, &c, of the patient, whether favourable or unfavourable, are to be taken into account. The aged and infirm stand the worst chance. The habitual drunkard has little to hope, and if aged, his doom is inevitable. The young and healthy, and such as have not abused their constitutions, are least likely to suffer ; still the virulence of the disease is sometimes so great, that the strongest constitution, and under the most favourable circumstances, is unable to resist its ravages. 

In forming our opinion as to the result, we should take into account the particular circumstances of the patient, as his means of providing for all exigencies ; cleanliness, free ventilation, pure dry air, advantages as to locality, residence, &c, in fact, his capability of controlling or neutralising all those causes which tend to aggravate the symptoms and render the disease more virulent. From what has been already stated, it is evident, that if we wish to preserve our reputation, we cannot be too cautious nor too circumspect upon this question. We should avoid being dogmatical ; neither encouraging too much on the one hand, by holding out false hopes ; nor too depressing on the other, by a peremptory decree of inevitable mortality. 

ON DEATH AND CONVALESCENCE. 

Death may happen in any of the three last stages, although it does not often occur in what can be strictly called the cold stage. However, I have seen an instance or two of persons dying without the full development of collapse. In such cases, the morbid anatomy has generally disclosed some organic disease of the heart, as 



THE EPIDEMIC OR ASIATIC CHOLERA. 

25 

hypertrophy, polypus, or some fibrinous excrescence, attached to the internal walls. Death seldom, in this country, occurs in the premonitory stage. I have seen but one instance, and then the patient died suddenly, or rather unexpectedly. The morbid anatomy disclosed disease of the brain, particularly ramollissement, and a very large quantity of serum in the ventricles. 

Death, however, is of very frequent occurrence in collapse, and perhaps it is one of the most fatal stages. The patient occasionally dies comatose, and the vital functions seem gradually to cease, from a total failure of the natural excitability. 

The febrile stage is also a fatal one : however, it is I more manageable, and the principles of its management ; are better understood than the preceding stage. 

Convalescence. — The mode of convalescence is a subject of rather greater interest than Avhat we have just now been discussing. Convalescence may take place from any stage, without the intervention of any of the | consecutive stages. But where immediate convalescence I occurs, it is almost invariably ushered in by some I critical evacuation. The most frequent and the most common crisis is sweating. The next is a flow of the urine, and the third urinary deposits. Crisis takes place most frequently in the preliminary diarrhoea. If we can succeed in inducing a crisis, particularly sweating, at this period, we generally cut short the disease. In this district,* we have treated between seventeen and ( eighteen hundred severe diarrhoeas, — the bulk of which, j I have no hestitation in saying, would, if neglected, have^ run into Cholera. The patients generally presented some slight degree of fever, with rigors, pains in the head limbs, and commonly slight cramps. These diarrhoeas were not returned in the Daily Numerical Reports. In fact, no cases of Cholera were returned at all, unless they unequivocally presented the characters by which I have distinguished the premonitory, or some of the consecutive stages. 

* The Parish of Wick and its vicinities. 

c 



26 

THE NATURE AND TREATMENT OP 

I 

The premonitory stage also is terminable by crisis. This, however, does not take place so frequently as in the preceding stage. However, as convalescence is often the immediate termination of this stage, we are justified in endeavouring to induce a critical termination. 

The crisis to the cold and collapsed stages, appears to be febrile re-action. Fever, of one character or other, and of greater or less intensity, almost always supervenes these two stages, when protracted or not fatal. I have seen instances of direct or immediate recovery ; but they are certainly very rare. Therefore, the crisis which we should attempt in these instances, is the superinducing febrile re-action, which, when established, we must endeavour to limit and controul, upon principles which I shall hereafter have occasion to explain. 

The re-action which succeeds the cold and collapsed stages, is a genuine typhus. We know that all cases of typhus, even when epidemic, do not assume alike, or in an equal degree, the same malignant characters. Some of them present symptoms of comparatively much greater mildness ; and this is coat. par. generally proportioned to the period at which the disease has come under professional treatment. Now, when we see a fever at its very commencement, we can often cut it short, and thus prevent the perfect development of the febrile phenomena. I have seen abundant instances of this ; and there can be no doubt that such cases, if left to themselves would manifest all the phenomena of typhus in the usual consecutive order. This check has been invariably effected by some critical discharge, whether of sweat, urine, bile, or blood. The attempt to accomplish this object, to be successful, must always be made at the commencement of the fever. If the disease has advanced, any attempt to arrest its progress will be vain and futile, if not positively injurious. All that we can do then, at an advanced period, is to regulate the progress of the disease, mitigate the intensity of the symptoms, and subdue the severity of the consecutive manifestations, 



27 

THE EPIDEMIC OR ASIATIC CHOLERA. 

' 

or the sequelae, as perhaps they may with equal correctness be called. 

Now, the fever which supervenes the cold and collapsed stages, or perhaps, more correctly speaking developes itself at these periods, has already advanced too far for successful attempts to induce a crisis. The fever existed from the beginning, or at least an early period, and the time for inducing a crisis has passed. Therefore, we must pursue the only other management open to us ; namely, to subdue the severity of the symptoms during the progress of the disease, and to prevent the formation of those organic derangements which are usually the cause of death in fever. 

TREATMENT. 

The Treatment may be considered as comprising two heads ; namely, the therapeutics and the prophylactics. The therapeutics will comprise the medical management of the various stages : the prophylactics, the management of convalescence, and the sanitary precautions which it behoves communities, boards of health, and all interested, in checking the progress, and limiting the extent of the disease, to adopt. 

Treatment of the preliminary diarrhoea. — In the management of this period, we have two indications to fulfil — First, to check the diarrhoea; Secondly, to induce a crisis. There is no means familiar to my experience so successful for this purpose, as a combination of calomel and Dover's powders. The calomel seems to keep up the healthy quantity of bile in the system, and favours its flow from the gall bladder into the intestines ; while the Dover's powder promotes the action of the skin. I have tried calomel and opium separately and combined, but they are very inferior in power and efficacy to the other formula. 

In order to increase their astringent powers, a proportion of the compound powder of chalk is added, and 



28 

THE NATURE AND TREATMENT OF 

given iii small doses, and at short intervals.* In children, or where there is a peculiar irritability of the bowels, and which is sometimes greatly increased by calomel, I give the blue pill, or the grey oxide in preference to calomel. The grey oxide may be substituted in the poAvders for the calomel. It has been objected that this preparation is liable to become peroxidated ;f but I have some reason to believe that the peroxide in this case is derived from the impurity of the calomel from which the oxide is prepared. The grey oxide is generally prepared by decomposing calomel with lime water. If the calomel, or whatever other salt of mercury may be chosen, contain corrosive sublimate, or any salt of peroxide, of course peroxidated mercury will be precipitated. 

The other effects which I have witnessed from pursuing the above plan, is a very rapid diminution in the number of stools, and a very sensible alteration in their consistence. They become more, solid and better coloured. A perseverance in the above plan is soon followed by copious perspiration, which always proves critical. If perspiration succeed, the patient generally becomes convalescent, and with common care, gives no further trouble. The Rev. Mr. Lovi, Dr. Miller, and myself, have treated, during the prevalence of the Cholera in the district of Wick, between 17 and 1800 patients of this description, who were completely relieved from severe diarrhoea by these means alone, and more than three-fourths of the above cases would unquestionably have run into Cholera. 

* Calomel, grs. 12 Pulv. Doveri, grs. 10 ; — Cretse Comp. scrs. 2 12 powders — one every half-hour, hour, or 2 hours, according to circumstances. 

Pil. Hydrarg,£ drm. to 2 scrs ; Pulv. Doveri, grs. 10 to 20; Pulv. Crete Comp. scrs. 2 ; Extract Hyoscyami ; Sufficient to form into 24 pills— 2 or 3 for a dose, at the usual intervals, t Dr. Barker. 

Oxyd. Hyd. Ciner; Pulv. Doveri ; Ex. Hyoscyami ; Sing. scr. 1, make into 12 pills — 1 for a dose every hour, or every other hour. 



