01 



NATIONAL LIBRARY OF MEDICINE 

Bethesda, Maryland 







ON EPIDEMIC CHOLERA. 





PATHOLOGICAL AND PRACTICAL TREATISE ON EPIDEMIC CHOLERA, ITS HISTORY, CAUSES, VARIOUS FORMS, AND TREATMENT. BY OB. MAHONY, 

L.F.P. & S., L.S.A. AUTHOR 01' AN " ESSAY ON THK INJUBIKS OF THE HEAD," &C. &C. 

LONDON: 

JOHN CHURCHILL, PRINCES STREET, SOHO. 

MDCCCLIII. 



C. AND J. ADLARD, PBINTEBS, BARTHOLOMEW CLOSE. 



PREFACE. 

The author, in these pages, indulges in physical theories, as yet dubiously received — and being aware that a novelty in science, however true, if there be no received truths with which it harmonises, has but little chance of obtaining in the present day a favorable hearing — feels constrained to enter rather elaborately into the character of what he suggests to be the exciting cause of Epidemic Cholera; yet, the pathological condition and the therapeutical treatment occupy most, if not his chief attention ; and he hopes, whatever exceptions may be taken to the assumed exciting cause, that, at least upon those points, useful hints will be found to pervade this volume — the object being to render it an essentially practical one. 

The author has had considerable opportunities 



6 

PREFACE. 

of observing the progress of the disease, and of marking the result of treatment, during the epidemics of 1832, and of 1849. In this latter year, over five hundred patients passed under his immediate observation, as medical officer to the Clonmel district Cholera Hospital. He therefore feels that, having had such an experience of a malady, the great mortality of which has arrested the serious attention of all, he would be guilty of more than a dereliction of duty — he would be criminally negligent of his obligations to the community, and of his respect for the profession — were he to keep concealed that which should belong to all. This it is which induces him to lay before his professional brethren the statistics of the hospital with which he was then connected, and the practice under which the greatest number of cases were restored. 

Having occurred in hospital practice, the cases have been selected from the author's notes, taken at the bedsides of the patients, and from the records of the Glonmel Cholera Hospital ; and are therefore more satisfactory, as affording proof of identity, than any similar ones that might be detailed from among the numerous cases treated out of hospital, at the time. They are adduced with the view both of illustrating the various 



PREFACE. 

7 

forms of cholera, and evidencing the value of particular remedies. 

In the arrangement he has adopted, the author rapidly glances at the following topics : — the history and remote or exciting cause of epidemic cholera — the proximate cause and pathological effects — the predisposing cause — the definition — the symptoms of the various forms— the prognosis — the appearances after death — the treatmentillustrative cases, and the means of preventing the disease. He aims at brevity to the utmost ; his object always being to offer, in the smallest possible compass, the leading facts and most important points connected with his subject. With this in view he studiously abstains from unnecessary detail. 

In the composition, the author has availed himself of the researches of many of those who have contributed to investigate the history of cholera, as well as of those who have thrown any light on its pathology; for which he is anxious to thus generally as well as individually in the text, make every acknowledgment. 

He aims at a production claiming some consideration for systematic arrangement and practical utility. How far he accomplishes the task, he cannot, of course, presume to say; 



8 

PREFACE. 

but defers to the determination of the more competent — at the same time assuring the reader, that neither pains nor industry are spared to render it, though condensed, yet he hopes, not very incomplete ; and he trusts it will be more favorably received as being the experience of one who indulges the impression, that he best performs his duty to the profession and to society, who is ambitious to add to the goodly stock of medical precedents those practical expedients which he believes to be matured by observation. 

Clonmel ; March, 1853. 



CONTENTS. 

HISTOEY AND REMOTE OB EXCITING CAUSE OF EPIDEMIC CHOLERA ..... 1 PROXIMATE CAUSE AND PATHOLOGICAL EFFECTS OF EPIDEMIC CHOLERA . . . . 44 PREDISPOSING CAUSE OF EPIDEMIC CHOLERA . . 49 DEFINITION OF EPIDEMIC CHOLERA . . 55 SYMPTOMS OF EPIDEMIC CHOLERA . . .56 PROGNOSIS IN EPIDEMIC CHOLERA . . 65 APPEARANCE AFTER DEATH IN EPIDEMIC CHOLERA . 69 TREATMENT OF EPIDEMIC CHOLERA . . 76 ILLUSTRATIVE CASES OF EPIDEMIC CHOLERA . . 131 MEANS OF PREVENTING EPIDEMIC CHOLERA . 173 

M 





1 

TREATISE ON EPIDEMIC CHOLEEA. 

HISTORY AND REMOTE OR EXCITING CAUSE OF EPIDEMIC CHOLERA. 

We shall in the first place remark, that the history of this alarming disease is entirely of modern date; and it is known to medical men by various names derived from some prominent symptom, or from the country of its original development. It is called Asiatic, because it made its earliest appearance in Asia. It is called cholera asphyxia, because many of its symptoms resemble those of asphyxia. It is called choleric fever, because, if the patient survive, a fever occasionally supervenes, of which the choleric symptoms are considered to be as the first stage, — thus, in some degree, resembling the first stage of the ordinary fevers. It is called malignant, to indicate its extreme severity ; and blue, in consequence 



2 

HISTORY AND CAUSE OF 

of the colour sometimes assumed by the skin of the patient. It is called spasmodic, because spasm is an essential character, — the external spasms being always more violent than in the sporadic disease. We, however, prefer to name it epidemic, as sufficiently distinguishing it from the common or sporadic form, and as it appears to follow in its progress most of the known laws of epidemic visitations. 

It is a fact well known, that cholera had frequently manifested itself in India, as an epidemic, for some time previous to its becoming diffused over Asia and Europe, and that there are certain parts of that country where it may be said to be almost endemic, from the constancy with which it is found to prevail. Curtis, in his work on The Diseases of India, describes it as spreading, in 1782, in the East, and as having been propagated from communication with an infected port in Ceylon ; and Paisley mentions it as having appeared with great malignance at Madras, in 1774. The Delta of the Ganges is remarkably congenial to this disease. The Brahmapootra, a river of great magnitude though not famed as the Ganges, rolls its vast world of waters into the same bay, the Bay of Bengal, and bears its part in extending the 



3 

EPIDEMIC CHOLERA. 

boundaries of this alluvial district, which is almost covered with vegetation, jungle, and marsh. 

Several attempts have been made to trace to its origin, in some one point, the epidemic of which we write ; but as cholera has always been found to lurk, as it were, in some parts of the Delta, those attempts have not been satisfactory, indeed it may be said they have totally failed. It is, however, certain that, in 1817, this remarkably fatal pestilence appeared in Bengal, and has subsequently spread over Asia, Europe, and part of Africa. It ran along the two rivers above named, and spread over lower Bengal, before the end of the autumn of that year, and then from that tract, as from a centre, extended itself in all directions. It was observed to have chosen in its progress the routes most frequented, or along which human intercourse and traffic were most freely carried on, and that it more especially traced in its course the populous banks of rivers, which gave rise to the opinion that it was propagated by contagion. Within a ye,ar it visited almost all the towns and villages of Hindostan. It occasionally passed over a village in its way, but generally returned to it, never remaining long in any one place, and rarely revisiting it. 



4 

HISTORY AND CAUSE OF 

In the map of India, in Orion's Essay on Cholera, the successive places which it attacked are marked by dates, and from this it appears to have travelled with surprising regularity, and at the rate of about sixty miles a month. 

In 1818 cholera reached the Burmese Empire, and regularly passing through the countries east of Hindostan, it entered China in 1820. On the other side of India it travelled with terrible malignance along the shores of the Persian Gulf in 1821, passing from Bombay to Muscat in Arabia, in which town 10,000 persons became its victims. It is recorded that in Bassora, on the Euphrates, 14,000 perished from this disease in one fortnight, and that in Bagdad, on the Tigris, one third of the whole population were swept away. In 1822 it passed through Persia to the Caspian Sea, and in 1823 it attacked Astracan and Orenburgh in Russia. At this period it abated in violence, and was little heard of until 1828. In this year it reappeared in Orenburgh, and in the two succeeding years extended through the southern provinces of the Russian Empire. It entered Moscow in 1830. In May of the following year it appeared in Riga and Dantzic. In June it attacked St. Petersburg!!,, and soon manifested 



EPIDEMIC CHOLERA. 

5 

itself through Poland and the north of Germany. In Russia, in 1831, over 60,000 fatal cases of cholera occurred. In 1831 it first arrived in England, reaching Sunderland about the end of October ; and advancing through Edinburgh and Glasgow, it attacked Ireland early in March 1832, and rapidly spread to almost every town, village, and hamlet. In February, 1832, it broke out in London, and soon spread to other towns in England. We also find it prevailing, during the summer of the same year, in Holland, France, and the Peninsula. In June, 1832, it appeared at Quebec, and became rapidly disseminated through the provinces of Upper and Lower Canada, and was diffused soon after throughout the United States. In Paris, in 1832, more, it is said, than 18,000 cases had proved fatal. In Great Britain the number of deaths from cholera, reported in the same year, was over 20,000. 

Thus, in the course of fifteen years, cholera advanced eastward to China, southward to Ceylon, northward to Archangel, westward to this country, prevailing at all seasons of the year, in all terrestrial temperatures, from the highest tropical heat to almost the lowest arctic cold ; in all states of the atmosphere, as regards 



6 

HISTORY AND CAUSE OP 

humidity, barometric pressure, or wind • at sea and on land; on all soils, from the most moist to the driest, from the most barren to the most fertile ; at all elevations, from the level of the sea to the highest inhabited regions; among all races of mankind whose country has hitherto come in the way of its march ; in short, in every variety of circumstance in which it is possible to regard human beings, it seems as it were to seek man out wherever he congregates. 

The fearful anxiety with which its approach towards this country was watched, and the general dismay with which the news of its arrival was received, we well remember. In 1832 the alarm injudiciously created by reporting the progress and fatality of the cholera, we feel assured did much towards extending its ravages, by exciting that fear which so much predisposes to its pestilential influence. Almost every one's moral courage failed him, in the awful results anticipated from its antecedents ; and often the most inconsistent excesses were committed, under the most absurd impressions. But the gloomiest fears were not altogether ill-founded, for, in 1832, in Ireland its mortality was indeed tremendous. The labours imposed upon medical men, during the epidemic in that year, had been 



7 

EPIDEMIC CHOLERA. 

of the most painful and harassing description, — called upon to combat a novel, widely-spread, and malignant disease, unknown to them but through books, which, in the urgency of responsibility, are at best only faithless guides, they had to contend against innumerable and formidable difficulties. In many localities there was no Hospital accommodation, and in other places imperfectly-ventilated houses, the selection of which, as Hospitals, could only be justified by the most pressing circumstances. Without order or previous arrangement of almost any kind, and when pressed by a crowd of the most malignant cases — which in this epidemic the early cases usually are — it was that, in most places, the profession had to make its dispositions and to create a system of management. Under such a state of things it could not be expected that medical science would derive much additional knowledge, or gain in reputation. 

In 1849 the epidemic, after traversing nearly the same route from East to West, again reached Ireland. The alarm at its approach to these shores was by no means great, indeed it did not amount to much more than a casual inquiry as to its locality ; and the newspaper press was all but silent upon the matter, save an occasional 



8 

HISTORY AND CAUSE OF 

dissertation as regards the non-contagibility of cholera. Thus were the self-possession and confidence of men retained in that calm serenity which so often proves preservative of health ; and although the malignance of the epidemic of 1849 was fully equal to the one of 1832, still its ravages were more under control of medical treatment, and the public mind was less fearfully anxious in 1849. In the epidemic of that year the experience of the past had been usefully employed ; and it is satisfactory to know that the mortality was by no means so high in 1849 as it was in 1832 in this country. But though much had been effected towards rendering medical aid to the poor and others afflicted with cholera, still it is to be feared that, in 1849, medical advice was not, in a large majority of the fatal cases* obtained in time to be more successful; medical men frequently were not called upon until the patient was collapsed and dying, when it is often too late to save the life of the unfortunate victim. 

In reference to this latter point there is one peculiarity, in patients affected with cholera, that demands our attention, and which we may here observe upon. In consequence of the cerebral disturbance,— -which is from the first moment of the shock apparent, in the dulness of mind, and 



9 

EPIDEMIC CHOLERA. 

indifference or inattention about seeking medical relicf — it is indispensable, for early treatment of the cases of this disease, that district medical inspection should be established during the presence of the epidemic. If the families of the higher and middle classes were seen at intervals, during its continuance, by their usual medical attendants, and medical officers employed by the guardians of the poor to visit the residences of the lower class, for the purpose of sanitary inquiry, at short intervals, the ravages of the disease doubtless would be cut short by arresting the premonitory symptoms, and the epidemic might very probably be of a milder type, by a still earlier attention to the general health. It is true this plan of medical inspection of the poor was attempted to be tried in some places during the epidemic of 1849. In consequence of the toilsome nature of the duty it was never well performed, and the necessarily inquisitive nature of it rendered it not popular; it was received rather unfavorably, and it raised a suspicion of ill in the minds of the poor, therefore it was obliged very soon to be discontinued. However it is a plan deserving a fair trial, and we think might assist to prevent scenes of desolation which can now scarcely happen, without great negligence 



10 

HISTORY AND CAUSE OF 

on the part of the people themselves and on the part of the authorities. 

The reappearance of cholera in its old quarters, and the inferred probability of its again advancing westward to these shores, is imminently calculated to arouse the apathy and stimulate the zeal of all. A question of grave importance, and one upon which much research has been bestowed, and considerable discussion expended, without arriving at any certain conclusion, is whether cholera is contagious or not. 

In the year 1817, when the disease appeared in India, we find a report by Mr. Corbyn, the assistant-surgeon in charge of the native hospital of the centre division of the army, under the Marquis of Hastings, dated Ereck, on the Betwa, November 26, 1817, wherein he states — "That this disease is not infectious I am perfectly convinced; all my attendants on the sick have escaped the disease, and I have, more particularly, at all hours of the day and night, respired the atmosphere of a crowded hospital with impunity." Many instances are known of British officers, who had attendants dying of cholera in their very tents, escaping its attacks ; and it is a remarkable fact, that in the early visits of the disease in India, Europeans were rarely victims to it. 



EPIDEMIC CHOLERA. 