THE EPIDEMIC OR ASIATIC CHOLERA. 

29 

Acetate of lead has been proposed as an astringent, and, at the suggestion of the late Sir David Barry, I gave it a very fair trial in the Bethnal Green and Spitalfields Cholera Hospitals. Both it and the nitrate which I also tried seemed to exert little or no controul over the purging. The sulphate of copper, as recommended by Dr. Elliotson in dysentry, and sulphate of zinc, to both of which I also had recourse, seemed to exert no influence whatever upon the symptoms or their progress. The plan already detailed I have certainly found the most successful. 

I have very seldom found blood-letting necessary at this period. But if there be any local symptoms indicating inflammatory action, or any vascularity of an active character, then blood-letting proportioned to the urgency of the symptoms, should be practised. However, in the whole range of cases to which I have above alluded, bleeding was resorted to in ten instances only.* 

Although the characters of the diarrhoea varied in different cases, — being in some bilious, yellow, green, or fermentable like yeast, black, white, or clay-coloured, — I found the above plan equally applicable to all ; nor has one instance fallen under my observation, or come to my knowledge, of mischief occurring from the indiscriminate adoption of the above method, — a circumstance which I think goes far to prove that all these diarrhoeas were nothing else than the preliminary to an attack of Cholera, and which would have inevitably followed, had not preventive measures been adopted. 

When the diarrhoea is very severe, and seems to be exhausting the patient from the number of the stools, and that griping and abdominal spasms are troublesome, I have found the following draught eminently serviceable :—: — 

* The great bulk of the diarrhoeas fell into the hands of the Key. Mr. Lovi, the Catholic Pastor of Keith. To his zeal, activity, and unremitting exertions, this neighbourhood is greatly indebted. I therefore saw only the severer forms of the prevailing diarrhoea. 

C 2 



30 

THE NATURE AND TRExVTMENT OF 

I 

Pulv. Crete Comp. grs. 10 to 20; Liquor-Opii. seel, drops, 20 to 40 ; Aquas Cinnamomi, clrms. 12. 

Make into a draught to be taken immediately, and repeated if necessary. 

As thirst generally prevails all through, I have permitted, and indeed encouraged, the free use of toastwater, thin gruel, or common cold water, which last the patients themselves generally prefer, and I put no restriction upon them in this particular. By the adoption of the above means, the most urgent diarrhoea will be subdued, unless, indeed, it has been so long neglected that the disease has been established in the constitution, and must go through its course. 

Treatment of the Premonitory stage. — The Premonitory stage, as already described, is indicated by the limpid, muddy, or rice-looking appearance of the stools. By the absence of bile or feculent matter in the dejections, and by their alkaline re-agency : the gastric irritation denoted by retching, pain in the epigastrium, and a burning sensation in the stomach, with great thirst. As the serum of the blood appears to be passing off during this stage, the obvious indication is to prevent this as far as possible, and to supply as well as we can that which is already deficient. For this purpose, a more astringent treatment is required : but we must not forget that some of the functions are suspended, and that the secretions are partly suppressed, or retained. Thus, the skin becomes dry from the suspension of its functions, mucus ceases to be formed, and the membranes are left undefended, while the secretion of the bile goes on, although the fluid itself is retained in the gall bladder, and does not flow into the intestines. In this case, we increase the quantity of calomel and Dover's powders, and add to it gum kino and catechu, to produce the necessary astringent effects. Of course the mode of combining and exhibibiting his remedies, must be left to the judgment and discretion of each practitioner ; the principles only which should regulate the practice can be laid down. I may, however, state, that the following formula Avaa 



THE EPIDEMIC OR ASIATIC CHOLERA. 

31 

drawn up by me, and published by authority of the Local Board of Health of this place, and recommended under their sanction for general use ; 

Calomel, grs. 20 ; 

Pulv. Doveri,* grs. 15 to 20 ; — — Gum Kino, drm. 1 ; ¦ Catechu, ser. 1 ; ¦ Cretan Comp drm. 1. 

Divide into 12 powders — one to be taken in a little treacle or honey, or any thing thick, every half- hour, hour, or two hours, according to the urgency of the symptoms. 

In some cases, Aye here administer the calomel, the blue pill, or the grey oxide, whichever may be preferred, with the Dover's powder, either in the form of powder, or combined with extract of Hyoscyamess, so as to afford the proper consistency for pills. Then we give the following astringent mixture, in doses of two table spoonsful at intervals, regulated by the circumstances of the case :—: — 

Pulv. Cretse Comp. 2 drms. ; Tinct. Kino, 4 drms.'; Catechu, 3 drms. ; Aquas Cinnamomi, G oz. 

To which may be added, if necessary, one drachm of Liq. Opii. Sedative. 

I observed, during the prevalence of the typhus fever in Ireland, of which I saAV so much, that even after the fever was fully formed, provided it was at an early period, 

* It has been objected that opium produces congestion in the brain. This in the abstract I believe is true : nor does calomel even appear to protect the system from the congestive effects of opium. However, when it is determined to the skin, as in Dover's powder, congestion seldom or never follows. Neither should the dose be so large as to produce even the least possible congestion. I have, however, substituted the following formula with good effect for that of Dover's powder : — 

' Pidvis Muriatis Morph. Comp.' 

Mur. Morphse, 1 . , Ipecacuanhas, ) part elual e 1 ual - Muriatis Sodte, part. octo. 

' Pulvis Sulphatis Morph. Comp. 1 

Sulph. Morphine, \ , Ipecacuanha, ' }part. equal Sulph. Potass, part. octo. These may be given in the same doses as the common Dover. 



32 

THE NATURE AND TREATMENT OF 

the system was then for the most part readily brought under the influence of mercury. It was also observed of the same fever, that when the mercurial influence was once established in the system, although its progress could not be thus wholly arrested, yet those organic congestions of blood, which prove so troublesome to the physician during the advance of fever, seldom or ever formed ; and the fever itself did not assume its usual malignant characters, as petechiee, sordes, &c, but took on the milder character of the bilious remittent, peculiar to the fall, or of the simple continued fever, so prevalent in the spring of the year. Now, with the recollection of these facts before me, and believing, as all who are acquainted with my opinions know, that the epidemic now prevailing so extensively in this kingdom is nothing else than a combination of Indian or Asiatic Cholera, with typhus fever, from which latter it derives its contagious characters, I resolved to treat this disease as I would the same periods of the more ordinary forms of typhus. Under these circumstances, it is always an object of primary moment with me, to superinduce the mercurial influence ; and I can appeal to the experience of my colleague to show, that when we succeeded, we never after experienced any great difficulty in the management. It is true that the consecutive stages succeeded each other, nor was the course of the disease shortened ; but we never had any organic sequels to contend with, nor was the convalescence deferred, keeping the patient, as it were, balancing on the pivot of his destiny, neither advancing towards recovery, nor sinking under the approach of death. Therefore, to superinduce the mercurial action in the system, is at this period not only safe, but active and efficient practice.* But the practitioner must not suppose that he can effect his purpose by the wholesale introduction of mercury, as if he were storing up merchandise in a warehouse. He who acts upon such a principle will be miserably disappointed. It was observed of the typhus in Ireland, that although the mercurial 

* Wo have not on record a single instance of death, in which mercurial action had been excited in the system. 



THE EPIDEMIC OK ASIATIC CHOLERA. 

33 

influence, when once established, secured the recovery of the patient, yet mercury when profusely administered, without superinducing its specific effects, not only failed to protect the patient, but often hastened the fatal termination, reducing him, the victim of cutaneous ulcerations, gangrenes of the fauces and mucous membranes, and every other species of cachexy. If, therefore, we cannot effect our object by the mild and moderate exhibition of mercury, we must give up the farther exhibition, and trust to the protective or sanative influence of what we have already thrown in.* 

There are, however, several methods of rendering the system more susceptible of the mercurial influence : independent of opium, Dover's powder, &c, the chief are bleeding, and emetics in nauseating doses. They appear to awaken the dormant absorbent powers of the system, so that constitutions Avhich before had resisted, now readily yield to the introduction of mercury. Bleeding I have myself tried upon several occasions, and with, good effect. But to be successful, indeed not positively injurious, it must be practised at an early period, otherwise the cold stage is readily induced, and this is then apt to run into collapse. 