11 

It is recorded in the Asiatic Journal for December, 1831, that the introduction of cholera into the Island of Mauritius was attended with circumstances of importance as respects the theory of non-contagion. The disease appeared in November, 1819, and was supposed to have been brought thither from Ceylon by the Topez frigate, which arrived at the Mauritius in October. A careful inquiry was instituted into the circumstances of the. case, and a committee of British medical officers was convinced that the disease was not imported. In their report, dated 4th December, 1819, they state that the first case occurred so early as the 6th of September, and that " they feel the strongest persuasion that it is not of a contagious nature." In this conclusion the Trench medical men who were present unanimously concurred ; and in a report by Dr. Burke, the chief medical officer, the disease is stated to have burst forth suddenly on the 18th of November, "in all quarters of Port Louis," from whence it spread to every district of the island. The reports of medical officers abound in instances of the attendants of patients afflicted with cholera not having contracted the disease. Dr. Albers, in his report of cholera, states — V During the epidemic it is certain that about 



12 

HISTORY AND CAUSE OF 

40,000 inhabitants quitted Moscow, of whom a large proportion never performed quarantine; notwithstanding this fact, no case is on record of cholera having been transferred from Moscow to other places, and it is equally certain that in no situation appropriated for quarantine has any case of cholera occurred." Another argument adduced in favour of the non-contagious nature of cholera is, that when the disease appeared in London, in 1832, the medical men and nurses who lived on board the ships fitted up as cholera hospitals for seamen, as well as the other medical men in daily attendance on the sailors, who numbered over 200 affected with cholera, not one of the medical men or nurses were attacked, "although the former were engaged almost daily in examining the bodies of those who died of the disease, and that in the lowest part of the ship, in an ill-ventilated cabin, in which all the dead bodies were placed." Another example of the same nature is recorded in his Practice of Physic, by Dr. Mackintosh, who says—" In the Drummond Street (Edinburgh) Cholera Hospital there were 280 bodies examined. Two and sometimes three hours were spent in examining each body. The room where these examinations were conducted was a 



13 

EPIDEMIC CHOLERA. 

miserable place, eight feet square ; generally six or eight persons were present, sometimes more, and in an inner apartment, about ten feet square, there generally lay six dead bodies. Not one of those who frequented this den of death, and who had their hands imbued in the secretions of the dead for six hours out of the twenty-four, were affected with cholera, although their hands were irritated and punctured daily." 

What tends still further to give cogency to the arguments against contagion, is the fact that the strictest quarantine regulations have totally failed to prevent its advance. 

On the other hand, during the prevalence of the epidemic of 1832 at Sligo, and other places in Ireland, great mortality among medical men and nurses had occurred, and the same was observed at St. Petersburgh ; but in reference to the latter, the report of Drs. Russell and Barry mention that " In some cholera hospitals favorably situated with respect to site, ventilation, and space, very few of the attendants suffered." Again, they report that " out of forty attendants on cholera patients, six were attacked and two died In the Military General Hospital, into which upwards of 400 cholera patients had been admitted from distant quarters up to 



14 

HISTORY AND CAUSE OF 

a certain date, only one attendant had been attacked." 

The Bengal Report records that "the force under Colonel Adams, which arrived in perfect health in the neighbourhood of a village in India infected with cholera, had seventy cases of the disease the night of its arrival, and twenty deaths the next day." 

The official Reports of the English Board of Health, and of the Irish Commissioners of Health, encourage the impression that cholera is a noncontagious disease. In the American Report "On Epidemic Cholera, as it appeared in the United States in 1849 and 1850," the point upon which the greatest labour is bestowed is that of connecting the appearance of cholera with local sources of malaria. In the Report of the Irish Commissioners, as well as in the map appended to it, the course of progression of the epidemic of 1849 is shown to be capricious ; and though no attempt is made to account for its spread, the Irish Commissioners announce their opinion, that "contagion is an element of little, if any, influence in the spreading of the disease." 

The facts and arguments adduced in support of the contagibility of cholera may be comprised under the following :—: — 



15 

EPIDEMIC CHOLERA. 

Ist. It has continually extended itself in all directions from the locality of its birth, with a progress not generally uniform, and about the same rate as human intercourse is conducted. 

2d. It has been observed in many instances to follow the course of great rivers and lines of roads along which merchandize is conveyed and human intercourse is carried on. 

3d. It has repeatedly been remarked to have manifested itself in a port or town soon after the arrival there of a vessel, a caravan, or car containing merchandize, from a place previously infected. 

4th. It has frequently occurred, particularly in this country, that a person in good health, after caressing the dead body of their relative or friend, who had died of cholera, was immediately attacked, and generally with the most malignant type of the disease. This latter fact we had ourselves often observed during the epidemics of 1832 and 1849. 

The first case of cholera that presented itself in 1849 at Clonmel was that of a carrier, who had just arrived from the city of Limerick, then infected. The disease did not for a few days appear to disseminate. On the fifth day a case occurred, but in a district rather remote from the residence of the carrier first attacked. On the sixth day, the 



16 

HISTORY AND CAUSE OE 

brother of the carrier and two others in the same locality were affected. On the tenth day it spread to other places, and was soon diffused through every street, lane, and alley of the town. But we have known instances of persons from country districts visiting to transact business in a town then infected with the epidemic, who were, on their return to their residences in the country, taken ill with cholera ; and though the individual case may have proved fatal, no other cases appeared in the district. 

It may be further remarked, that although none of the attendants at the cholera wards of the Clonmel Hospital were attacked, though near 400 patients passed through the hospital, there were three nurses in attendance upon private cases, in the town, seized with the disease, and died — whilst one of the nurses of the fever wards, and who had little intercourse with the cholera wards of the hospital, was also attacked, but recovered. 

Contagion or infection — there is no difference in the terms, or, philosophically speaking, the distinction is not correct — has been classed under two heads, that caused by actual contact with the sick, and that caused by application of morbific matter from clothes or merchandize impregnated 



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EPIDEMIC CHOLERA. 

with it, or the malaria arising from animal and vegetable substances in a state of putrefaction. Experiments have long since shown that atmospheric air does not convey malaria, morbific matter, or infection, to any great distance sufficiently concentrated to induce disease, and even to be able to convey it to a short distance, the air must be in a direct draft or current. Simple contact, we believe, never alone causes disease; but we have numerous authorities to sustain the proposition that a direct current of atmospheric air from pent up or accumulated putrid matter does sometimes create infectious diseases ; and that if it be not impregnated with virus sufficient to produce that specific effect, it is always certain to establish in those, who may be destined to constantly inhale it, a state of health which predisposes to all epidemic diseases. Thus we behold this class of maladies to usually break out and to lurk in the suburbs, the lanes, and the alleys, rather than in the centre and open streets of towns and cities, doubtless owing to the habitual respiration of an atmosphere rendered impure by the overcrowding of the poor in their ill-ventilated habitations, which are unfortunately too often the receptacles of filth in all its foul varieties. But equally with 2 



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HISTORY AND CAUSE OF 

this cause deficient food and clothing, irregular living and intemperance, are found to induce a powerful predisposition to cholera. However, considerable as is the influence of unwholesome or insufficient food, it is, perhaps, as secondary, when compared with the danger resulting from the habitual respiration of an impure atmosphere. This is a fact which cannot be too forcibly inculcated and impressed upon the minds of the people. 

Contagion, in the modern sense, is not that fear-abasing thing in which every one in former times believed. In fact, the old notion that infection was the sole source of epidemic maladies, is in the present day totally exploded, and nobody now thinks of making the fear of infection a pretence for isolating those stricken with disease, and a pretext for abnegating the performance towards them of our social duties. The facts and circumstances adduced in support of the infectious nature of cholera, although it must be readily admitted have some force, yet they must not be deemed by any means decisive of the question, because the following views suggest themselves in explanation. 

Ist. To the first argument it may be answered, that any atmospheric influence, or combination of 



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EPIDEMIC CHOLERA. 

circumstances in that regard would most probably be progressive. 

2d. That it is perfectly possible that cholera is not, as asserted, limited in its march to lines of human intercourse, but, as has been observed in this country, more extensively and capriciously diffused ; although from these lines being more open to observation — connecting large and populous towns, where the disease from various causes attracts the greatest attention — the remark as most striking has been recorded. 

3d. That, granting that atmospheric influence is progressive — and if so, it must be at about the same rate as human intercourse — it is not, in these times of active commercial enterprise, a matter of surprise that cholera should appear after arrivals from any infected port, town, or place. 

4th. That it is admitted, that inhaling atmosphere impregnated with poisonous gases, assist in the diffusion of cholera, by producing the predisposing state ; hence a human body which had imbibed, in its specific virulence, the choleric poison, whatsoever that is and whencesoever it might originally have been derived, may be as likely, if not more likely than other sources of infected exhalation, to exhale that imbibed virus, and produce the condition of the living organism 



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HISTORY AND CAUSE OF 

necessary for the epidemic influence to effect in it the physiological disturbance which we call cholera. Further, this view both explains and derives some force from the fact that, though persons having imbibed the choleric poison, still, having removed beyond the sphere infected, do not propagate the disease, because the epidemic influence does not exist in the locality to which the persons returned previous to the manifestation in them of the disease, or during the stage of incubation. 

The portability of some special morbific agent in the person and clothing of patients affected with cholera, is assumed in the American Report. But this cannot be the sole morbific agent concerned in the case. True, this morbific agent may not be possessed of very especial powers, and yet have actual existence — it may under a combination of circumstances, which in our present state of knowledge we are unable to demonstrate and define, be of sufficient potency to effect a morbific influence within a given space. " Individual cases sometimes occur," say the Irish Commissioners in their Report, "which would seem to lead distinctly to the conclusion that personal infection did occur ; but, in other cases, it can be established that the disease has appeared where contagion could not originate it ; and it 



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EPIDEMIC CHOLERA. 

can also be shown that the disease has not appeared, or has not spread in circumstances in which there was full exposure to contagion." 

To this it may be objected that these varying complexions of unexplained facts afford equal evidence against other assumed causes of its propagation ; and that the contingent and uncertain operation of any cause cannot afford cogent argument against it, because we find that any of the causes offered in explanation of the apparently capricious character of the visitations of cholera evince the same inexplicable inequality and partiality. 

The occurrence of cholera under every variety of weather, and its temporary dispersion, sometimes by even slight changes in the currents of the atmosphere, prove that the morbific principle is not universally disseminated through the air, and has led to the inference, that local exhalations, subjected to the action of an atmosphere impregnated with certain properties, form with it the exciting cause of this epidemic. It is scarcely allowable to affirm dogmatically what is the cause or what the concurrence of causes which have aided the progression of cholera from the far east to the far west; and when we charge with the propagation of this new pestilence of the nineteenth century the effluvia constantly emitting 



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HISTORY AND CAUSE OF 

from filth, over-crowding, open cesspools, &c. we do not mean to convey an opinion that cholera may be generated from such sources. These do not predispose to cholera any more than they predispose to any epidemic or disease to the attacks of which the human body is liable. The operation of these agents is not so much the modifying and fixing the character of the disease with which those who may be subjected to their influence are to be attacked, as by debilitating the constitution and weakening the vital energies, thereby depriving the human system of that potency to resist the assaults of disease, whatever type or character it might assume. Experience confirms the fact, that the decomposition of organic matter, whether vegetable or animal, loads the air with malaria, which taint the constitutions of those who habitually inspire it, destroying life in a hundred subtle ways, and creating the predisposition to be assailed by every infectious and epidemic disease that might prevail ; and it is further established, that whilst the choleric influence exists, passions, habits, and privations, added to the inhalation of impure air, may so far predispose persons for an attack, that many cases will occur at one and the same time and place. 



EPIDEMIC CHOLERA. 

23 

Epidemic cholera possesses few of the characteristics of the ordinary contagious or infectious class of diseases; it is not confined to cities, towns, or localities. In India it appears sometimes suddenly, — sweeps along the surface of the country, occasionally attacking the rich man in his insulated habitation, as well as the poor in his lonely hut, wherever it finds either incapable of resisting its prostrating power. It thus pursues its course, and then as suddenly vanishes, without leaving the power in its victims to communicate any form of the disease to their fellow creatures. Considering how little even yet we know about the physical causes and channels of propagation of this disease, the Irish commissioners have no doubt very prudently arrived at the conclusion that "the subject is still enveloped in great obscurity." Still, though it may be presumptuous, in our present state of knowledge, to affirm anything positive relative to the contagious or non-contagious nature of cholera, in order to come to a right comprehension, and to assist in arriving at a correct conclusion, amid conflicting argument and opposite opinions, we, in the first instance, assume that contagion and infection are synonymous, in the medical acceptation of the words ; and, as has previously been observed, 



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HISTORY AND CAUSE OF 

that contagious diseases can be developed in the human body only from one of the following causes:— lst, by contact with an infected person, or any article containing the virus ; 2d 3 by means of infected food or drink received into the stomach ; 3d, by the absorption of malaria. — Now, applying these rules to the present investigation, it is evident, with respect to the first, that were the poison introduced into the system through the pores and absorbent vessels, the progress of accession would be too slow in its operation to account for the suddenly fatal attacks of cholera; and, perhaps, we may safely surmise that, in this view, cholera is not contagious. As regards the second case, we are not aware that anything has appeared to justify such a supposition, and we believe no fact has been authenticated or applicable that would warrant the inference. In this view, also, we may, we think, safely affirm, that cholera is not infectious. The third cause, the action of malaria on the blood, whilst circulating through the lungs, is, in the present day, assumed as the cause of the propagation of all infectious diseases. The occurrence of cholera under every variety of weather, and in situations topographically opposed to each other — at one time many hundred miles inland, at 



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EPIDEMIC CHOLERA. 

another on the sea shore — make it evident that malaria, or marsh miasma, alone cannot be an exciting cause of this disease ; and this opinion is confirmed by the fact, that marshy grounds or low situations are not more liable to cholera than high and dry lands are. 

It is difficult to ascertain the precise limits to which epidemic cholera may extend without human intercourse, or whether it would have crossed the Atlantic, had there been no communication with America. That the plague had been transmitted from one country to another by means of woollen goods, is recorded in history; but the strict quarantine of recent times makes it unlikely that it is similar with cholera. However the exciting cause of epidemic cholera may remain " enveloped in doubt and obscurity," it appears certain that there is a kind of morbus cali t which, at particular periods, favours, as it were, the spread of diseases, by creating that susceptibility which attaches to predisposed individuals, and to the inhabitants of certain localities. 