With respect to nauseating doses of emetics, the Dover's powder, as already recommended, will be found more successful than any other means. However, it will sometimes happen, and in particular constitutions, that even the smallest doses of" opium disagree. In such cases, I administer the mercurial in combination with compound powder of chalk, kino, and catechu. It may happen, and sometimes it is the case from the very beginning, that the sensibility of the gastro -intestinal mucous lining is such, that it will not bear the internal administration of mercury, under any form of prepara- 

* Soreness of the gums, with slight ptyalism,'is to be regarded as the most unequivocal manifestation of mercurial influence; but it would be a dangerous error to suppose that this influence has not been induced, because we have been unable to affect the gums, or excite ptyalism. — Need I refer to the history of the present epidemic as an illustration. 



34 

THE NATURE AND TREATMENT OP 

tion, nor under any modification of combination. In such cases, mercurial frictions, or mercurial vapour baths or fumigations, present us with the only alternative ; and, indeed, when there is considerable gastrointestinal sensibility, perhaps the internal administration should always be assisted by mercurial friction. 

The result of this plan often is the re-appearance of bile in the discharges. This may be either of a yellow or a green colour, the rationale of which has been already explained. If of a bright yellow, the mercurial may be continued, because this generally arises from a deficiency and consequent dilution of the bile. The green depends upon an acidulous re-agency, and should be corrected by the absorbent earths, and other well known correctives. A deep brown is the most natural and healthy colour, and proves that the mercurial has fully performed its duty. 

Sometimes the retching in this stage becomes very distressing, and brings on great soreness and tenderness of the prcecordia. In such cases, the plaister of muriate of ammonia and soap, described by Paris in his Pharmacologia is very useful ; but its effects being very gradually produced, it is not suited to urgent cases. Either the mustard sinapism with a tea-spoonful of salt, or caustic ammonia, diluted according to the severity of the symptoms, may be substituted. Every one knows how to apply a mustard cataplasm. For the diluted ammonia, a compress of linen or lint, wetted with it, and placed on the part, is the proper medium of application. 

I have found great benefit too in this stage, as well as in the preliminary diarrhoea, from the immersion of the feet and legs in hot salt water. Indeed, a hot salt water bath would be still more advisable ; but as in a great proportion of instances the bath is impracticable, I have then contented myself with the immersion of the feet in a pail of hot salt water. The patient should then be put to bed, and the treatment regulated upon the principles already explained.* 

* Since this sheet was sent to Press we have tried the salt 



35 

THE EPIDEMIC OR ASIATIC CHOLERA. 

Treatment of the Cold Stage. — I have already observed, that we must regard fever as the only favourable termination to this stage. If neglected, in 99 cases out of 100, transition into collapse will be the result. — How then is re-action to be induced ? Let me warn against the stimulus of brandy and other ardent spirits and the essential oils. The most rapidly fatal cases, and attended with the severest cramps and excruciating tortures which ever occurred in this neighbourhood, were those in which the patients, or their officious friends, sought relief by the administration of whisky or brandy. There was one case occurred in this hospital (William Hogg), who having suffered from the premonitory stage for some little time, being suddenly seized with cramp, his friends administered somewhere about a half mutchkin of whisky. He was brought to the hospital, and died in about three hours, I have seen two or three other cases of a similar description. The best method of inducing re-action, is by the repeated administration of a warm saturated solution of salt, till full vomiting, with some degree of re-action, succeed. The directions given in this hospital, as the most intelligible, are to put three or four handfuls of salt into boiling water, and when all the salt that is soluble in the fluid is dissolved, to add as much cold water as will reduce the heat, so that it may be swallowed. Of this the patient is to have a breakfast cupful every five or ten minutes, till vomiting take place. This is generally followed by some degree of re-action ; the pulse becomes more firm and sensible, and sometimes hard. The tongue becomes warmer and coated, the face flushes, and the respiration becomes more hurried. If the patient should relapse or fall back again into the cold stage, then the emetic should be repeated every half-hour, until re-action is permanently established. 1 

emetic in the premonitory stage, and with very good effect. Two effects have been the result. — In some a critical solution of the disease, in more obstinate cases a transition to the febrile stage without the intervention of the intermediate stages. The salt-water emetic is one of the most active means that I know of. 



36 

THE NATURE AND TREATMENT OF 

admit that it will occasionally happen that, although we may succeed in establishing re-action, yet it will not be permanent, and the patient at last becomes collapsed, and dies. This I have witnessed upon one or two occasions ; but I invariably discovered that these persons had, for a considerable time previously to their attack, indulged in spirituous potations — in fact, in bestial drunkenness. _ I could present a tabular record of these instances, but a degree of respect for the feelings of surviving relatives, induces me to withold the particulars. 

It has been already hinted, that the blood during this stage is gradually parting with its watery and saline principles, and therefore to supply the deficiency seems to be a feasible indication. I have seen what has lately made so much noise in London, under the name of " the Saline Treatment," adopted, but uniformly with unfortunate results. At the request of the Central Board of Health, I tried it in the Bethnal Green Cholera Hospital, when physician to that establishment. Every patient died. It was tried at the White House, and the result has been published by the professional gentleman of that establishment. I must confess that the effects were precisely what I anticipated — namely, a transition into collapse. Now, the saline is merely the refrigerating treatment of Cullen and others, under a new name. The exhibition of saline solutions induces cold, reduction of pulse, &c, the very things we should be anxious to avoid, for our object is fever, but the saline treatment removes or subdues fever. 

The effects which I have observed from saline medicines administered in this way, are an aggravation of all the symptoms of the cold stage, and its conversion into collapse. I must confess that, from ample experience, I would dissuade from even the trial of it. 

In endeavouring to manage the cold stage, we must not overlook the fact, that the blood is, as it were, inspissated and deprived of its saline particles. Every means of restoring the healthy condition of the blood should be attended to. What effect the salt emetic may have in 



37 

TnE EPIDEMIC OR ASIATIC CHOLERA. 

this way, it is difficult to conjecture, but immersion in a hot salt water bath, experience has shown to be efficacious. Now, it is by no means improbable, that during the immersion, a large quantity of the saline fluid may be taken up by the skin and mixed with the blood, so as (in part at least), to restore its healthy constituency. — Whether this be the principle, or that of " Endosomose," described by D'Autrochet, I know not ; but of this lam satisfied, that the blood of persons, which would not separate into serum and crassamentum before immersion, when drawn after immersion, has separated, although more slowly than under ordinary circumstances. The bath is the preferable plan ; but when this is impracticable, immersion of the feet, legs, and hands in a pail of hot salt water may be substituted. 

During the cold stage, the thirst, which was inordinate in the preceding stages, still prevails, though not so urgent. I have found great advantage at this time to substitute well seasoned beef-tea or gravy-soup for the toast and water. Nor is this contra-indicated by the burning sensation in the prcecordia, for in fact it favours the accession of fever, which is the natural solution of the cold and collapsed stages. Gravy-soup is perhaps the most grateful drink at this time ; but if this cannot be procured, a very excellent substitute may be found in common beef-tea, well seasoned with a due proportion of good mushroom ketsup ; or common water and ketsup in equal proportions, or adjusted according to the taste of the patient. Generally speaking, this drink may be administered warm ; but I invariably consult the taste of the patient upon these points.* 

To relieve the vomiting and the burning pain in the proecordia, a mustard cataplasm, composed of two tablespoonsful of flour of mustard, one tea-spoonful of common salt, with as much vinegar as will give it the due consis- 

* It happens, but not invariably, that in collapse, aud also in the cold stage, the breath is deadly cold. I have remarked when the breath is cold, or that the tongue is remarkably cold, then the drink is preferred warm. However the rule above pointed out is the safest principle. 

n 



38 

THE NATURE AND TREATMENT OP 

tence, should be applied to the epigastrium, by being spread on linen or brown paper. 