How far " the cosmic forces of nature " are engaged in the production of this morbus cccli, this abnormal atmospheric influence is a most important and interesting inquiry, and it is one which next demands our attention. 



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HISTORY AND CAUSE OF 

It is well known that no substance with which we are acquainted is more surcharged with electricity, in proportion to its dimensions, than the gem-like drop of dew, and that when impregnated with malaria it is destructive of human life, if taken in by the lungs — thus indicating phenomena at least analogous to that which we are permitted to assume constitutes the epidemic influence. (?) 

Among the many interesting and instructive results obtained by the researches of recent explorers in the domain of physical science, must be observed the views which they have opened to us of the nature and mutual relations of those subtle and all-pervading agencies — call them cosmic forces, imponderable elements, or whatever other name best expresses the little we really know about them — which present themselves to our senses in the phenomena of light, caloric, electricity, magnetism, and perhaps animal and vegetable life. A mass of observations has exhibited these in such intimate connections — the presence of any one of them involving the nearness of all the rest — as to render it very possible that they are only phases of one and the same principle, modifications of some expansive primaeval force or activity, or property of setherial matter, 



27 

EPIDEMIC CHOLERA. 

universal as gravitation, and perhaps antagonistic thereto. 

A distinguished reviewer of Whewell's Philosophy of the Inductive Sciences, thus remarks, tt rj^g researches o f a ]} the latest inquirers seem to have left no doubt as to the identity of all the species of electricity . . , as far as their powers can be summoned into sufficient activity, they all appear to perform each other's work; and it seems an exaggeration of timidity to hesitate in pronouncing them the various manifestations of some single and pervading principle. The intimate connection of this principle, again, with heat and with lights which is perhaps little more than the peculiar effect of the vibrations of heat upon the optic nerve, plainly associate these with the former, and invite us to expect the near approach of some decisive discovery, which, in combining them all, shall form before long the great philosophical glory of the nineteenth century." 

"Many organic forces," observes Passavant, " have in their working much similarity with the powers of inorganic nature, yet are not identical with these. Now, since in nature generally) subsistence is ever evolved out of subsistence, it seems more in accordance with nature's economy 



28 

HISTORY AND CAUSE OF 

to contemplate the organic forces not as an absolutely new order of powers, but as modifications of those already observed in the wider field of the inorganic, the modifying agency being that of the vital principle (and the will where this power gives to the vital principle a particular character or direction), which works upon, and assimilatively transforms these powers, in the same way as it transmutes the inorganic material substances into organic." Recent experiments have also shown that the organic principle does not only effect new combinations of the substances which it takes up in the way of nutriment, but that it can actually transform into other substances those which chemistry deems primary or simple substances — or through its alchemic power of assimilation, produce those new combinations from the surrounding atmosphere — Thus, cress was sowed in powdered sulphur, flint, &c, — and the germinating plants were irrigated with distilled water. They grew, and in the ashes of these plants were found precisely the same constituents which are found in the ashes of such as grow in the ordinary way in the open air. 

As organic bodies then impress their own peculiar character on the materials which they 



29 

EPIDEMIC CHOLERA. 

assimilate, so is it likewise proved that they possess the power of doing this also with the universal forces or principles of nature. In other words, the organism takes in, and interiorly subjects to itself the cosmic force or setherial spirit which it modifies according to its own necessities and ends. 

It is certainly much more in accordance with the advanced progress of physical research to seek in the organic powers merely modifications of those of universal nature, than that we should assume a number of forces and of substances, essentially different from, and without any connection with or relation to those which present themselves through space. We must, however, guard against making forces identical that are only analogous, of assuming for instance that the nervous and electric agencies are one and the same, instead of referring them to a common base. In the low and imperfect organisms of certain fishes, worms, and insects, these forces present themselves in their least modified form, which affords a presumption that in the economy of nature these cosmic forces are more and more modified, or assimilated to the principle of life in the more highly developed systems of the superior animals ; — and above all, in our own cerebronervous 



30 

HISTORY AND CAUSE OE 

system — as the most perfect organism existing, — these universal forces, activities, or powers, are more and more altered, more and more assimilated to the principle of life and of psychic action, which they sustain and serve. This view derives cogency from the fact, that a higher agency nowhere, be it in the domain of nature or of spirit, abolishes or annihilates a lower ; but subdues, assimilates, and appropriates the latter to itself. " The evolution of light by the glow-worm, by the minute phosphorescent infusorium, is a phenomenon of higher order than the gorgeous coruscations of the aurora-borealis, or the terrible unloading of the thunder-charged strata of the clouds, for it is a phenomenon of life;" but the process in the higher and in the lower phenomenon is at ground the same ; the life that is seen directing the former does but impress its own character on the elements which it has taken from the wider sphere. 

The experiments of Rengger we may also adduce in this behalf, as they go to prove that the shining of the eyes of different animals at night is not that of a mere reflection of the light from without. The eyes of the night-ape were observed to shine only when the darkness was profound, and the light then emitted had rendered 



31 

EPIDEMIC CHOLERA. 

distinguishable objects at a distance of nearly two feet from the eyes of the animal. In the canis azarce the shining ceased when the optic nerve was divided or injured ; but injuries of the cornea or the iris did not affect it. 

The decided resemblance which the nervous force, in its ordinary way of acting, presents to the imponderable agents, makes it more conceivable that the relation between the organism and the external world, where it is not merely mechanical, is in a great measure a mutuality of action and reaction between these elemental principles, and their cognate — the organic sether (nervous fluid). The idea suggested by Dr. Darwin, that the brain secretes the " spirit of animation," and diffuses it by means of the nerves, may perhaps be not so very remote from the actual laws, were we to superadd that the cerebro-nervous system does but impress its own character on the elements which it has taken from external nature, the principle of organic life being the modifying agent. It is admitted, that the proper conductors of a dynamic action in animal existence are the nerves; but the sympathies often observed between one particular organ and another are a proof that such workings also take place without the intervention of these 



32 

HISTORY AND CAUSE OF 

conductors, —the nature of the interposed organs having no influence on these sympathies, and the action of the engaged structures on each other is as little intercepted by the parts that separate them, as that of the magnet on the iron by an intervening piece of wood. Hence it seems probable that a subtle organic fluid, a nervous force, permeates the palpable organic structure; and, upon this hypothesis, the cerebro-nervous system not only attracts from without, and modifies to its own necessities the "cosmic force," but possibly also acts upon organic bodies beyond the sensible limits of its own organism (?). 

Assuming that this organic sether re-acts upon its cognate — the inorganic forces, it is a legitimate inference that it also acts upon organic bodies beyond the limits of its own organism; and possibly may, by imparting within a small compass its abnormal condition in a patient affected with cholera, add to the morbus cccli, and thus, in connection with the sympathetic action, may tend to propagate to those predisposed, and more immediately in contact with the patient, an attack of the disease during the prevalence of the epidemic influence. 

The assumption that the "cosmic forces" exist in an abnormal condition during the prevalence 



33 

EPIDEMIC CHOLERA. 

of the choleric influence — in other words, that the atmospheric composition during the persistence of epidemic cholera is contrary to its natural state, derives at least some plausibility, if not force, from the fact of the very important discovery recently made, that peculiar microscopic animalculse constantly exist in the characteristic " rice-water " discharges of persons affected with cholera, and also in the atmosphere and water of infected places,, {Dr. Holland on the Hypothesis of Insect Life as a Cause of Disease) thus evidencing the presence of the necessary association of conditions under which the creative laws invariably work. 

The investigation of the minutiae of organic structure by the microscope is of such recent origin, that its results cannot as yet be expected to be very clear. Some facts, however, are worthy of attention with regard to the present inquiry. 

It is ascertained that the basis of vegetable and animal substances consists of nucleated cells; that is cells having granules within them. Nutriment must be converted into these before it can be assimilated by the system, — the tissues are formed from them. It has likewise been noticed that the globules of the blood are reproduced by the expansion of contained granules; they 3 



34 

HISTORY AND CAUSE OF 

are, in short, distinct organisms multiplied by the same fissiparous generation, {Dr. M. Barry on Fissiparous Generation) So that all animated nature may be said to be based on this mode of origin, — the fundamental form of organic being is a globule, having a new globule forming within itself, by which in due course it is discharged, and which is again followed by others in endless succession. The elements out of which organic bodies are composed, every one knows, are four — carbon, oxygen, hydrogen, and nitrogen. The first combination of these in animals are into what are called proximate principles — albumen, fibrin, &c. ; thus the structure of the animal is composed. 

Daubeney, in his Supplement to the Atomic Theory, remarks that " the same simple laws of composition pervade the whole creation; and if the organic chemist only take the necessary precautions to avoid errors in resolving into their ultimate elements the proximate principles upon which he operates, the result of his analysis will show that they are combined precisely according to the same plan as the elements of mineral bodies are known to be." And in Todd's Cyclopedia of Physiology, Carpenter 'on Life ' observe — " No reasonable ground has yet been 



35 

EPIDEMIC CHOLERA. 

adduced for supposing that, if we had the power of bringing together the elements of any organic compound in their requisite states and proportions, the result would be any other than that which is formed in the living body." 

It was announced some years since by the French physiologists, Prevost and Dumas, that globules could be produced in albumen by the action of electricity — the identity of the globules thus produced with living cells, and the fact of the reproduction of living globules are, however, both doubted by physiologists of repute; but, although particular illustrations may be held in mere doubt, it cannot necessarily injure, much less refute, the general argument. If therefore these globules and reproductive cells be identical, the production of albumen by artificial means, which may yet be discovered in the laboratory, is the only step wanting in the process of artificial generation, and acquiring a demonstrative knowledge of the association of conditions that Nature's laws require to the production of animal existence. But it may be very properly asked, what actual experience says respecting the origination of life. Are there any authentic instances of either plants or animals, of however humble a kind, or low in the scale of creation, having come 



36 

HISTORY AND CAUSE OF 

into existence otherwise than in the ordinary way of generation? In answer to this, we will remark that, perhaps, if the question were asked of ten men of scientific reputation, nine might answer in the negative. But we know that this impression exists, because in many instances some superficial observers of former times having in certain instances assumed a non -generative origin for life, have been either proved by moderns to be erroneous in fact, or that ordinary generation did take place, although in a manner which escapes observation. It must, however, be admitted, on the other hand, that the majority of recent inquirers, more absolute still, assert that generation must in every case be concerned. But how is it possible to be satisfied with the offered explanation of the appearance of a crop of white clover, for instance, when lime is laid down upon a piece of waste moss-land — that the seeds had been there in a dormant state for an unknown series of years, and that germination was the result of the stimulant action of the lime ; though the spot of moss-land may be many miles from where clover had ever been cultivated. (Vide Vestiges of the Creation.) 

There are several eminent in science who frankly profess to find at least great difficulties 



37 

EPIDEMIC CHOLERA. 

in accepting the doctrine of invariable generation. A distinguished naturalist in the article Zoophytes, in Encyclop&dia Britannica, 7th edit., treating of the entozoa, or creatures which live within the bodies of others, thus observes, " To explain the beginning of these worms within the human body, or the common doctrine that all created beings proceed from their likes, or a primordial egg, is so difficult, that the moderns have been driven to speculate, as our fathers did, on their spontaneous birth ; but they have received the hypothesis with some modification :—: — Thus it is not from putrefaction or fermentation that the entozoa are born, for both these processes are rather fatal to their existence; but from the aggregation and fit apposition of matter which is already organised, or has been thrown 

off from organised surfaces Their origin 

in this manner is not more wonderful or more inexplicable than that of many of the inferior 

animals from sections of themselves. . . . We 

think the hypothesis is also supported in some degree by the fact, that the origin of the entozoa 

is favoured by all causes which tend to disturb the equality between the secerning and absorbent systems." 

Dr. Allen Thomson, in the article Generation, 



38 

HISTORY AND CAUSE OF 

in Todd's Cyclopaedia of Anatomy and Physiology, states several considerations arising from analogical reasoning, which, he says, " seem to him to show the balance of evidence at the side of the primitive production of infusoria, the vegetation called mould, and the like." 

Thus we account for the presence of animalculse in the sero-lymphous discharges of cholera patients, and we maintain that their existence is a consequence, not a cause. 

It is of some importance in our present inquiry to arrest the attention of the reader to the fact, that when the atmosphere is excluded from contact with a vegetable infusion, no animalculae are produced, showing that, for the development of life, the presence of certain atmospheric properties constitutes one of the associations of conditions required. 

The doctrine of an organic creation by law is thus advocated by an able writer in the British and Foreign Medical Review. 

" We see a simple germ, the nucleus of a cell, develop itself into a feeling, moving, thinking man, by drawing into itself, and combining into new forms, the particles of what we are accustomed to call inorganic matter. These new forms are caused by the very act of combination 



39 

EPIDEMIC CHOLERA. 

to manifest properties of a new and peculiar kind ; and their actions constitute the life of the being. Hence we must attribute to all those substances, which are thus drawn from the inorganic into the organic mode of existence, a latent capacity for the latter, — just as we say that the oxygen, hydrogen, carbon, and nitrogen, which make up the organic substance termed muscular fibre, and which in that state or mode of combination possess certain vital properties, possess also a latent capacity for combining in that mode of aggregation termed crystalline, and for the exhibiting the solubility, translucency, and other qualities of a salt, (all of which are totally opposed to its vital properties, and cannot coexist with them,) when united into the form of cyanate of ammonia. If we were only acquainted with those elements as they exist in organic compounds, their transposition into a crystalline salt would be almost as marvellous to us as the.opposite change is now. If this latent organisability or vitality be admitted (as we conceive logical proof to have been given that it must,) as a property of a large proportion of what we call inorganic matter, is there any such wonderful difficulty in imagining that it may be brought into play in some other manner than by the 



40 

HISTORY AND CAUSE OF 

agency of a pre-existing germ ? We think not. But let further investigation and more extended experience decide." 

The accidental development, or rather creation, of the " acarus Crossii " in our own times, may further be adduced in evidence to sustain the general argument we advance in support of the hypothesis, that all animal and vegetable creation draws its vitality from the same source that sustains inorganic bodies — the "cosmic forces of nature." 

Some few years since Mr. Crosse was instituting experiments in crystallisation, and was operating with a powerful voltaic battery upon a saturated solution of silicate of potassa, when, quite unexpectedly, insects made their appearance. The reception given to this and other experiments of a like kind deterred Mr. Crosse from the pursuit ; and Mr. Weekes, of Sandwich, some years after, took up the subject, and with great care pursued the same experiments, with a like result. Mr. Weekes, on account of ferrocyanuret of potassium containing a large proportion of carbon — the principal constituent of most organic bodies — employed a saturated solution of it in one of his experiments, and from this solution the insects were in greater numbers 



EPIDEMIC CHOLERA. 

41 

produced. The insects thus demonstrated by the experiments of both these gentlemen seem to have been the same —"a species of acarns, minute and semi-transparent, and furnished with long bristles, which can only be seen by the aid of the microscope." Mr. Weekes, in his pamphlet published in 1842, describes their motions, and states that in the gelatinous matter first formed in the solution by the electric action they procured food. He also observed some of the insects, soon after their existence had commenced, were found to be likely to extend their species. In Mr. Weekes's experiments, every care that ingenuity could devise was taken to exclude the possibility of a development from ova. The water was distilled, the silicate of potassa was subjected to a white heat, the wood of the apparatus was baked in a strong heat, and the whole was covered with a bell-shaped glass shade, from which the atmosphere was excluded by the fumes constantly rising from the solution submitted to the voltaic action, and for the emission of which there was a small aperture, so arranged at the top of the shade that only these fumes could pass. Thus every source of fallacy seems to have been shut out ; and it appears that the action of the electricity — a phase of the " cosmic 



42 

HISTORY AND CAUSE OF 

force" — was the chief agent in the production of the phenomenon. 

From the foregoing generally it may be permitted to be deduced, that organic existence is, if not created, sustained by law ; that certain physical conditions are indispensable for the working of these metaphysical or creative laws, which we may call chemico-electric ; that the association of the requisite conditions for organic creation exists in the body of a person affected with cholera, as is proved by the microscopic objects discovered in the characteristic discharges from such a patient, and also that this association exists in the atmosphere and water of an infected locality; that the chief of these requisite conditions seems to be a peculiar state of those "cosmic forces," or vital laws, existing through space ; that this abnormal condition, thus shown to prevail at specified periods, is, we assume, the exciting cause of the physiological disturbances effected in the bodies of those who, from certain weak states, are incapable of resisting its prostrating power, or whose constitution may be predisposed to yield to this, the epidemic influence. 

We may, in this place, remark, that we derive considerable support for our views of the remote cause of cholera from the interesting results of 



EPIDEMIC CHOLERA. 

43 

the experiments instituted at Edinburgh by the late Dr. Mackintosh. Upon the supposition that cholera is caused in consequence of the blood having been deprived of its saline constituents, Dr. Mackintosh injected into the veins of some of his patients affected with the disease a saline solution. The effects produced seemed to promise the most favorable consequences ; but although the organic actions of the body were by this means temporarily maintained to a remarkable extent, yet this encouraging result was not long sustained, and could, by again injecting, be revived, but not permanently, because the cerebro-nervous system, being in a debilitated or torpid state, was therefore unable to modify or to mould to its own necessities the " cosmic force of nature," and thus eliminate the " spirit of animation," — the nervous force, or vital energy, through which that mutuality of action and reaction between the organism and the elementary forces of the external world are established, and which is indispensable to the due sustainment of individual life. 

Certainly, if ever we obtain to a satisfactory solution of the difficult problem — the exciting cause of epidemics — it must, we apprehend, be founded upon this principle — the presence of a 



44 

CAUSE AND EFFECTS OF 

temporary abnormal condition of the " cosmic forces," limited in extent, organic and inorganic nature being deemed essential unity. 

PROXIMATE CAUSE AND PATHOLOGICAL EFFECTS OF EPIDEMIC CHOLERA. 

The cerebro-nervous system of man consists of four divisions :—lst,: — Ist, the cerebrum and cerebellum, constituting the brain proper, which is appropriated to the mind • 2d, the m,edulla oblong ata, appropriated to hearing, seeing, smell, and taste ; 3d, the medulla spinalis, appropriated to touch and voluntary movement ; 4th, the great sympathetic nerve, appropriated to the thoracic and abdominal viscera. It appears that these four great divisions are perfectly distinct, that each constitutes a system by itself, and rules over its own peculiar class of functions. We think by the brain ; we hear, see, smell, and taste by the nerves of the medulla oblongata; we move and feel by those of the medulla spinalis ; while the heart throbs, and the stomach, intestines, liver, kidneys, &c. act by means of the great sympatlietic 



45 

EPIDEMIC CHOLERA. 

nerve. All these actions are thus performed by the nervous force, energy, or sensibilit — the sensorial power — emanating from this nervous system. 

This nervous energy is not always uniform in its operation, it is capable of being increased or diminished. When it is increased, all our faculties and functions acquire an accession of strength and activity ; when it is diminished, their sensibility decline in a corresponding degree ; in short their vigour at any given period is in exact proportion to the copiousness with which this power is diffused over them. As then the activity of voluntary motion, of the external senses, and of the mind, are not always in operation, it follows that the sensorial power, so far as they are concerned, falls occasionally into a state of repose, as we see in sleep. But the functions, in the due performance of which it can never with immunity lie dormant, are those of animal life ; and so long as we exist it animates the heart and the other viscera, keeping up the circulation, digestion, absorption, and the other vital powers. These functions are essential to existence, and by a wise law of nature the sensorial power is directed to them in a continuous stream, because when interrupted vitality is perilled, and its total cessation, 



46 

CAUSE AND EFFECTS OF 

even for the shortest period, would destroy life. 

Now, the first link in the chain of morbid actions which constitute this disease seems to be a shock, or " embrouillement" of this cerebronervous system, the relation between the organism and the elemental forces of nature having been either deranged or impeded. The immediate effect of this is, that the whole nervous system falls into irregular and depraved action ; the great sympathetic loses its influence over the organs which it supplies, the heart exhibits a morbid imbecile excitement, the absorbent system is suspended, and the vital energies are universally prostrated. 

The chemico-electric actions are disturbed, the assimilative functions not only of the nervous but of the glandular system are impeded, the heat of the body almost ceases to be eliminated, the thermometer indicating a temperature of from 60° to 80° Pahr., the sensorium remains clear, but is languid and becomes torpid. The secretion of urine is early totally suppressed, and the hepatic ducts are constricted. The stomach falls into a state of violent inverted action, evincing, in the suddenness of the expulsion of its contents and without nausea, a spasmodic origin ; 



EPIDEMIC CHOLERA. 

47 

the peristaltic function of the intestines is also greatly increased, assuming internal muscular spasms by the abruptness of the discharges and the absence of almost all warning. The blood not sufficiently supplied with its normal vital qualities deteriorates, and in passing through its vessels the crassamentum becomes congested, and is rendered incapable of affording a healthy support to the organic functions, while the separated serum, holding in solution its saline constituents, surcharges the blood-vessels, and is forced by internal spasmodic action through the capillaries into the stomach, intestines, and over the surface of the whole body. Thus worn out by intensity of anguish, the mind at length gives way, it sinks into insensibility, coma, and death soon closes the scene. 

The phenomenon of animal heat is one which stands much under the control of the vital principle; the living organism can support a high degree of heat, as well as an extremely low temperature, without feeling much inconvenience; but in cholera patients, even where the surface of the body is deadly cold, if the temperature is not carefully graduated, considerable sufferings may be added to those already being endured. 



48 

CAUSE AND EFFECTS OF 

The observations of Brodie and Chossat have amply refuted the old doctrine, that the heat of the body is produced by the combination of the carbon and hydrogen of the blood with the oxygen of the atmosphere in respiration. " Heat ceased to be generated, nay, the upper part of the body (in which the function of respiration takes place) was the first to exhibit a deathlike coldness, as soon as the influence of the cerebral upon the ganglionic nervous system was arrested, by injury of the spinal cord above the fourth vertebra, or by deep wounds of the brain, although respiration, and consequently the therewith connected process of combustion in the lungs, held its accustomed course, and carbonic acid and hydrogen gas were generated in no less volume than before," 

This would appear to prove that De la Riva's hypothesis is not without foundation, that " animal heat is produced by a reciprocal action of the cerebral and ganglionic nerves, in the same way as heat is generated between the points of two wires, by which the positive and negative electricities discharge themselves." 

It is evident that many of the processes of organic life are nothing more than modifications of the action of the imponderables in inorganic 



49 

EPIDEMIC CHOLERA. 

nature, the principle of individual life being the modifying agent. 

As then we observe in patients affected with cholera an early and almost total cessation of the generation of animal heat, and as caloric is thus eliminated in health by the cerebro-nervous system, as well as by the assimilative functions, it follows that the first link in the chain of morbid actions in cholera is an " emhrouittement" of that system; and this is further confirmed by the constant presence of alternate contraction and relaxation of internal and sometimes external muscular fibre, and indeed by the sudden and general prostration of all the vital energies. 

PREDISPOSING CAUSE OF EPIDEMIC CHOLERA. 

Perhaps there exists no demonstrative proof that any occupation, mode of living, age, or idiosyncracy has a direct tendency to induce a predisposition for an attack of epidemic cholera ; but some well-marked cases have been observed, in which exhaustion, hollow dark-encircled eyes, and shrunken features, succeeded anxiety and 

4 



50 

PREDISPOSING CAUSE OF 

fatigue during the prevalence of the epidemic influence, and terminated in collapsed cholera. 

It is worthy of remark, that a debilitated condition of the human constitution, induced by the use of improper articles of food, particularly such as produce laxity of the bowels, or by the habitual indulgence in intoxicating drinks and dissipated habits, favours an attack. It is also very generally admitted that the inhabitants of ill-ventilated and over-crowded apartments, in the lanes and alleys of cities and towns, (which are usually the receptacles of filth in all its hideousness,) and who are therefore constantly respiring impure air, arising from animal and vegetable matters in a state of putrefactive decomposition, are rendered thereby peculiarly susceptible in fixing in its transit this as well as most other epidemics. 

But, perhaps, these causes act not merely by occasioning a general depression of the vital powers. Any one of them tends to produce in the circulating fluids an accumulation of disintegrating azotised compounds in a state of change, and thus may afford the greatest facility to the development of any epidemic or other disease in the system, whatever the nature of the specific influence may be. As 5 therefore, each of these 



51 

EPIDEMIC CHOLERA. 

causes operates separately, when they act concurrently their potency is of course vastly augmented; and this accords with the observations of those of the profession who have had much experience of epidemic cholera. 

Instances were abundantly furnished during the prevalence of the epidemic of 1849, and particular cases are recorded in the Report of the General Board of Health, to determine the fact that the habitual or even occasional ingestion of decomposing matters in the food or drink impregnates the system with putrescent compounds, deteriorates the blood ; and thus apparently the selection of such an individual by the epidemic influence occurs, — doubtless finding such a state of the system most favorable to the development of disease. 

The experiments of Smith, of Liebig, and of others have amply shown that the vapour exhaled from the lungs contains a considerable portion of organic matter. If this vapour be condensed, kept in a closed vessel, and be exposed to an elevated temperature, a putrid odour is emitted from it, depending on the decomposition of an imperfectly oxidised albuminous substance — these always exhaling under similar circumstances the peculiar odourwhich characterises faecal discharges. 



52 

PREDISPOSING CAUSE OF 

It is also assumed, from the fact that garments long worn emit a foul odour, that the perspiration contains a similar substance. Hence imperfect ventilation and over- crowding exert their deleterious effects not alone by preventing the full oxidation and elimination of the substances which are normally undergoing decomposition within the body, bat operate to concentrate the putrescent effluvia or miasma that are excreted from the lungs and skin — which produce the same morbid effects upon those habitually exposed to them as if these had their origin from some remoter source. Thus we see that an insufficient supply of pure air becomes the means not alone of preventing the due elimination of decomposing substance from the system, but of reintroducing its poisonous compounds into the circulating fluids, by that process designed for the purification of the blood — respiration ; and in this manner that state of the system, which determines the selection by the epidemic influence, is produced. (?) 

The habitual indulgence in intoxicating drinks not only tends to induce general irregularity of the nutrient process, and a consequent deficiency of the vital powers, but one of perhaps the best ascertained of the consequences of the introduction into the blood of alcohol is the rapid oxidation 



EPIDEMIC CHOLERA. 

53 

it undergoes, whereby itself is eliminated from the circulating fluid. As the attraction of alcohol for oxygen, in that process, enables it to quickly appropriate to itself the oxygen supplied by the process of respiration, it must therefore tend to prevent that oxidation of other substances which is indispensable for their elimination, and the excretion of which is perhaps one of the most important and special objects of respiration. Thus the peculiar action of this cause induces the same condition of the blood as that which results from an obstructed or an impure supply of atmospheric air; and thus again we see that state of the system induced which determines the selection by the epidemic influence^?) 

Fatigue, or excessive muscular exertion, also not alone occasions a depression of the vital powers; but it is in the present day almost universally admitted that all muscular exertion comprises a disintegration of its tissue, the elements of which combine with oxygen to fit them for being eliminated in part by the respiratory process, under the form of carbonic acid, water, &c; by the kidneys, under the form of urea, and other compounds ; and by the skin, under the form of water, &c. Now, if the disintegration of muscle by exercise take place in a greater ratio than the 



54 

PREDISPOSING CAUSE OF 

constituents about to decompose can be oxidised and eliminated, these elements must of course remain in the circulating fluid, for a given time, in that state ; and thus is induced the same deteriorating condition of the blood, and the same susceptibility of the system to be acted upon by the epidemic influence, as that which we assume may be derived from either of the other causes mentioned. (?) 

If the foregoing physiological rationale be admitted, as we feel assured it will at least be considered possible, it is a matter of direct induction that this condition of the blood — charged with decomposing organic compounds — however induced, is the immediate source of the predisposition state. Now, to eliminate these decomposing matters demands an augmented energy on the part of the sensorial power ; but as this vital force is itself dependent upon the healthy function of the cerebro-nervous system, as well as upon the normal condition of the " cosmic forces," it follows that this process must necessarily be impeded or totally obstructed during the prevalence of the morbus cccli. Thus giving rise to epidemic diseases. (?) 