Sometimes, however, the symptoms are so urgent and distressing, that there is not time to wait for the effects of the cataplasm. In such cases, vesication may be very speedily induced, by placing a fold of linen on the part, and dropping on it, moderately, concentrated ammonia. I have seen these means afford relief, in several instances. While we are thus endeavouring to subdue the severity of the symptoms, we should continue the mercurial and astringent plan already pointed out, and the patient should be kept warm, by means of hot blankets, and the application of stomach and feet- warmers, &c. 

If re-action do not speedily follow the above means, the patient soon sinks into the succeeding stage — namely, collapse. 

Treatment of Collapse. — I can offer but little in addition on the treatment of this stage. It is to be treated much in the same way as the cold stage, only with greater activity. However, the practitioner who anticipates much success in the treatment of this stage, will, I fear, be disappointed. Recoveries certainly do, though rarely, happen ; but still I believe we must not attribute much to the remedial means employed. Although I cannot point out much in the way of remedies to prove successful, I may warn against the employment of those which prove positively injurious, and mostly fatal. Among the first I rank brandy, and all other stimulants composed of ardent spirits. More, probably, have been killed by these means, than by the unassisted severity of the disease itself. Let us examine the object of brandy : to excite the enfeebled or arrested motions of the heart, so as to continue the circulation. But does not the enfeebled state of the circulation, or its actual cessation, result from the injection of the substance of the heart itself, with poisonous blood, — thus destroying the excitability of the moving agent ? Therefore, to excite the motions of the heart, while the blood remains in its unhealthy condition, is hopeless ; and had we the means of doing it, they would prove most pernicious. 



39 

THE EPIDEMIC OR ASIATIC CHOLERA. 

Another means, and to a certain extent more rational, has been proposed, — the injection of watery saline solutions into the veins. This at first sight seems a rational indication, deduced from the chemical pathology of the disease. However, it is physically impossible that it could effect the legitimate object — the dilution of the blood. A very superficial degree of physiological knowledge must be sufficient to prove this. The veins convey the blood or the injected fluid to the right side of the heart ; but to be effectual, the dilution should be in the left ; because the grand primary object is the supply of the heart's own substance with healthy blood, so as to restore its excitability. The dilution, therefore, should take place in the left ventricle. Then, perhaps, if the heart's excitability were not so far destroyed, as that it would not obey the stimulus of distension, the coronary arteries might be filled, and thus some good effected. But it is impossible to convey the solution directly to the left side — certainly not by injecting the veins, unless the foramen ovale could be opened — and, therefore, upon sound physiological principles, it cannot prove successful. This I predicted from the first ; and although I have seen a good deal of it, and even in the hands of sanguine practitioners, I have never witnessed a successful case. We must, therefore, treat collapse as we would the cold stage, but still more assiduously, in the hope that nature may effect that— namely, re-action — which we, in the present state of our knowledge, know not how to compass by art.* 

Dr. Dawson, in a letter published in The Examiner, proposes the use of chloroform inhalation as a remedy likely to prove efficacious in cholera ; and asserts that he found it very beneficial in some very severe cases of the English form of the disease. It is a sin- 

* I certainly have seen reports of successful injections ; and, therefore, I can only say, that if experience confirm the benefit, we are bound to practise them, though theory will not at present explain satisfactorily the rationale. I have given them a fair trial, and do not myself feel warranted in pursuing the plan. 



40 

THE NATURE AND TREATMENT OV 

gular circumstance that, within a week or ten days after the publication of Dr. Dawson's letter, two instances were mentioned in The Times newspaper,* of recoveries from Asiatic Cholera, by ether inhalation. The inhalation, in one case, was quite accidental ; but the patient being attacked with Cholera, when prevailing in Europe, and suffering most intensely, laid hold of a bottle of sulphuric ether near him, and inhaled its vapour. Immediate relief was the consequence, followed by sleep, perspiration, and speedy recovery. Another instance is detailed in the same journal, equally successful. These facts justify the hope that chloroform may prove a valuable auxiliary, if not a complete means of cure. For myself, however, I can offer no opinion from experience ; but in so dreadful a disease we are warranted in resorting to any means that holds out the slightest prospect of benefit. No doubt, if Cholera, should again visit us, chloroform and ether will be enlisted into our service. 

Treatment of thii Typhoid stage. — It has been already stated, that fever may supervene any of the foregoing stages, although it more frequently follows in the course before described, — that is as a consecutive to either the cold or collapsed stages. This fever, as was observed by Barry and Russel during their mission to Russia, generally put on a typhoid character. It cannot, however, be treated, with success at least, as the more ordinary forms of typhus. The refrigerating plan, so useful in the other forms, is wholly inadmissible here. I have tried, in this stage also, what has been lately termed "the saline treatment," and have always found it highly pernicious. From the typhus consecutive to Cholera, patients are apt even spontaneously to relapse into the cold or the collapsed stage. The saline treatment, in a state of disease, in which the tongue is so apt spontaneously to resume the coldness of the cold stage, with the state of pulse and skin coincident with it, appears to me eminently calculated to re-induce these phenomena, which it hchoves us, by every means in our power, to prevent. I have had, upon many occasions, practical proof of these 

* The Times, January 3, 1848. 



THE EPIDEMIC OR ASIATIC CHOLERA. 

41 

unfortunate results. I saw several instances of this in Whittlesea ; and one case in particular, I remember, which apparently was doing remarkably well, but the pulse appearing to be very weak, a little carbonate of ammonia, dissolved in water, protected too by spirit of lavender, being given in small and repeated doses through the night, I found on visiting at the hospital next morning, that the patient was shortly after seized with severe purging, became cold and collapsed, and died in the course of the day. My friend and colleague in this hospital, too, can attest the severe effects resulting from saline remedies, administered under similar circumstances, so that we have totally proscribed them in our own practice, and interdicted their use to the patients in our hospital. 

The fever itself requires little else than mere dilution. This is best effected by common water, toast and water, or any other convenient dilution of a medium temperature—say from 50°, 60°, or 65° of Faht. Patients very seldom die of the mere fever, but of the consequences upon the brain, or some other important organ; but almost always affecting the brain. These derangements are mostly of a vascular description, and I have in another part explained my view of their nature. I shall now proceed to describe the treatment which I have found best adapted to each. 

I consider the degree of suffusion of the eye as the most certain index of what is going on within the head, and the state of the pupil, the index of the description of morbid vascularity in the brain. When the pupil is contracted, the vascularity partakes of the character of inflammation — inflammation certainly of the sub-acute kind. In this state I open the temporal artery, and if sufficient blood can be drawn from this source, it is the best from which to take it. When the flow is not sufficient — from 10 to 12 oz. are generally required — the patient should be bled from the arm. Nauseating doses of emetics are generally eminently useful in inflammation ; hut they will not do in this fever. I have found the true James's powder answer better than any 

D 2 



42 

THE NATURE AND TREATMENT OF 

other remedy. It generally brings on free perspiration, which is salutaiy, and a combination of it, with a very small proportion of a mercurial, promotes its action. The quantity of the mercurial should be extremely small : for in per-acute, or active inflammation, large doses of mercury excite synocha fever, and lead to suppuration and abscess. In the sub-acute species, they excite low 'fever, muco-purulent exudation, and ultimately ulceration. I, therefore, in this species of cerebral derangement, have given from to \ grain of calomel, or any other mild mercurial, Avith from 3 to 5 grains of James's powder, guarded by a sufficient quantity of extract of Hyoscyamus to form a pill ; and this dose is to be repeated every half-hour, hour, or every other hour, till the symptoms give way, and perspiration succeed. When opium is indicated, which is not often the case, it is the preferable plan to add the requisite quantity of the pulvis mur. morph. comp^ In order to prepare the stomach for a second dose, if it reject the first, a little camphorated spirit may be given, in infusion of cloves, or tincture of cloves in the camphor julap. If this does not answer, the head should be shaved, and it will be well always to shave the head on the slightest appearance of suffusion of the eye. An evaporating lotion,* when the head feels hot, should be applied. 