Of 372 cases admitted into the Clonmel Cholera Hospital, in the year 1849, 37 were 



55 

EPIDEMIC CHOLERA, 

of ages under 10 years; 139 were of ages of 10 and under 30 ; 121 were of ages of 30 and under 50 ; and 75 cases were of ages of 50 and upwards to 80. Thus, then, it would appear that children are less predisposed than adults, and that old people are prone to be attacked by this disease ; indeed it appears that they are much more predisposed than children. Females also seem more predisposed than males ¦ 207 of the above number of patients were females. 

DEFINITION OF EPIDEMIC CHOLERA. 

Vomiting and purging of sero-lymphous matter ; spasms or cramps of the muscular fibres, particularly the muscles of the extremities ; general prostration of the vital energies; universal collapse. After a few hours, reaction, or insensibility, coma, and death. 



56 

SYMPTOMS OF 

SYMPTOMS OF EPIDEMIC CHOLERA. 

Once seen, cholera will easily be recognised. When in its more severe form, the frequent purging, the watery stools, the constant retching and vomiting, the shrivelled, pinched-up expression of countenance, the death-like coldness of body, the sunken eye, the hollow, whispering, or husky voice, the cramps or spasms, often the pulseless wrist, and the prostration of strength, are all symptoms which readily point out to the most inexperienced the character of the disease. 

There were, however, to be met with, as the epidemic appeared in this country, various shades of the disease, and so great were the differences in the forms which presented, that it may be useful, as it is convenient, to view them in distinct groups, constituting as many types, which are neither stages nor yet species, but varieties of the epidemic, induced by the same remote cause, and having the same pathological tendencies. 

In order to' guard against the possibility of confusing the judgment of the JDeginner, by giving solely a minute detail of symptoms, and, mayhap, thereby prevent that celerity of decision 



57 

EPIDEMIC CHOLERA. 

as to the plan of treatment to be adopted, which in this disease is of such urgency, we may be permitted in this place to suggest to the young practitioner, what with this view will perhaps suffice for most ordinary purposes, that, if epidemic cholera be present in a place, and that a person be seized with purging, without or with slight pain, that he pass watery stools, that he retch and have vomiting, then he may be adjudged to have an attack of this disease, and should forthwith be submitted to proper medical treatment. 

It had been justly remarked by a practical writer, that no disease perhaps has presented itself to our observation with so many and in such varying aspects as the cholera which manifested itself in 1832, and again in the year 1849, in Ireland, as an epidemic. It would therefore be impossible to give in minute detail any accurate description of its symptoms in one group as applicable to all cases, and hence, for mere convenience of record, we deem it will be more acceptable to the reader to adopt the arrangement defined. 

In taking this course to distinguish certain stages as it were in the progression of the symptoms of the disease, it is not intended to mark 



58 

SYMPTOMS OF 

any regular succession of them with a view to be enabled to say to what extent the malady has proceeded, and thereon to found a prognosis, because we had frequently observed the greatest irregularity, as well in the succession of the symptoms as in their duration and severity. We had seen the disease manifest but trifling indications for days before any serious apprehension could be entertained ; we have known it run its course from apparently a state of health to dissolution in less than three hours. We have remarked that any one of the group of symptoms may take precedence; we have seen any one or more frequently absent, and we have observed nearly all of them to present in rapid succession to a fatal termination. 

This irregularity in the symptoms has been remarked (vide M'Coy on Cholera) to an extent that the different extremes of the malady could scarcely be recognised as pertaining to the same class of disease, did not their occurrence at the one time and place, and their relation by intermediate grades, prove their identity of origin. They all, however, evince a strong tendency to pass into the state of universal collapse, which may be said to be the radical form of epidemic cholera. 



59 

EPIDEMIC CHOLERA. 

The first group, or the stage of invasion.' — The symptoms are in a great number of cases mere numbness, rarely cramps, ushered in by a chill" and sometimes general tremor of the body. These are quickly, perhaps immediately, succeeded by nausea, thirst, and a burning sensation in the epigastrium. The circulation is little excited, the pulse rather full and often irregular and intermittent ; there is little if any alteration in the temperature of the body, and the face is sometimes rather flushed, the eyes occasionally encircled with a livid areola. 

Often, for some days previous to the attack of pain in the region of the stomach, the patient labours under diarrhoea, accompanied with a slight degree of tormina. 

The impression upon the cerebro-nervous system is exhibited thus early by a tendency to stupor, by a marked indifference, and a peculiarly heavy expression of the eyes, and unwillingness to be disturbed. Indeed during the whole progress of the disease, in any of its forms, there is present a sluggishness and apathy. This apathy is particularly observable in patients not applying for relief, although fully alive to the sense of impending danger, and the importance of early recourse to medical treatment, upon which safety 



60 

SYMPTOMS OF 

so much depends ; and hence it is the manifest duty of every member of a family to communicate immediately, in the event of any one of them, during the prevalence of cholera, being thus attacked. The first invasion of this disease generally occurs between sunset and sunrise; it is therefore of the most vital importance to forthwith communicate, if any one should, in the course of the night, be suddenly seized with this or with either of the succeeding forms of the epidemic. 

The second group, or " Cholerine." — This form of the malady is usually ushered in by the preceding, or by the symptoms common to the first stage of inflammatory fever, with spasms of the extremities, often reaching to the external muscles and the viscera of the abdomen. The 

patient vomits or retches violently, as if from sudden spasmodic action, — complains of pain in the stomach, and is copiously purged. The ejected matters from both stomach and bowels are generally nearly much the same, not unlike whey or rice-water, the usual contents of the primae vise having been first discharged. The heat of the body is below, often considerably below, the natural temperature; the pulse is small, weak, and frequent, and the respiration is hurried. 



61 

EPIDEMIC CHOLERA, 

To this variety of the epidemic, collapse does not always succeed, or it is less urgent, and it is usually followed by reaction, and often by recovery, after being, perhaps, for several days kept on the verge of the more fatal type; or the patient lingers for several days in some of the sequela, and ultimately may or may not recover. 

The third group, or cholera with collapse — This type supervenes either of the above forms, but it more generally makes its assault suddenly, with great prostration of strength, and purging of turbid, greenish, liquid matter, attended, or quickly followed, by vomiting of a whey-like fluid, with flakes of mucus and albuminous matter floating in it; but of course these peculiar evacuations, at the commencement, contain portions of the natural contents of the primse vise. Spasms and pain are felt in the extremities, particularly in the calves of the legs ; in some the external spasms are altogether absent, in others they extend to the muscles of the abdomen as well as its viscera, then seize the muscles of the thorax, and but seldom reach those of the back, loins, or face. The spasms usually present the clonic form ; in some cases they are tonic at first, and then alter to the other character. The eyes lose their lustre, sink deep 



62 

SYMPTOMS OF 

in their sockets, and are encircled by a livid areola. The skin contracts over the shrunken muscles, and the countenance altogether assumes a ghastly expression. The extremities and surface of the body become deadly cold ; in some cases the hands first, and afterwards the rest of the body, become of a purplish blue colour ; the oppression and feel of anxiety at the prsecordia increase; the voice becomes husky, and the utterance laboured; the pulse is small, quick, oppressed, and scarcely perceptible at the wrists and temples, and soon, in these parts, becomes totally imperceptible, and every thing indicates a state of collapse. A cold clammy sweat covers the skin, which sometimes "increases to a copious, cold, raw moisture, which bedews the shrunk, sodden, cold integuments, particularly of the extremities ; and the restlessness is indeed terrible to bear/' — {Annesleys Sketches of the Diseases of India.) The tongue is clean, dry, or slimy, and soon becomes cold, yet the patient will complain of a burning sensation at the epigastrium, if enquired after, and the thirst is intolerable and cannot be quenched. " The urine seems not to be secreted, and not only it but the saliva and all glandular secretions appear to be completely arrested during the progress of this dreadful malady."— (Annesley.) 



63 

EPIDEMIC CHOLERA. 

As the disease proceeds, the evacuations and spasms generally cease. 

Towards the close of the fatal termination the sense of anxiety and oppression at the prsecordia increases, the breathing becomes hurried, the mind now loses its equilibrum, the restlessness degenerates into a sort of jactitation, the vital actions sink, and insensibility leads to the catastrophe, frequently a few hours only after the attack. 

If reaction should be established, the disease will not run this rapidly fatal course. The state of collapse may last from an hour to a few days before death closes the scene ; or, after an uncertain time, some warmth may be observed to commence to be generated, the pulse is again felt at the wrists and temples, and we see that convalescence begins. However, if reaction proceed to excess from any cause, the patient complains of headache, the vessels of the conjunctivse are injected, the eyes are suffused, and there is an aversion to light ; the pulse is now increased in force; the tongue loses its clean, cold, moist appearance, and becomes whitish, foul, and warm, sometimes brown or nearly black. The mind loses its remarkable clearness, and becomes confused, or as it were torpid, which does not 



64 

SYMPTOMS OF 

necessarily imply any structural alteration in the nervous centre. The urine also is now secreted, and dark and bilious matter is discharged from the bowels. The temperature of the body rises above the natural standard, and sometimes approaches to that of fever. This state may last for a week or ten days, and yet terminate in coma and death. 

Again, other cases of the sequelae of collapse will evince more of the inflammatory than of the typhoid character. In the majority of those cases we have latent pneumonia, discoverable only by auscultation ; and the symptoms which generally present themselves are headache, the sensibility and activity of the senses and of the mental faculties are blunted, and the brain or its membranes may become secondarily affected. Pungent heat and dryness of the skin, the pulse frequent, the tongue red, flatulence, hiccough, and nausea. 

Stupor and muscular prostration are more frequent than paralysis or spasms. If these last appear, the brain is usually affected. The urine is small in quantity and high coloured; the external margins of mucous membranes are red ; the conjunctive injected, the pituitary membrane dry. If this state of things become more intense, the 



65 

EPIDEMIC CHOLERA. 

tongue is covered by a thick adherent coat, which is red, dry, and rough • the gums, lips, and teeth are incrusted with a brownish matter, the thirst is considerable, and towards the fatal conclusion the countenance is indicative of suffering; the nostrils expanded, the eyes red, dull, and hollow, and the cheek-bones projecting, and of a deepred colour. 

The symptoms of cholera in children we had remarked to be less violent than in adults; cramps are seldom present, — they are cold, calm, and still ; features shrunk ; eyes hollow, dull, the pupils generally much dilated; thirst is as intolerable as in adults, — they constantly cry out for cold water, or evince a perpetual desire for drink. The purging appears to be less in proportion to the vomiting. 

PROGNOSIS IN EPIDEMIC CHOLERA. 

Although cholera, when taken under treatment at the first moment of invasion, is a disease easily managed and subdued, still when general congestion of the internal organs arrives, and pul-5 



66 

PROGNOSIS IN 

sation in the superficial arterial system is imperceptible, the best directed resources of the medical art will, we apprehend, continue to be too frequently baffled. 

When the tongue is cold, the hands blanched, shrivelled and chill, the pulse innumerable, or altogether lost; when the spasms and vomiting abruptly cease, and at the same time the thirst and jactitation increase, with bloody suffusion of the eyes, and insensibility — death is fast approaching. 

When with returning warmth of the extremities and tongue, the pulse becomes more distinct and full, and the spasms and vomiting gradually cease, while the excretions assume a feculent and bilious appearance, and the patient becomes more sensible to external impressions, favorable hopes may be entertained. 

An unusual severity of the early symptoms leads to an unfavorable prognosis; whilst those cases that are mild at the commencement afford the greatest proportion of recoveries. 

In subjects debilitated from disease or weak from want of sufficient wholesome food, the epidemic makes rapid progress. We observed that patients just convalescent from fever were not only more than proportion ably predisposed 



EPIDEMIC CHOLERA. 

67 

to the malady, but the results also proved unfavorable in the majority of the cases. 

Sanguineous alvine evacuations justify an unfavorable prognosis; — the exudation from the pores of the skin of a gelatinous fluid, likened to frogspawn, and emitting a peculiar cadaverous odour, generally portends a fatal termination. These two are usually to be observed only as presenting in the cases of the drunken, the dissipated, and invalids of a broken-down constitution. A few instances are recorded of these phenomena occurring in vigorous and robust patients. We had observed the former in robust constitutions, but the latter symptom seems more generally to be (almost exclusively) presented in cases of the broken down debauchee. 

Advanced age and infantile life are unfavorable to recovery from this disease, and indeed it appears to be fatal in the direct proportion of the capability to resistance on the part of the constitution of the patients. In the Clonmel Cholera Hospital in 1849, the deaths were to the ages, under a decimal classification, in the proportions following : — 18 were fatal in 37 cases, of ages under 10 years; 22 in 80 cases, of 10 and under 20 years; 11 in 59 cases, of 20 and under 30 years ; 23 in 73 cases, of 30 and under 



68 

PROGNOSIS IN 

40 years; 19 in 48 cases, of 40 and under 50 years ; 15 in 43 cases, of 50 and under 60 years ; and 24 deaths in 32 cases of patients of 60 years and upwards. 

Most persons recover from the first type of this epidemic, when judiciously treated; and more patients recover from the second than from the third type of the disease. In the Clonmel Hospital in 1849, of 157 patients admitted in a state of perfect collapse — wrists pulseless — 83, or about 5 in 9, terminated fatally, whilst of 198 not collapsed only 32, or about 2 in 13, died. 

We may here remark that in addition to this number of fatal cases of cholera, 17 patients died at the Clonmel Hospital in 1849, who maybe said to have not been medically treated, inasmuch as the majority of that number were moribund on admission and died within an hour, most of them not having taken any medicine, whilst some few had refused to take anything but cold water and whiskey-punch. 

It further appears from the statistics of this hospital that the epidemic is more fatal among females than among males. Of the 83 cases of deaths of those patients who were perfectly collapsed on admission into the hospital, 69, or 



69 

EPIDEMIC CHOLERA. 

about 5 in 7, were females, whilst of the 32 deaths of those not collapsed on admission, 1 9, or about 3 in 5, were females. 

APPEARANCE AETER DEATH IN EPIDEMIC CHOLERA. 

The victim to cholera has scarcely ceased to breathe when the chemical actions of decomposition begin. The body assumes externally a livid appearance. Six hours subsequent to death the subjects present on dissection features dependent, first on the rapidity of the fatal attack, and second on the excessive reaction consecutive to collapse, which latter is a state of general congestion. 

In cases that terminate rapidly the following anatomical characters are observed : 

The head. — The vessels of the cerebral envelope are turgid with dark-coloured blood, and those of the brain are also more or less loaded. The substance of the brain is firm, and no appreciable lesion appears. 

The thorax. — The lungs are sometimes inflated, more frequently collapsed ; their blood-vessels are gorged with dark-coloured blood. The coronaries 



70 

APPEARANCE AFTER DEATH IN 

are injected with black blood, and the right side of the heart and the venous trunks are often unusually filled with more or less of a similar fluid. 

The abdomen. — The veins of the omentum and mesentery are turgid : — 

The liver. — This organ seldom presents any morbid appearance referable to the effects of cholera, other than that its vessels are full of black incrassated blood ; and the gall bladder is distended with viscid bile — the ductus communis choledochus being constricted, thus preventing the flow of bile into the intestine ; this constriction of the bile duct is so considerable that unless much pressure is made on the gall-bladder, bile will not flow through it. Where temporary reaction has taken place the gall-bladder is generally empty, having discharged the bile into the duodenum ; yet the duct is again constricted. 

The intestines. — Viewed in situ the intestines appear white and nearly bloodless. The inner coat or mucous membrane exhibits a particular vascularity, sometimes of the minutest vessels gorged with blood of a reddish-brown colour, but there is no thickening of the membrane, yet the follicles seem more developed than usual; and the whole tube contains more or less of the peculiar serous secretion, which has been rejected 



71 

EPIDEMIC CHOLERA. 

by vomiting or at stool, and is devoid of fsecal odour. 

The stomach.— -The villous coat of the stomach is sometimes more or less suffused with an erethematic blush most considerable about the cardiac orifice. Occasionally a coating of viscid adherent pulpy matter is observed in both stomach and intestines, imparting a thickness, but, by drawing the coats of the stomach or intestines, thus apparently thickened, between the finger and thumb, a white opaque fluid is squeezed out, and the " mammillated" thickness effaced, the mucous membrane of the part so treated being afterwards of its normal consistence. This particular state of the mucous membrane was first described by M. Louis, who considers it as a result of chronic inflammation, in which opinion M. Andral and others concur. It has, however, been recently found, in cases where during the lifetime of the patient no symptom of inflammation was exhibited; and the fact that this condition of the membrane is found in the autopsy of those who die in the collapsed stage of cholera, shows that it may come on very quickly, and tends to disprove that this "mammillated" state of the mucous membrane entirely depends on chronic inflammation. 



72 

APPEARANCE AFTER DEATH IN 

Broussais has advanced a supposition that cholera is little more than gastro-enteritis ; but surely this is successfully opposed by the fact, that inflammations of the stomach and intestines occur, in their several forms, without, in any case, giving rise to the symptoms of malignant cholera with collapse ; and further, the appearances after death in this disease do not accord with the ordinary effects of inflammation. Besides, the recent origin and epidemic nature of cholera add cogency to the reasons above assigned, and convince us that it is not a simple inflammation — a supposition, indeed, utterly untenable, and every way unworthy of the ingenious author. 

The spleen appears to undergo little change during the progress of this disease. The pancreas presents nothing unusual. 

The urinary bladder is empty and contracted, " having more the appearance of a virgin uterus than a bladder." (Dr. Kellie.) 

The muscular structure of the whole body is firmer and darker-coloured than in the healthy state. 

The mental being the last faculty which yields to the ravages of this disease in the early or in the collapsed stage, we therefore may infer that in 



EPIDEMIC CHOLERA. 

73 

these cases the more immediate cause of death appears to be congestion in the cerebral vessels. 

In those cases which are protracted, and terminate fatally after reaction has been fully established, the following anatomical characters are observable : — 

The head. — In protracted cases no Very unusual turgescence of the vessels of the brain or its membranous envelope is remarked. The substance of the brain is not unfrequently in a softened condition, and ecchymosed spots are occasionally observed, particularly in those cases where in the course of the disease convulsions or paralysis, or both, may have presented. 

Thorax. — In a large proportion of subjects, one or both lungs present unequivocal traces of pneumonia; according to Mr. Jackson, "in about one half of the cases which terminate fatally after decided reaction is established," anatomical characters of pneumonia are observable. In some few cases which prove fatal at the end of fortyeight hours, partial and interlobular pneumonia is sometimes met with. 

The heart occasionally is more flaccid than natural; and fibrinous clots are often found in the right ventricle, sometimes extending from this into the left. We are not aware that these 



74 

APPEARANCE AFTER DEATH IN 

clots have been found solely in the left ventricle — we believe not. 

Abdomen. — The mucous membrane of the alimentary canal in general exhibits in several patches a slight inflammatory tinge, but its texture rarely undergoes any appreciable change. A viscid pulp is sometimes observed in patches, and frequently so adherent to the inner surface of the stomach or intestine, that it would appear to be almost a partial solution of the villous coat. But this we conceive to be the albuminous matters arrested in their passage into the dejection — the result of muscular relaxation and contraction upon the defective assimilation under the choleraic influence. (M. Mialhe — vide British and Foreign Medico- Chirurgical Review, for October, 1852.) The follicles and solitary glands are in all cases conspicuous, and give to the mucous membrane a granular appearance. The contents of the intestine are like those evacuated during life, but are now tinged with bile. This biliary tint is limited to the duodenum, and perhaps to the upper part of the jejunum in those cases in which reaction was only transitory. In some cases the mucous membrane is observed to be pale nearly through the entire canal. In very many instances the muscular coat of the intestine 



EPIDEMIC CHOLERA. 

75 

is in some portions contracted, whilst in other parts the intestine is much dilated. The liver appears of various sizes and colours in different subjects ; occasionally small ecchymosed spots are observed on its surface, and it is sometimes flabby and friable. The gall bladder is usually empty, or nearly so. 

The kidneys, nearly natural in colour and consistence, show no manifest lesion to account for the suppression of their secretion. The cortical substance is usually purplish, but sometimes pale, with its vessels dark and congested. A whitish fluid can, by pressure between the fingers, be observed to issue at the mammillary points. Some pathologists have assumed this creamy, pus-like fluid as a character peculiar to this disease; but it has been met with in subjects who died of other diseases. (Dr. Budd.) It probably consists of the defective assimilation — albuminous matter, and the concentrated constituents of urine. 

The urinary bladder frequently contains a small quantity of urine. 

In consequence of the suppression of the secretion from the kidneys in this disease, urea is found in the blood and bile. In ordinary circumstances it does not exist in the blood, being 



76 

TREATMENT OF 

separated from it by the kidneys as soon as it is formed. (Dr. Roupell.) 

TREATMENT OE EPIDEMIC CHOLERA. 

The medical treatment of cholera when taken at the first moment of attack, is frequently not difficult to conduct, still when extensive congestion of the internal organs has taken place, and pulsation at the wrist and temples has ceased, this — the collapsed condition— is not so simple and so easily managed as some of our medical authorities would seem to think, and the best-directed resources of the medical art unhappily too often prove of little avail. Formidable as is the character of the epidemic, and appalling the rapidity with which it sometimes proves fatal, yet, it is consolatory to know that, when prudently and properly grappled with, particularly in its earlier stages, it is as much within the control of medical appliances as other less formidable maladies. It ought to be well understood — it cannot be too much impressed upon our minds — that cholera is a disease subject to the same laws, pathological and therapeutical, 



77 

EPIDEMIC CHOLERA. 

as are applicable in an inquiry into the treatment of all other diseases ; the intense severity of the nervous shock, and the rapidity with which the consequent morbid changes occur, constitute its characteristic difference. The plan of treatment, therefore, entitled to the least respect or confidence, must be founded upon the careful application of the recognised principles of medical science. 

We regret to be obliged to observe, that it is too much the fashion in the present day to generalize the plan of treatment recommended for a disease. This indeed has, in theory at least, become now rather common; and is often not only apparently detrimental to the reputation of medical writers, but injurious to the profession, the writer not being thus enabled to convey with perspicuity his matured views. Hence it is, doubtless, that we behold one authority pronouncing bleeding as the remedy for cholera; and another declaring that there is nothing to be depended upon so much as brandy and opium. But the veriest tyro in the profession knows that we cannot force indiscriminately into practice remedial agents so opposed to each other in their effects, without feeling that we are abandoning the laws of scientific medicine, and 



78 

TREATMENT OF 

plunging recklessly into a chaos of empiricism, where pathological reasoning and logical deduction never enter. The endeavour, therefore, which we make must be clearly detailed, to throw even a little light upon the management of this inscrutable and intractable malady ; and to do this profitably requires that the treatment shall be distinctly considered under a suitable arrangement. As we have grouped the symptoms into varieties, types, or stages, it will here be equally convenient to keep in view the same order, and we adopt it in our detail of treatment " CHOLERAIC INVASION," " CHOLERINE," 

" CHOLERA WITH COLLAPSE," and the " SEQUELS 

5? 

OF COLLAPSE. 

The morbid appearances upon dissection elucidate merely the effects of insensibility, or torpor of the cerebro-nervous system, which we contend is the first link in the chain of depraved actions which constitute cholera ; and the circumstances which present themselves to the pathologist are the remarkable ones, — a determination of blood to the internal organs, and congestion of the venous system in general. For all practical purposes an inquiry into those effects should be looked upon as of the greatest importance and urility, if not indispensable; because chiefly 



79 

EPIDEMIC CHOLERA. 

upon these must be based all medical treatment, rather than upon any attempts, however ingenious, to discover the exciting cause of the epidemic. 

The " choleraic invasion then being the first result upon the organic structures of the temporary shock which the nervous system has just sustained, bringing in its train, if not quickly remedied, all the previously recorded phenomena, the indications of treatment manifestly are, — to arouse without exciting the cerebro-nervous system, and enable it to eliminate in its normal state the vital force, — to remove the tendency in this stage to congestion of the vessels,' — and to induce the action of the assimilative functions. 

These indications have, according to our experience, been best fulfilled by the judicious use of the remedial agents following : — A steam or hot water bath — general frictions of the body and extremities with hot oil of turpentine — artificial heat applied externally, particularly along the spine, and to the extremities — bloodletting, in healthy robust patients — calomel in moderate doses, and opium in full doses — enemata, small in quantity, containing at least 01. Terebinth. Should diarrhoea precede the attack, or become troublesome, tannin in two or three grain doses, 



80 

TREATMENT OF 

in combination with calomel and opium, in small doses frequently repeated, and tincture of opium may be added to the terebinthine enemata, and repeated if necessary. When bile shows in the dejections, a warm aperient and a light aperient-alkaline tonic, generally, will be alHhat may be required to restore the patient to the enjoyment of his usual state of health. 

If a steam or hot bath can be conveniently had, the patient should be placed in one for five or eight minutes, and when removed into a warmed bed the entire body and extremities ought to be well rubbed with 01. Terebinth, made hot, by immersing the bottle containing the terebinth, in boiling water for some short time. Artificial heat, by means of tin vessels containing hot water, hot sand in bags, &c. may be employed ; patients sometimes will not endure the application of much heat, care therefore should be taken that it be not pushed beyond that which would be grateful in a healthy state. 

The tendency to congestion is, of course, best removed by arousing the normal nervous energies; but least that desirable effect may not be quickly accomplished, it will in the interval be judicious to take measures against the possibility of congestion actually occurring. With a view to 



EPIDEMIC CHOLERA. 

81 

obtain this indication the abstraction of blood is par excellence the remedy. 

In the form of cholera now before us, we are generally presented to a robust person, otherwise healthy, and his pulse is full and frequent. To hesitate in such a case whether the abstraction of blood or the administration of stimuli is the better practice, is in all probability to sacrifice the patient. Blood then is drawn until some constitutional effect is obtained — cautiously guarding against producing syncope, because we ought to be apprehensive lest the shock upon the nervous system has rendered the brain not sufficiently powerful to resuscitate the vital action. 

It is generally conceded, that calomel and opium in conjunction best assist in restoring the healthy functions of the several organs. This combination, in the proportion of five grains to one, ten to two, or even fifteen to three grains of opium may now be administered, and repeated if the first dose be rejected, or if otherwise necessary. The efficacy in this stage of two grains of opium and ten of calomel is positively great, when preceded by the turpentine frictions, &c, and immediately followed up by an enema composed of 01. Terebinth., sij ; 01. Olivar, 3j; Aq. Calid., giss • M. ft. Enema. This form we prefer, 6 



82 

TREATMENT OF 

— if the quantity be large the distension caused thereby will produce the expulsion of the 01. Terebinth., but when thus administered it is usually retained, and would seem, by its local stimulus, to impart energy to the bowels sufficient to the correct performance of their functions, while, by its absorption, it tends greatly to allay the spasm and irritation, both locally and generally. 

Turpentine preparations can easily penetrate into the economy, and of which the latter can easily rid itself again. This is constantly observable by the peculiar violet-like odour which the urine assumes very soon after 01. Terebinth, is applied to the mucous membrane, or even to the pores of the skin ; and its odour is also distinguishable in the breath of such persons, much sooner than might be conceived possible to occur were the oil to be first passed by the lymphatics into the blood and mixed with it reach the lungs. As then terebinthine preparations obviously possess the power of exciting eliminatory action, and as it is of paramount consequence to maintain this active twofold power of absorption and elimination in cholera, more particularly where we are desirous of acting energetically, as in malignant cases, this remedial agent ought never to be omitted in our treatment of this 



83 

EPIDEMIC CHOLERA. 

malady, in any of its stages. We have employed it extensively in the management of the several varieties of cases of this epidemic, and with the most beneficial results. In estimating the value of 01. Terebinth, in cholera, its styptic properties constitute an essential element. We have almost invariably observed its application in enemata, as above intimated, to be most effective in restringing the mucous membrane, and causing the serous discharges to disappear, or to be with greater facility arrested. 

Should diarrhoea exist, we may, to the first dose of calomel and opium, add a few grains of tannin, and we should administer the following powders, commencing two hours after the first dose of calomel, opium, and tannin : 

Be Clilor. Hydrarg., gr. ij ; Ext. Opii Aq., gr. £ ; Pulv. Tanninse, gr. ij ; 

M. ft. Pulvis. Habeat quatuor tales. — Sumatur una 2 aa q. q. hora. 

We should also repeat the turpentine enema. If diarrhoea be not present, the tannin should be omitted in the powders, and the calomel and opium, in small doses, may be continued every two hours until the choleric symptoms are subdued. 