The above plan is applicable to inflammatory action, wherever seated, supervening the typhoid stage of Cholera. But I have already noticed a species of morbid vascularity, allied in some measure to inflammation, depending upon distension of the lymphatic veins, with dark coloured blood. The treatment of this depends chiefly upon exciting the action of these veins, so as to enable them to get rid of their morbid contents. Mercury is our sheet anchor here, and it should be given so as to produce its specific effects in the system. 

* Composed of alchohol, 2 pai'ts; rather, one part; and camphor mixture, 3 parts, To a portion of this as much hot water as will render the whole milk warm, should be added, and a cloth dipped in it placed upon the head. It should be wetted as fast as it dries or becomes hot. 



43 

THE EPIDEMIC OR ASIATIC CHOLERA. 

Bleeding, however, is the first means to which we should resort, and a quantity proportioned to the strength of the patient, and the urgency of the symptoms, should be drawn from the jugular, if possible, when the eye is much suffused, the pupil greatly dilated, with coma and laborious stertorous breathing. In less severe cases, the blqdti? may be drawn from the arm, as being more manageable. The mercury should now be pushed, and we cannot use a better formula than the one above, only reversing the relative quantities of the mercury and James's powder. Thus, we may give from three to five grains of calomel or the grey oxide, with from half a grain to a grain of James's powder, or ipecacuanha, with the requisite quantity of extract of hyoscyamus, to make into a pill to be taken every half- hour, or two hours, according to the urgency of the symptoms. The sooner we can bring the system under the influence of mercury, the sooner will the veno-congestive inflammation be resolved, and the brain restored to its healthy state. The nauseating effects of the James's powder in minute doses, probably assists the absorption of the mercury; and I have upon some occasions added a minute portion of tartar emetic. _ In urgent cases, mercurial frictions and fumigations should be had recourse to, in addition to the above. — The evaporating lotion should also be applied, as above directed, to the head ; and in more urgent cases, blistering the nape of the neck should not be neglected. Such are the curative means which belong essentially to the treatment of the fever. It now remains for me to make a few observations upon some accessary symptoms, which have not yet been provided for. Some of these supervene all the stages ; some are peculiar to the febrile stage. 

The first, and by far the most important, is supression of urine. This symptom is principally an attendant on the cold and collapsed stages. It should not be neglected, and no means, likely to overcome it, should be left untried. When it prevails in these stages, the miniated tincture of iron, with compound spirit of juniper, administered in any appropriate vehicle, is 



? t 

THE NATURE AND TREATMENT OP 

the most powerful remedy, and the doses should be repeated until some effect is produced. From ten to twenty drops of the tincture, with one drachm of the compound spirit of juniper, may be given every two or three hours, till a flow of urine is produced. When suppression attends the febrile stage, but with dilated pupil, the proportion of muriated tincW& should rather be diminished, but the above plan may be pursued, provided the febrile heat be not excessive. 

"When the pupil is contracted, and urinary suppression exists, I prefer acetic extract of colchicum, acetic extract of juniper, and extract of hyoscyamus, of each one grain, every two or three hours, with which may be taken one drachm of sulphuric or nitric aether, in one ounce or ten drachms of infusion of juniper. These will, in favourable cases, bring on a discharge of urine in any of the stages, in which suppression is troublesome. 

In retention, there is but one means of giving relief, and that belongs to the department of surgery. No practitioner can be at a loss in such a case to perform his duty. 

OF THE TREATMENT OF CERTAIN ADVENTITIOUS SYMPTOMS, NOT ESSENTIALLY INTEGRANTS OF THE DISEASE. 

Spasms and Cramps. — These may prevail at any period. Friction and the warm bath afford the greatest relief. The linimentum saponis, with spir. terebinthinas, and tinct. opii. combined in proportions according to circumstances, I have found greatly to assist. When cramps alone prevail, the limb or limbs should be immersed in Avarm water, and after immersion, well rubbed with the liniment as above. When abdominal spasms prevail, the warm bath, with the friction as above, is the best remedy. 

If chloroform or perchloride of formyl, as it is also named, should be found as beneficial as the letter previously alluded to, and subsequent reports would lead 



THE EPIDEMIC OR ASIATIC CHOLERA. 

45 

us to expect, this, no doubt, is the period in which we should hope for the greatest advantage from its use. Its tranquilizing and sedative effects upon the nervous system, bid fair, and certainly inspire us with the hope that it may prove an active and powerful agent. I need hardly observe, that the circumstances which contra-4"!lJoKite the use of opium, do not apply to chloroform, so far as we are acquainted with its therapeutical actions. 

Flatulence — Often prevails in the febrile stage, and when prevailing in any stage (for it is not confined to this stage, through more frequently present at this period), is a source of very great distress, giving rise to spasms and cramps. It is best relieved by a little of the pil. galb. comp. with a draught, containing a few grains of calcined magnesia, in a little aromatic — as cinnamonwater. In some cases, the foetid spirit of ammonia, with a little of the liquor opii. sedativ. and tinct. of hyoscyamus, gives immediate relief. I have never found flatulence an intractable symptom, unless where the digestive organs were organically deranged, and this is not the place for the consideration of this subject.* 

Vomiting in the stage of He-action. — This symptom sometimes becomes very troublesome. The discharged matter is perfectly limpid, like water. It resembles much what is discharged in pyrosis. This led me to adopt Pember ton's practice of kino and opium. Thp Dover's powder and kino, however, I found more effectual — From 3 to 5 grains of each may be given, at every accession of vomiting, and a draught, consisting of from 10 to 30 drops of the sedative solution of opium, in an ounce of camphor mixture. If these means do not prove effectual, a blister should be applied to the epigastrium. I have found acetate of lead, and sometimes sulphate of zinc extremely beneficial in some instances. 

* If tympany be clearly established, some of the metallic tonics and astringents, especially acetate of lead as recommended by Dr. Graves or the sulphate of zinc, with opium or morphia may be given with advantage. 



46 

THE NATURE AND TREATMENT OF 

Purging. — Sometimes a purging prevails during the febrile stage. It assumes different appearances. Sometimes it looks like washings of beef"; sometimes it is mucous orgruelly-looking; but more frequently it is green. The free but guarded use of mercury, is the best restringent. When it is red, like the washings of beeftthe acetate of lead, the tartrate of iron, the sulphate of cl^ i> per, or of zinc, combined with Dover's powder, is the best remedy. I cannot take upon myself to say which of the above metallic restringents is the preferable. 

When the motions are yeasty, whitish, or clay coloured, a combination of blue pill, the grey oxide, or calomel, with Dover's powder, is the best remedial means. When fermentation takes place, as may be known by the frothy condition of the motions, a combination of a mercurial, with comp. galbanum pill, extract of rhubarb, and of hyoscyamus, in well known proportions, with which may be administered some absorbent — as calcined magnesia, suspended in cinnamon water, is, so far as I know, the most efficacious remedy. 

Abdominal Tenderness with Tension. — The treatment of this symptom is entirely comprised in leeching, fomentation, blistering, and emollient clysters. 

Vesical or Urinary Irritation. — Acetic extract of colchicum, hyoscyamus, camphor, and pulv. muriat. morph. composit, present us with the most effectual remedies. 

Anasarcous swellings of the lower extremities — Are sometimes the consequence of the febrile stage, especially when desquamation of the cuticle has supervened the termination of this stage; or that the fever has been attended with much redness of the face or skin, or that any eflorescence resembling exanthematous eruptions has appeared in the course of the fever. These swellings, though sometimes considerable, — of which remarkable instances have occurred in this hospital, and several out of doors, — readily give way to tartrate of iron, and supertartrate of potass, with the compound decoction of sarsaparilla. 

One very severe case, followed by cutaneous ulceration 



THE EPIDEMIC OR ASIATIC CHOLERA. 

47 

t 

i 

— probably the effect of the mercury administered for his relief, occurred in this hospital. Alex. Dewar, aged 20, admitted the 10th of August, completely blue, cold, pulseless, and senseless. He is now slowly recovering, under the use of the compound decoction sarsaparilla. 