84 

TREATMENT OF 

The hot turpentine frictions may be repeated often if necessary, but need not be pushed to the extent of excoriating or blistering the skin. 

The simultaneous actions of the remedies and appliances thus directed, must be supported by sustaining the strength of the patient with light, unstimulating, nutritious food; chicken -broth, tea, milk and water sweetened and used warm, may constitute the ordinary drink. 

When the choleric symptoms have subsided, should the bowels remain confined, we may employ an aperient draught, composed as follows : 

R Magnesiee, Serupulum; 

Magnesise Sulph., 3vj ; Aq. Cinnamomi, Jiss ; 

Tinct. Rhei Comp., siij. M. ft. Haustus. 

When a flow of bile into the intestines takes place, the excretions resume a feculent and biliary appearance; after which recovery usually takes place from an attack of cholera in this form, under the use of light aperient alkaline tonics, and the common attention to diet and regimen. 

In cholerine, the indications above suggested as applicable to the first stage, equally hold good; but now congestion is imminent, and, indeed, may already be fast advancing, and as rapidly be embarrassing the previously abnormal 



85 

EPIDEMIC CHOLERA. 

condition of the functional powers of the cerebroganglionic system. The abstraction of blood, therefore, from the venous system is clearly indicated, but it is in vain to attempt general bloodletting, because the blood is stagnant and cannot flow- and cupping-glasses have been applied repeatedly to deep incisions made over the epigastrium, but only a few drachms of blood could be obtained. 

Those indications, therefore, will be best attained by the prudent, simultaneous, and energetic use and application of the medicinal agents following : — a steam or hot bath, the patient to be rolled in warmed blankets, calomel and opium in full doses at first, and afterwards in frequentlyrepeated small doses, frictions, with hot OL Terebinth., of all parts of the body, and to be frequently repeated, enemata, small in quantity, chiefly composed of 01. Terebinth., a solution in Spt. Yin. Rect. of creosote and acetic acid, assafcetida in full doses, combined with small doses of calomel and opium, counter-irritation along the spine, and to the epigastrium; should the sero-albuminous liquid discharges from the bowels still continue, notwithstanding the repeated simultaneous use, for ten or twelve hours, of the calomel and opium, the creosote solution and the 



86 

treatment of 

terebin thine enemata, a mixture of decoction of matico tannin and tincture of opium, or one consisting of nitric acid, laudanum, and camphor mixture. So soon as bile appears in the evacuations, alkaline aperients. 

When the reaction of convalescence is established, all that may be required to restore the patient to health, in this form of cholera, is attention to diet and regimen, which ought to be light, nutritious, and generous. 

When a patient is brought into the hospital he should immediately be placed in the steam bath for five or ten minutes, or, where this cannot be obtained, he may be rolled in warmed blankets ; and ten grains of calomel and two of extract of opium should be instantly given. If this dose be rejected by the stomach, it will be proper to forthwith repeat it. 

It is necessary to remark that, even where the surface of the body is deadly cold, caution is required that the patient be not left in the bath for too long a time, because it would add considerably to the sufferings, by increasing the restlessness and jactation ; and possibly by forcing an augmented action of the exhalants would tend to destroy still further the balance, or lessen the quantity of liquid blood in circulation, thereby 



87 

EPIDEMIC CHOLERA. 

adding to its incrassated disposition, and thus hasten the approaching stage of congestion, or collapse. 

At this period of the treatment, leeches have been applied to the anus, with, apparently, some good results ; but the difficulty of getting them to take, renders their application almost impracticable ; and, indeed, it is nearly impossible, for many reasons, to estimate the effect of bleeding in any manner in this type of the disease, particularly from the circumstance that it is frequently only practicable in those mild cases, in which a favorable result is most common. 

In following up our treatment in this type of the malady, the indications to be accomplished are, first, to re- excite, not stimulate, the cerebroganglionic nervous system; second, to arouse the assimilative and the eliminatory functions; and third, to sustain the vital powers until nature makes a rally. 

When the patient is removed from the bath into a warmed bed, the scalp, spine, thorax, abdomen, and extremities should be well rubbed with 01. Terebinth, made hot. Artificial heat may be employed, by the appliances previously suggested, although, indeed, patients very generally will not endure much external heat, and probably 



88 

TREATMENT OF 

it is seldom of any efficacy. The hot turpentine frictions ought to be frequently repeated, particularly if spasms be severe, and where the vital powers seem failing. The terebinthine enemata should also, thus early, be administered, this being small in quantity is commonly retained, but should it be too soon passed off it must be forthwith repeated, with or without the addition of twenty minims of tincture of opium. We have almost invariably observed this internal and external use of 01. Terebinth, produce the most salutary and soothing effects, even where, from the violence of vomiting, an opiate did not assist. 

01. Terebinth., by its permeant qualities, readily affects the organic structures, and is quickly eliminate — thus, by its twofold action, it powerfully tends to arouse without stimulating the nervous centres ; and applied as enemata, it is frequently most effectual in restoring the healthy functions of the intestinal canal in cholera, diarrhoea, and dysentery. Terebinthine preparations are, therefore, of primary importance in the treatment of this epidemic, and we confidently commend them. 

The stomach has discharged its contents, and the patient seems exhausted, with, perhaps, increased serous vomiting at this particular period. 



89 

EPIDEMIC CHOLERA. 

If we now consider the condition of the mucous membrane of the stomach, the vessels gorged with blood, the propriety of having recourse to stimulants becomes very problematical. A vast quantity of serous fluid is pouring out and rejected by vomiting, thereby increasing the as yet but partial congestion by depriving the blood of its fluidity, and the patient complains incessantly of burning heat in the epigastrium, and of an ininsatiable thirst; it is therefore of the greatest consequence to arrest the vomiting, without stimulating the exceedingly-irritated mucous membrane. To effect this desirable object many remedies are tried, saline mixture in a state of effervescence w T ith lemon juice, infusion of columbo with preparations of opium, counter-irritation on the epigastrium; but we have seen the most constant, decided, and marked benefit derived from the use of the following formula : — 

R Creosotse ; 

Acid. Acet. 3 la sij ; Spiritus Yin. Eect., Jss. M. ft. Solution. 

Of this solution, from eight to twenty drops may be given in an ounce of any aromatic water, or of camphor mixture, every two hours, or after each time the patient vomits. 

Every one must be aware of the difficulty 



90 

TREATMENT OF 

sometimes experienced in allaying the violence of the sudden vomiting without nausea, of cholera patients, which so rapidly prostrates the strength. This solution of creosote and acetic acid, as we have observed above, admirably fulfils this indication, it excites no nausea, nor any other unpleasant symptom. Its action seems to be moderately excitant, antispasmodic, sedative, and perhaps styptic, allaying the burning sensation at the epigastrium, imparting an agreeable feeling of warmth in the stomach and bowels of the patient, and restringing the mucous surfaces, thus checking simultaneously both the vomiting and purging. That it acts directly as an astringent we are not prepared to affirm, but that it operates with efficacy in arresting the seroalbuminous discharges, poured out upon the mucous surfaces of the alimentary canal, we do not entertain the remotest doubt. We have, in short, repeatedly successfully treated cases of this type or stage of the epidemic with the creosote and acid solution, after one full dose of calomel and opium; but more frequently we have employed the terebinthine appliances conjointly. 

The strength should be supported with warm diluent drinks, the little remaining should not be exhausted by temporary excitation. Chickenbroth, 



EPIDEMIC CHOLERA. 

91 

green tea, &c, are admissible, milk and water warmed and sweetened we found an agreeable diluent. Many patients call incessantly for cold water, this we observed to constantly occur in those who had taken stimulants ; these invariably increased the sense of burning heat in the stomach, as well as the thirst and vomiting ; no harm ever appeared to ensue from moderately indulging them with cold water ; but care should be taken not to over-distend the stomach, lest it might cause our medicine to be rejected by vomiting. 

If, within an hour, or two at most, after submission to treatment in the manner advised, the symptoms are not greatly relieved, particularly if the spasms have been severe, the epigastrium and along the spine may be well rubbed with a stimulating embrocation, composed of equal parts of compound Camphor liniment and 01. Terebinth.; one part of Acid. Acet. Fort., and two parts of 01. Terebinth.; one part of Aq. Ammon. Fort, and two of 01. Terebinth.; or croton oil liniment ; and the following pills should be forthwith commenced, to be taken in conjunction with the creosote and acid solution, &c. : — 

R Pulv. Assafcetidse, gr. viij ; 

Ext. Opii, gr. ss; 

Chlor. Hydrarg., gr. ij. M. ft. Pil. ij. 



92 

TREATMENT OF 

This dose, of two pills, ought to be given every hour, or every two hours until decided relief be obtained. 

In some instances where the spasms have been so violent as quickly to induce the approach of the stage of collapse, we have employed this formula with very considerable success ; and often in a very short space of time this remedy seemed to completely remove all the urgent symptoms, and transfer, as it were, the patient from a state of torture to one of calmness and ease. 

Cases will rarely occur where the stomach rejects everything, and in such we have found the addition of one drachm of tincture of opium to the terebinthine enemata of the greatest value, by placing the patient in a condition for receiving our remedies. 

Should diarrhoea have preceded the attack, a few grains of tannin may be advantageously added to the calomel and opium, in the first full dose ; and if it still be persistent after the vomiting, and the other choleric symptoms have ceased or abated, either of the mixtures following may be usefully employed ; 

R Decoct. Matico, 33 y iij j Pulv. Tanninse, gr. xij ; 

Tinct. Opii, SJ. M. ft. Mistura. 



93 

EPIDEMIC CHOLERA. 

Vel.— R Acid. Nitrici Dil., 3ij ; Misturse Camphorse, 3viij ; 

Tinct. Opii, 3j. M. ft. Mistura. 

One ounce of either of these mixtures may be taken every third hour. 

The acid mixture seems rather to give tone to the mucous membrane of the alimentary canal, and thus restores its healthy functions, whilst the matico mixture acts as a direct astringent. When convalescence is about to be established, the tonic and antiseptic properties of nitric acid appear to correct the disengagement of flatus from the depraved state of the secretions in the intestinal tube, preventing its evolution by arresting the fermentative process, which sometimes at this period of the disease becomes troublesome by causing distension of the abdomen, nausea, and griping pains in the bowels. In these cases the sedative and antispasmodic actions of the camphor and opium with the nitric acid, as in the above formula, produce invariably the greatest improvement. 

If convalescence should not advance satisfactoril — reaction losing its vigour — the turpentine frictions and enemata must be repeated, and ten or fifteen grains of calomel with or without two or three grains of opium ought to be forthwith 



94 

TREATMENT OF 

given, and the small doses of calomel and opium with the creosote and acetic acid solution may be recommenced, and continued until the vital energies again manifest. In some instances of the advanced period of this type of the malady, where the reaction would seem to be imperfectly established, we have known the quantity of calomel to have been increased to scruple doses, and the quantity of opium to have been increased to eight or ten grains in each dose, with the most effective results. 

Although we may have been so fortunate as to procure a remission of the symptoms very early by our treatment, still as some of them, particularly the internal spasmodic actions, have a great tendency in this disease to recur after the operation of our remedies is over, it will therefore be advisable to continue their use in such a manner as to maintain a constant therapeutic effect, for a few days. 

When the remedies and appliances recorded in the preceding pages were employed early and conjointly, the successful treatment in the Clonmel Cholera Hospital in 1849 was almost in every instance nearly certain. Sleep was induced, and the patient awoke free from the most depressing and painful symptoms, or was greatly relieved. 



95 

EPIDEMIC CHOLERA. 

The natural heat is eliminated, the vital functions are aroused, the pulse becomes distinct, full, and regular, and when bile appears in the alvine evacuations it is a sure sign that amendment has taken place. Convalescence is generally sustained by mild aperients, and the ordinary attention to diet and regimen. 

Cholera with Collapse. — We entertain a hope that the views of the pathology and etiology of epidemic cholera, which we have ventured to briefly announce in these pages, will not be without some advantage, at least in elucidating our plan of treatment • and we shall best convey our views by continuing the detail of our general formula under the present heading. 

In the collapsed form of cholera the treatment above sketched is equally applicable. The abstraction of blood, however, is here totally inadmissible, even if practicable, because the quantity of fluid blood in circulation is scarcely sufficient to sustain life, and is momentarily narrowing its sphere of action. The extensive application of external stimulants is beneficial, in conjunction with our other remedies, particularly along the spine, and to the epigastrium, and may consist of the embrocations previously suggested, with mustard cataplasms and blisters. 



96 

TREATMENT OF 

A combination of calomel and opium in the proportion of ten grains to two,, fifteen to three, or even twenty grains of calomel to four of opium should be administered as early as possible, and repeated according to the urgency of the symptoms, and the frequency of its rejection by vomiting. If there be not an appearance of improved vitality within a few hours, after having employed the bath, the hot terebinthine frictions, the terebinthine enemata, the stimulating embrocations, the creosote solution, and the first dose of calomel and opium, it will be advisable to repeat the same dose of calomel with a grain of extract of opium every two hours until three doses are taken. The hot frictions should also be continued, and if necessary the terebinthine enemata, and the hot bath. Should there however be an early remission in the severity of the symptoms after the first dose — the pulse at the wrist becoming perceptible, and the heat of the body returning, or the tongue becoming warmer than it had previously been, the following formula will be more suitable : 

R Chlor. Hydrarg., 

Pulv. Assafoeticlse, aa gr. v ; Ext. Opii, gr. ss. M. ft. Pil. ij. 

These two pills should be taken and repeated every two hours, until reaction manifests: Conjointly 



97 

EPIDEMIC CHOLERA. 

with these, the creosote solution, enemata, and stimulating frictions may all be employed, and the hot bath, if deemed necessary. 

In combining opium with calomel, some caution is required. The therapeutic action of a small portion, as a grain, a grain and a half, or two grains of opium in cholera, is that of a moderate stimulus, and seems to arouse or increase the sensorial power whilst it promotes the general action of the calomel; whereas large doses of opium may be injurious, they may increase the tendency to congestion and consequently aggravate the state of collapse by the depressing effects which succeed their narcotic action. The same caution is also required in administering cordials. Concentrated stimulants do much mischief — they are almost sure to accelerate the fatal termination, if perseveringly given in cases of collapsed cholera. 