Three women were pregnant. In one, labour came on during convalescence, but the labour making no progress, she was obliged to be delivered, by perforating the cranium. The child died during the attack of Cholera. She was seven months gone. Another miscarried — twins — between three and four months after conception. The third also miscarried. "We have a fourth now in hospital, uncertain as to the completion of her time, but I think she will do well.* Several pregnant women have gone on well. 

To comprehend the following Tabular Abstract, it may be observed, that in the first column are stated the stages of the disease under which the patients were labouring at the period of visiting. The second gives the number of each which fell under the immediate superintendence of myself and colleague. The four succeeding columns point out the numbers that died actually in the original stage, or after transition into one or more of the consecutive stages. Then are given the total deaths in each stage. The above explanation, mut. mutand. applies to the columns of recoveries. Then is given the mortality in each stage, and the lowest column contains the average mortality of the entire disease. The above explanation applies to the Hospital Abstract. 

Table I. — The thirty-three cases of Cholera in the premonitory stage, and the eleven in the cold stage, stated to have terminated by critical solution, either did not enter into any of the consecutive stages, or in so slight a degree as hardly to deserve the name. The latter part of this observation applies to the critical solutions of the cold stage, which generally showed some 

* This woman ultimately recovered. 



48 

THE NATURE AND TREATMENT OF 

slight degree of febrile re-action ; but so very slight, as hardly to deserve the name. They all took the salt emetic, followed by some mercurial and Dover's powder, and the feet were generally put into hot salt water.' The crisis mostly consisted in free diaphoresis, with indications of bile in the evacuations. 

Of the fatal cases, two were upwards of 80 years of age; five above 70; seven between 60 and 70; and eleven between 50 and 60. We may, therefore, fairly substract the two above 80, and the five above 70 from the mortality, and then we shall have the average estimate as follows : Cases, 317—7=310. Deaths, 59—7 =52 : 310 : : I:sf f the real mortality — expressed in whole numbers, 1:8. 

The Rev. Mr. Lovi stated to me, that he had succeeded in about 30 cases of collapse, to which he had not called my attention, the symptoms soon giving way; but it is more probable that they were the severer forms of the premonitory or cold stages. 

Table II. — Of the fatal cases, two were above 70 ; four above 60 ; and five between 50 and 60 years of age. Six were sent into the hospital, either because their friends deserted them, or that they wished to save themselves the trouble and danger of " chesting" the bodies. The mortality, therefore, should be reduced 8, leaving the deaths at 20. The cases will then stand thus: — Cases, 95—8=87. Deaths, 28—8=20 :87: : 1 : 4^-. 

The recoveries from the fever consecutive to collapse may seem rather high, but the collapse in eight or nine of the above cases was not so clearly nor so distinctly marked : it may, therefore, be questioned, whether they were not cases in the severest form of the cold stage. Four, however, were of the most decided character, being blue, senseless, pulseless, and speechless, with slow, laborious, stertorous respiration, and cold as ice. I saw two recoveries under similar circumstances at Whittlesea. 

P.S. — The average mortality in the practice of myself 



49 

THE EPIDEMIC OB ASIATIC CHOLERA. 

and colleague appears great compared with that of the resident practitioners. The total cases this day (16th October), amount to 405, and the total deaths to 68. Therefore, 405 — 317=88, the cases treated by the other gentlemen, and the deaths 68 — 59=9 ; therefore 9 : 88 : : 1 : 9^ their average mortality. This anomaly requires explanation ; and the cause is, that cases reported by these gentlemen becoming worse, were by them very properly transferred to the hospital, and terminating fatally, tended to swell our list of mortality, while they added nothing to the mortality of the original reporters; but, on the contrary, furnish a deceptive numerical list of recoveries. This explanation is necessary, more particularly as all the medical gentlemen here, without a single exception, have done me the honour to adopt the principles of treatment recommended by myself. 

Such is the result of my experience in the management of Epidemic Cholera. There are many circumstances, perhaps, omitted ; but my object has not been the minutiae ; but the leading and most frequent phenomena of the disease. I shall now proceed to the second head— the prophylaxis. 

B 



50 

PROPHYLAXIS. 

Convalescence. — The convalescence is generally short, and therefore requires but little treatment. It often happens, however, that during this period, especially on the solution of the fever, that the patient is attacked after meals, or in fact anything being taken into the stomach, with vomiting ; and whatever is taken is immediately ejected from the stomach, and the tongue becomes cold. This depends upon some peculiar irritability of the stomach, and it is almost always certain to attack pregnant women convalescent from Cholera. Nothing seems to allay this irritability so well or so speedily, as a little good mulled wine, or a little weak brandy and water. The tongue immediately becomes warm, and the irritability of the stomach subsides. 

Provision for the Treatment of the Sick. — Hospital accommodation is one of the first objects that should engage the attention of any community. It is idle to be speculating upon an immunity from the disease, and more have been sacrificed from an unwillingness to provide proper hospital accommodation, than perhaps is calculated upon. A suitable building should therefore be provided, with six beds at least or more for every thousand of the population. These should be kept for the accommodation of patients in the premonitory, the cold, and the collapsed stages. 

True, the Sanitary Commission object to such preparation, but certainly upon insufficient grounds. Waving contagion altogether, still we must admit that the virulence of all epidemics is greatly aggravated by poverty, starvation, want of cleanliness, insufficient ventilation, cold, and damp, while, on the contrary, wholesome diet, pure dry air, cleanliness, &c, mitigate the violence of the most malignant distempers. From my experience in 1832 and 1833, 1 am satisfied that hospital provision for the poor forms a most important element in the treatment — the poor should have ready access to medical attention, and the advantages and comforts of a commodious and 



PROPHYLAXIS. 

51 

well-ventilated building. But the entry should be perfectly optional ; nor would I prohibit the access of friends to the patient. Under such regulations, there would be neither empty wards, nor unoccupied beds. 

For the patients, when in the febrile stage, I should strongly advise the erection of a Marquee. With the sanction of the Board of Health, I have adopted this plan here. A Marquee, about 40 feet long, and 16 or 17 broad, has been erected. A boarded flooring, raised about 3 inches from the ground is placed in the inside. In the centre is a hot air stove, with the funnel so constructed, that the smoke is conveyed downwards under the floor. Thus, the temperature can be raised or diminished at pleasure. By letting down the walls of the Marquee the air is cooled, and there is a thorough ventilation without any drafts or currents. Closing the walls and opening the air part of the stove, the temperature is again elevated. A thermometer suspended in the Marquee determines whether the Marquee or the stove should be open. Our Marquee has now been in operation for one month, and we have not lost a single case in the febrile stage since we put it in operation. Indeed, the typhoid characters seem to be completely suppressed by this management, for in the Marquee they all assume the more mild form of simple continued fever. The duration, too, of the febrile stage, seems to be greatly shortened by this means, as we find the sick recover, sufficiently to be discharged, in about twothirds of the time required when they went through the entire of the disease in the cholera building. 

District Dispensaries for supplying medicines to persons labouring under diarrhoea, is another object of great moment. The disease is often wholly arrested by timely assistance at this period. The number of course must depend upon the population and extent of the locality. 

Burial of the dead is also a subject of importance. When a person dies of Cholera, the body should be wrapped up in a tarpaulin, sear cloth, or painted canvas, and put in a coffin pitched inside on the seams, and screwed down. The sooner interment takes place the 



52 

PROPHYLAXIS. 

better. It ought to be within 12 hours. This, too, independent of all considerations with respect to contagion. 

The bedding and clothes of the person, if valueless, ought to be immediately burned. If of greater value, they should be put into a copper of boiling water, and well boiled for two hours. Such articles as cannot undergo boiling, should be baked. There is no danger of infection after the adoption of these means of purification. Bedsteads, tables, and such articles of furniture, may be well exposed to the open air for a day or two, and then they are harmless. 

Ventilation is of the highest importance in every stage of the disease ; and, therefore, no means of thorough ventilation should be omitted. — Cleanliness, too, is equally essential, and when practicable, the wards should be frequently emptied and washed. 

The dwellings of the patients, who are attended at their own houses, should be well lime- washed and cleaned. 

Local Board* of Health. — The first object of a Board of Health should be to gain the confidence of the people. On their first establishment, no circumstance should be too trifling for their notice, and they should give due publicity to all their acts and measures. Nothing does so much injury as mystery, or even the appearance of it. The Board of Health here, place in a conspicuous part of the town, a copy of the Daily Report to the Central Board. Thus, all are informed of the real state of affairs, and the exaggerated and unfounded reports which become current, when there is nothing authentic, are either wholly suppressed, or rendered completely harmless. 

To induce patients to go to the hospital, their friends should not be prevented visiting them. The regulations as to diet, hospital establishment, &c, should be hung up in each ward, for the inspection of the patients and their friends. By adopting this plan, we have found no difficulty in inducing the patients to come into the Hospital ; and before the erection of the Marquee, we were compelled to decline taking in cases that were anxious 



53 

PROPHYLAXIS. 

to avail themselves of Hospital accommodation. Nor is there any objection to permit the friends or relatives to visit the patients There is far less risk in visiting a Cholera patient in a well ventilated hospital, than when in the wretched miserable hovels, in which some are compelled to end their days. 

Hygiene : — By this term, we understand those sanilory principles and measures of purification which tend to prevent the appearance of disease, or which circumscribe its extension where it has appeared. Hygiene, therefore, will admit of being divided into two kinds — -public or general, and individual or domestic. 

Public or General Hygiene. — It has been already observed that pure and wholesome air is a most important element in the prevention or arrest of epidemic disease ; hence every means of securing a pure atmosphere. Many illustrations of this principle might be adduced, but I shall mention one : — In Spitalfields, certain of the more crowded parts, as Petticoat Lane, &c, were totally destitute of every means of cleansing, as sewerage, &c. ; fever, of a typhoid character, was never absent from this locality ; but since the improved system of draining and sewerage has been introduced, typhus has become comparatively a rare occurrence. Of the efficacy of a foul or noxious atmosphere in propagating epidemics, I saw it noticed somewhere, that of a number of contiguous shipping, one only was the abode of Cholera, the others being perfectly free from the disease. Upon investigation, it was found that the solitary habitation of Cholera was moored close to and opposite a sewer, which emptied itself in front of the ship. On moving her moorings, the disease was extinguished. 

Here, then, we see the effects of an impure atmosphere. This impurity, unquestionably, must have acted by rendering the system more susceptible, as it could not, by any possibility, have excited the disease ; hence, perfect sewerage and draining should receive immediate attention from the proper authorities, and cesspools and other receptacles of filth, and which have no outlet, 

c 2 



54 

PROPHYLAXIS. 

should be filled up. The sewers should be frequently washed, by forcing water through them in a rapid current ; indeed, unless this be done, the accumulation of filth may prove very injurious.* Water, in a state of vapour, favours the spread of Cholera, but the disease cannot withstand a deluge. It would be unnecessary to enter more at length upon the duties of public functionaries ; cleanliness of the streets, and the purity of the atmosphere, comprehend the leading principles of sanitary systems. 

Hospital accommodation has been already noticed, and here, perhaps, it may be expected that something should be said relative to disinfecting agents. As destroyers of the morbific agents which excite Cholera, they are perfectly inert ; but as neutralisers of certain noxious effluvia, they may prove useful in hospitals, or where numbers of persons, sick or healthy, are congregated together; but it must be clearly understood, that we know of no agency which they can exert upon contagion, or certain forms of miasm. 

Of these agents, chlorine seems the most effectual. The deodorising powers of Sir Wm. Burnett's fluid, chloride of zinc, have been now fully proved, and has received the sanction of the admiralty. In The Lancet, Bth Jan., 1848, a very cheap deodoriser is mentioned : it is a waste product after the manufacture of chlorine, consisting of chloride of manganese, a variable proportion of chloride of iron, a little hydrochloric acid, and free chlorine. Although 150 tons are produced per diem, it has been applied to no useful purpose. Mr.^ Young, of Manchester, finds that it prevents the decomposition of organic matters ; cesspools, and other places emitting the most offensive odour, have been immediately purified and sweetened. It acts by decomposing the hydrosulphate of ammonia, producing instead hydrochlorate of ammonia and sulphuret of manganese ; hence it might be applied * It is highly probable that, should Cholera revisit this country, the improved sewerage of London will materially modify the disease in the metropolis. 



55 

PROPHYLAXIS. 

to washing out sewers, cesspools, drains, and other receptacles of filth, which should afterwards be washed with simple water. 

It has been remarked that damp air favours the spread of epidemics ; hence, measures should be adopted to secure a. dry atmosphere. Means for this purpose, however, are applicable only to hospitals, dwellings, and buildings. Recently ignited chloride of lime is the best exsiccant, rapidly absorbing the moisture of the air ; vessels containing it may be placed in convenient situations, or if the air which supplies the building could be conducted through dried chloride of calcium, it would be still better. The means of effecting this of course forms matter for special consideration; the chloride, after use, may be again ignited and fitted anew. 

Quarantine. — This is a subject which, no doubt will excite considerable anxiety, and from the views which I have supported, it may be presumed that I am a supporter of a rigid quarantine ; I am, however, decidedly opposed to quarantine, as a means of preventing Cholera. If the Cholera of 1832 acquired a contagious character, and was propagated by contagion, experience has shewn that no restrictions could prevent its appearance ; it broke through the sanitary cordons, defying alike the bayonet's point and the cannon's mouth. If not contagious, quarantine is not only useless, but injurious, from the barriers which it opposes to the ordinary transactions of life. The most effectual obsticle to the spread of Cholera will be found in the principles of hygiene, laid down in these pages. 

Individual or Domestic Hygiene. — This portion comprehends those sanitary rules and principles which it behoves all those to observe who would escape an attack of Cholera. We must start from this axiom — the more healthy and vigorous the frame, the less the susceptibility to the morbid influences of disease. Even where the Cholera has or is now prevailing, an enfeebled or otherwise broken down constitution are the circumstances which invite attack, and render the disease more fatal. To strengthen the body, therefore, is the 



56 

PROPHYLAXIS. 

grand principle of prophylaxis, the principal elements of ¦which are diet, air, and exercise. 

Diet. — Nutritious and wholesome diet is of the utmost importance. We naturally live upon farinaceous and vegetable food, as well as animal. Although scanty, poor, or watery diet enervates the body, and increases the susceptibility to disease, we should not forget that gluttony and intemperance have a similar effect :— 

" Est modus in rebus ; sunt certi denique fines, Quos ultra citraque, nequit consistere rectum." 

The bread, if new or badly baked, is unsuited to sickly seasons. New bread, in a weak or impaired state of digestion (and this to a greater or less extent is always the case in an epidemical constitution of atmosphere) undergoes fermentation, giving rise to the evolution of gases and acidulous agents, which distress not only by their action upon the tissue itself, but also by the distention, and other consequences which they induce. 

Vegetables which resist the solvent powers of the stomach, and hence named crude or indigestible, as well as those which run into fermentation should be particularly avoided ; those characterized by the opposite qualities being substituted. Food, of whatever nature, which resists the action of the gastric juice, as well as that which runs into fermentation, causes a deranged or morbid action of the secreting surfaces, and the result is an impure chyme. Hence, impurity is extended to the chyle, which, poured in this state into the blood, causes a corresponding vitiation of this important element. Under these circumstances, when there is such a tendency to diarrhoea, it is almost certain to appear, and be followed by Cholera. Nor are these the only results ; the natural and constitutional susceptibilities are awakened and increased. This is proved by the fact that although such irregularities may occur under ordinary circumstances with impunity, they cannot be practised with impunity in sickly seasons. 

A system of dietetics would be perfectly inconsistent here, and therefore I shall only refer to general principles. 



57 

PROPHYLAXIS. 

I feel it therefore right, in connection with animal food, to notice the slaughtering of cattle for alimentary use. The practice at present is to kill during the day, but I am informed by several practically acquainted with the matter, that this plan is pernicious, as meat so killed is not wholesome. An animal killed during the day, technically "in the sun," never stiffens; and the meat, much more readily, undergoes putrefaction, and becomes tainted. Meat so killed, under favourable circumstances as in summer, undergoes immediate putrefaction. Midnight is the proper time for slaughtering, meat so killed will keep sweet for several days, even in the hottest and most unfavourable weather. In circumstances in which wholesome food is of so much moment such facts claim special attention. 

Water: — The purity of the water for drink as well as for ablution, is of more consequence than would at first sight appear. The supplies to this metropolis are liable to be contaminated with many impurities ; rains overload it with mud and sand, hot and moist air, with the impurities of organic decomposition. Filtering will freefrom the first, and the second may in some measure be neutralised by agitation with animal charcoal. 

It may be urged that the internal use of water is too limited to render absolute purity of much moment. But it is extensively used in the preparation of the different beverages, tea, coffee, soups, stews, and various culinary preparations, and hence its purity is an object. Good spring water perhaps is the best, and when that cannot be obtained, filtration is the only alternative. 

Air. — Pure air, with which ought to be associated sufficiency of light, is no less essential. Ventilation has been already noticed, and the advantages of perfect access to pure dry air strongly insisted upon. The miserable dwellings of some of the poor, as well as their crowded state, are certainly calculated to aggravate disease, and if we superadd insufficient ventilation, with defective light from Avant of windows, we have some of the most active agents in spreading and aggravating the malignancy of epidemic disease. It may, therefore, be worth 



58 

PROPHYLAXIS. 

consideration how far the window tax may operate in giving a more malignant and fatal character to Cholera should it appear. The poor have not within their reach those means of prevention enjoyed by the more affluent, hence the disease spreads more widely among them, ultimately acquiring a degree of virulence which sets at defiance all sanitary advantages, all prophylactic precautions, and in seizing on the more affluent victim, would seem to remind him that attention to the wants of the poor offers the best means of security for himself. 

Exercise. — Exercise in health is one of the most obvious means of preserving it. Indolence predisposes to disease, the functions become languid, at last torpid, and disease is the consequence. The skin should be kept in a state of activity ; hence, occasional ablution, followed by friction, is judicious. Exposure to damp, as night air, is very injurious. A great proportion of the endemics abroad, attack during exposure to night air ; and during the prevalence of Cholera in 1832 I was able to trace several and indeed fatal seizures, to imprudent exposure to damp night air. Persons who seemed wholly proof against the disease, although much exposed, going out at night, took ill almost immediately, and died within a few hours. 

Sufficient and warm clothing is another prophylactic means not to be neglected, and clothing is so well understood that no comment is required. 

But of all things, temperance is of the utmost importance. The matter has been already noticed, and I have only to add, that from all we can learn of the history of Cholera, as now prevailing upon the borders of Europe, intemperance seems to be its most certain victim. 

Steam Press of W. H. Cox, 5, Grant Qneen Street, Lincolns-lun-Fields. 



I mi 

Note. — These are independent of 879 Bilious Diarrhoeas.— From an examination of the Druggists' accounts, I find the Diarrhoeas to have amounted to nearly 1800. 

! l=si 

5 

253 

199 

616 1 

2 

46 

59 i 

25 

80 

3 

1 

317 I 

Totals - 

| 

3 

3 

0 

0 

1 1^8 I*4 

1:45| 1:7 

2 2 0 1 

176 58 10 9 

138 45 7 9 

1 2 3 0 

2 0 0 0 

35 11 0 0 

10 42 

4 

1 3 18 

24 

0 3 0 

1 0 0 0 

182 70 52 13 

Premonitory Stage Cold Stage Collapse Typhoid Stage 

_ 

— 

•9 

A 

6 

o 

'o 1 

o 

1 ¦ft 

si I t( ¦ Shi - —¦- i t3 .5 ca 

S 1 o p 1 

go a o 

"3 ft 

3 02 

6 E 

I 

EECOVEEED. 

1.4 ft™ 

ft 

6 'o Q d 

a 

DIED. 

if 

M 

50 

visiting the Patient. 

Stages of the Disease at the period of 

Numerical Abstract of Cases of Cholera, in the different Stages, treated at Wick, with the Results, &c, Corrected to 16th October, 1832. 

TABLE I. 

TABLE I. 

Numerical Abstract of Cases of Cholera, in the different Stages, treated at Wick, with the Results, &c, Corrected to 16th October, 1832. 

Stages of the Disease at the period of 

visiting the Patient. 

50 

M 

if 

DIED. 

a 

6 'o Q d 

ft 

1.4 ft™ 

EECOVEEED. 

I 

6 E 

3 02 

"3 ft 

go a o 

S 1 o p 1 

si I t( ¦ Shi - —¦- i t3 .5 ca 

1 ¦ft 

o 

'o 1 

o 

6 

A 

•9 

— 

_ 

Premonitory Stage Cold Stage Collapse Typhoid Stage 

182 70 52 13 

1 0 0 0 

0 3 0 

24 

1 3 18 

4 

10 42 

35 11 0 0 

2 0 0 0 

1 2 3 0 

138 45 7 9 

176 58 10 9 

2 2 0 1 

1:45| 1:7 

1 1^8 I*4 

0 

0 

3 

3 

| 

Totals - 

317 I 

1 

3 

80 

25 

59 i 

46 

2 

616 1 

199 

253 

5 

! l=si 

Note. — These are independent of 879 Bilious Diarrhoeas.— From an examination of the Druggists' accounts, I find the Diarrhoeas to have amounted to nearly 1800. 

I mi 



j 2 "^ Hos PitalP ita1 ' tlie recoveries from Collapse seem to exceed those in the general return; but this arises from the difficulty of distinguishing the termination of the cold from the beginning of the collapsed stage, as well as receiving them into Hospital from the other Practitioners. ' 

62 

1 - 3H 

si 

41 

0 

3 

18 

28 

I 22 

0 

0 

95 

Totals - 

I 

1 

3 

0 

0 

» 

1:26 I:7* 1: I|| 

0 

2 2 

10 15 13 3 

0 0 0 

0 

i 

0 0 

6 

12 

1 4 23 0 

o 5 0 6 

18 

3 

1 

0 0 0 

0 

0 0 0 

0 

26 29 36 4 

Premonitory Stage Cold Stage Collapse Typhoid Stage 

o 23 ! 23 :*l3 

s 

. 

* ! 

— 

I— I 

i— i 

I 

'o 0 

C 

'o 

to 5* 

a 3.3 "8 i 

O 

'3 ace a cc o 

I I 

CO 

EECOVEEED. 

¦a . 

Ji 

n 

CO 

•s. O 

DIED. 

CO 

¦5 a §f Oh 

CO 

Cholera Hospital. 

Stages at the period of Admission into 

Numerical Abstract of Cases of Cholera, in its different Stages, treated in the Cholera Hospital Wick Corrected to 16th October, 1832. 

lAUXjUj 11. 

lAUXjUj 11. 

Numerical Abstract of Cases of Cholera, in its different Stages, treated in the Cholera Hospital Wick Corrected to 16th October, 1832. 

Stages at the period of Admission into 

Cholera Hospital. 

CO 

¦5 a §f Oh 

CO 

DIED. 

•s. O 

CO 

n 

Ji 

¦a . 

EECOVEEED. 

CO 

I I 

'3 ace a cc o 

O 

a 3.3 "8 i 

to 5* 

'o 

C 

'o 0 

I 

i— i 

I— I 

— 

* ! 

. 

s 

o 23 ! 23 :*l3 

Premonitory Stage Cold Stage Collapse Typhoid Stage 

26 29 36 4 

0 

0 0 0 

0 

0 0 0 

1 

3 

18 

o 5 0 6 

1 4 23 0 

12 

6 

0 0 

i 

0 

0 0 0 

10 15 13 3 

2 2 

0 

1:26 I:7* 1: I|| 

» 

0 

0 

3 

1 

I 

Totals - 

95 

0 

0 

I 22 

28 

18 

3 

0 

41 

si 

1 - 3H 

62 

j 2 "^ Hos PitalP ita1 ' tlie recoveries from Collapse seem to exceed those in the general return; but this arises from the difficulty of distinguishing the termination of the cold from the beginning of the collapsed stage, as well as receiving them into Hospital from the other Practitioners. '