It should however be in the recollection, that the actions of all our remedies, in the treatment of patients affected with this epidemic, appear to be influenced by the torpor of the general nervous system; and hence we find that the ordinary doses of medicine do not produce the same effects, nor act as quickly in this as they usually do in most other maladies. 7 



98 

TREATMENT OF 

The concurrent testimony of almost all who have treated epidemic cholera in various countries seems to acknowledge that calomel is a therapeutic agent of considerable efficacy, and one upon which much dependence may be placed in the treatment. Perhaps, as compared with any one article of the materia medica, that testimony may not be altogether incorrect; but the plan of giving calomel in scruple doses, frequently repeated, had been extensively tried in this country in 1832, and its results have proved that the encomiums at one time so liberally bestowed upon it were not justified. 

Calomel, by increasing the actions of the general secretory and absorbent systems, — opium, by exciting without stimulating the cerebronervous system, — (that opium "increases the secretion of sensorial power" would appear by the violent exertions persons intoxicated from the abuse of this drug are enabled to make) — and assafoetida, by its antispasmodic properties restoring to their normal state the inverted irritative motions,' constitute, perhaps, the most effective of our remedies in the management of this disease. Calomel, opium, and assafoetida seem each to promote the therapeutic action of the other ; and from the use of the formula above given, we have 



99 

EPIDEMIC CHOLERA. 

often seen the greatest benefit derived; indeed, we have repeatedly observed this medicine to prove most efficacious. 

When the constitutional effects of mercury were produced on a patient subjected to the mode of treatment detailed, we had remarked that rapid convalescence usually followed. 

Should diarrhoea precede the attack, and if the serous fluid be passing in quantity from the bowels of the patient, notwithstanding the employment of the terebinthine enemata,—the creosote solution, the full dose of calomel and opium, and the counter-irritations,— the enemata ought to be repeated, with the addition to it of one drachm of tincture of opium ; and the following powders substituted for the pills of calomel, opium, and assafoetida, if cramps he absent i — 

R Chlor. Hydrarg., gr. ij ; 

Ext. Opii, gr. | ; 

Pulv. Tanninse, gr. iij ; — Aromat., gr. iv. M. ft. Pulvis. 

Habeat tales quatuor — sumatur una, secunda quaque hora. 

With each powder may be taken six or eight drops of the creosote solution in an ounce of spearmint water, cinnamon water, or any of the aromatic waters. 

These powders we esteem to be preferable for many reasons to acetate of lead, which, however, 



100 

TREATMENT OF 

when administered in large doses, in combination with opium and acetic acid, is sometimes of use in the cases just indicated. "We have tried acetate of lead in scruple doses, dissolved in distilled vinegar as enemata, with some advantage in these cases ; but prefer the terebinthine preparations, for the reasons assigned when treating of the modus operandi of 01. Terebinth. 

At this period of the collapsed stage the several preparations of aether, aromatic spirits of ammonia, brandy and lime water in equal parts, have been recommended as beneficial. When cautiously employed, and given with a view rather to sustain than to stimulate the vital powers, these may not, in small doses, be injurious. With the same prudential restrictions and to effect the same object, wine, and other excitants of the same class, in sago, gruel, arrow-root, and the like, may be given with advantage. In the use, however, of even this latter class of stimulants, too great caution cannot be adopted that we do not exhaust, by temporary excitation, the little strength remaining, and thus accelerate the fatal termination. 

After the first danger has subsided, and the vomiting and purging subdued, our attention should be directed to support the strength by 



EPIDEMIC CHOLERA. 

101 

proper means ; and next to induce the secretory organs to perform their healthy functions. 

The absence of the urinary secretion ought first now to demand our solicitude. 

That a morbid condition of the blood tends to produce renal disease cannot be denied, as the same cause may produce any other organic malady; and as the choleraic influence by its depressing agency lowers the vital energy — or obstructs the normal modification of the " cosmic force" — and thereby diminishes the power of resisting chemical influences within the body, the circulating fluids do not maintain their healthy composition — the blood is incrassated, its saline and aqueous elements are removed, and urea is found in the bile, the brain, and the blood. 

The chemical character and composition of the secretion from the kidneys have engaged the attention of Drs. B. Jones, Prout, Garrod, Liebig, Christison, Golding Bird, and others, and from their researches the doctrine now generally received, with reference to the physiological action of these organs, is that they separate, not form, the constituents of the urine. 

In cholera we remark that the kidneys do not perform their function, and urea, which they in a state of health eliminate, remains to, as it were, 



102 

TREATMENT OF 

poison the general circulation. Hence we may observe in those cases a peculiar disinclination to exertion of any kind, bodily or mental, with other symptoms, such as vomiting with nausea, and hiccough. When the suppression of urine from deficient secretion is complete, " coma almost invariably becomes established before the end of the fifth day; a complete suppression of urine, therefore, is obviously incompatible with life." (Dr. Prout.) The great importance of attending to the secretion from the kidneys in all diseases, and particularly in cholera, is therefore quite manifest. 

In a preceding page the anatomical characters or the autopsy of the kidneys are fully recorded. As there is no appreciable lesion of their organic structure in this disease — no mechanical obstructio — no traces of inflammatory action apparent — it follows that these organs suffer the same irritative motions as the hepatic duct, the intestinal tube, and the general muscular fibre evince — the reflex function of the cerebro-ganglionic nervous system being disturbed — spasm therefore performs a most important part in causing the suppression of urine in cholera with collapse. But as at this period of the treatment the spasmodic general symptoms are more or less subdued, it now becomes necessary to render the incrassated, 



103 

EPIDEMIC CHOLERA. 

if not coagulated, blood suitable for the secretory action of the kidneys. 

The cholera-poison, according to Dr. Johnson, excites in the kidneys the same tendency to diseased actions as that usually excited in these organs by the materies morbi of scarlet fever. Renal disease, however, seldom if ever presents during the convalescence from cholera — the period when it more frequently occurs in scarlet fever ; the former, therefore, must greatly differ from the latter. It has been suggested that this difference consists in the fact, that the cholera-poison is quickly eliminated, the other not being so. But this would constitute a peculiar characteristic; and as the existence of this specific cholera-poison is the merest hypothesis, we are inclined to the opinion that the materies morbi of cholera, if we be allowed the expression, is the result of malassimilation. Hence the treatment must be governed by the pathological conditions, and not deduced from any notions of analogical reasoning however well founded. 

The excess of urea in the blood accumulates owing to the suppression of urinary secretion — the suppression of secretion, first caused by spasmodic action, is now protracted by the coagulated state of the blood, a result of the deficiency of its more 



104 

TREATMENT OF 

liquid parts. To combat these circumstances our best-directed efforts ought now to be called into requisition. 

As above-mentioned, when reaction, however slight, takes place, or the stomach ceases to reject liquids, and when the first danger has subsided, we should forthwith avail ourselves of this to repair, if possible,, the loss the blood has sustained, and to procure the secretion from the kidneys. These may be accomplished by giving diluents frequently, and in such quantity as the stomach will retain. Milk and water sweetened may be employed, as it appears to be tolerated by the stomach, and its assimilation is less difficult, involving as it does the albuminous rather than the gelatinous principle. Soda water is also useful, as containing some of the saline ingredients which have been removed in the serum that constitutes so large a share in the liquid discharges ; and at this period of the disease Dr. Stevens's formula, composed of half-a-drachm of sesqui-carbonate of soda, a scruple of muriate of soda, and seven grains of chlorate of potash, dissolved in four ounces of water — this draught to be taken every hour or oftener, according to circumstances — seems to promise advantages. We have seen this saline plan of treatment of cholera entirely relied upon, 



105 

EPIDEMIC CHOLERA. 

certainly not with the good results its early advocates promised, and we think it a remedy perfectly inefficacious for the cure of any form of this malady ; but as an adjunct we may, with the view above mentioned, employ Dr. Stevens's prescription. We prefer the following formula, and had observed patients to derive the most decided benefit from its use, at this stage of treatment : 

R Sesqtri-carbon. Sodse, 3iij Magnesige, Jss; 

Aq. Menth. vir., Jviij ; Spiritus JSther. Nit., 3vj. M. ft. Mistura. 

Of this mixture one ounce may be taken every hour or every second hour until it operates. We had also occasionally omitted the magnesia in this mixture, and substituted iodide of potassium with very considerable success.- When diarrhoea has preceded the attack, the magnesia ought not to be so early administered, and the iodide of potassium we would strongly recommend. The experiments of Dumas and Bonnet have shown the action of iodides on the blood and fibrine. When an alkaline iodide is taken into the blood, its solvent action is made apparent. "If the fibrinous elements are in their normal fluid state, it may only render them less disposed to coagulate; while if they are coagulated it dissolves 



106 

TREATMENT OF 

them." (Vide British and Foreign Medico-Chirurgical Review, October, 1852.) 

When the reaction is manifesting, and the dejections are assuming a bilious character, the irritability of the stomach diminishing, and the secretory functions are being restored, mild aperients are admissible, but drastic purgatives are to be strictly avoided. 

Where the discharges produced from the bowels are strongly fetid and of a dark-green colour, accompanied with colicky pains and flatulence, we have found the succeeding formula to afford very considerable relief, to alter the acrid nature of the excretions, and to seem frequently to control excessive reaction : 

R Acid. Nitric. Dil., sj ; Misturse Camphorse, Jviij ; Tinct. Opii, 3j ; 

Syrupi Aurant.> 3j- M. ft. Mistura. 

One ounce of this mixture may be taken every two or three hours. The solution of creosote is also of great advantage under similar circumstances, and may be substituted for the nitric acid in the above mixture. If the pain be severe, opium and camphor is a good combination with the creosote, otherwise it is not necessary to 



107 

EPIDEMIC CHOLERA. 

associate them. The action of the creosote solution effectually relieves pain of ordinary intensity, when produced by the distension of flatus disengaged from the depraved state of the secretions of the intestinal tube — by its antiseptic properties correcting the fermentative process, and thus preventing the further evolution of gaseous materials. 

When reaction is established the period of convalescence may be said to begin. Still, the period of convalescence is one of some complexity, and requires our unceasing vigilance. Either reaction becomes violent, and whatever morbid tendency may have previously existed in the constitution of the patient is now called into activity — or the tongue for many days retains a foul coating, the mucous membrane scarcely recovers an absorbent power, the nervous system seems oppressed, and there is an obvious tendency to relapse. The pathological condition of the visceral organs, and the great distension of one set of vessels which usually occurs in " cholera with collapse," naturally tend to disorganisation of the more delicate tissues ; and hence it will be seen that a persevering vigilance is indispensable to the perfection of recovery. 

It would be superfluous to enumerate the 



108 

TREATMENT OF 

means which have proved wholly inoperative in this malady ; nor do we propose to detail the palliatives which are usually employed to alleviate the intensity of suffering, and to smooth the avenues to eternity. There can be no specific for this, no more than for any other disease. 

In no affection to which man is heir, is empiricism more pernicious ; and the physician who announces an infallible cure, either acts dishonestly, or is incapable of comprehending the true principles of pathological science. In this formidable epidemic a very few hours, indeed, perhaps, a few minutes, frequently decide the fate of the unhappy patient, and if that short interval be lost in testing expedients his doom is irrevocably sealed. Nothing therefore will justify experimental practice unless a hopeless case. 

The douche bath is one of those expedients, and as a curative agent in cholera, it cannot be too strongly reprobated. We had had some sad experience of this remedy forced upon us, and although slight reaction appeared upon the skin, it was only transitory, and seemed to be entirely produced by the general frictions applied after its use. We know of no case in which it proved useful; and we have reason to believe that it ought not to be relied upon. 



109 

EPIDEMIC CHOLERA. 

Through the whole course of treatment, to induce a healthy reaction our most successful efforts will be those having for their objects to arouse, and not to stimulate, the cerebro-ganglionic nervous system — because the deficient supply of nervous force causes irritative motions, and accounts for the general collapse or state of congestion. 

The result of the very interesting cases treated in Edinburgh by Dr. Mackintosh in 1832, tends to confirm these views ; and proves that the loss of the serous and saline constituents of the blood does not constitute the disease. 

Dr. Mackintosh tried extensively a modified plan of Dr. Stevens's treatment of cholera with salines — this modified plan Dr. O'Shaughnessey, we believe, first suggested. It consists in injecting slowly into the veins ten pints of a solution of chloride of sodium and sesqui-carbonate of soda, gss of the former and 9iv of the latter, to ten pints of water, at a temperature varying from 106° to 120° Fah. "After the injection of a few ounces, the pulse, which had ceased at the wrist, becomes perceptible, the heat of the body returns. By the time three or four pints have been injected, the pulse has become good ; cramps have ceased ; the body that could 



110 

TREATMENT OF 

not be heated has become warm, and instead of a cold exudation on the surface there is a general moisture; the voice, before hoarse and almost extinct, is now natural; the hollowness of the eyes, the shrunken state of the features, the leaden hue of the face and of the body have disappeared, and the expression has become animated; the mind cheerful; restlessness and uneasy feelings have vanished. Vertigo, noise in the ears, and sense of oppression at the prsecordia, have given way to comfortable feelings; thirst, however urgent before the operation, has ceased. The secretion of urine was soon restored ; but in this," says Dr. Mackintosh, "we were more frequently disappointed than in any of the other favorable symptoms . ' ' These very encouraging appearances were however merely transient ; the evacuations continued, and became even more profuse; the patients very soon again sank into their former state, from which, by a repetition of the injection of the veins, the patients may a second time be aroused, but the improvement was only temporary, and the fatal terminations were not even long deferred. Of 156 cases thus treated, only 25 recovered — about 2 in 13. 

Upon the striking and instructive phenomena thus produced, we may remark that, although it 



111 

EPIDEMIC CHOLERA, 

seems that the congestion of the vessels and its effects can be removed by the means adopted, yet as these are the consequence not the cause of the morbid condition which constitutes the disease, the symptoms reappear so soon as the artificial circulation ceases to be sustained, because the cause — the abnormal functional state of the nervous centres — still remains. 

There are many medicines which, when injected into the veins, have the same therapeutical action as when taken into the stomach ; and from the unfavorable condition for absorption, of the alimentary canal in epidemic cholera, this mode of administering our remedies has been recommended by medical practitioners of high attainments. It therefore deserves a passing notice from us. This mode of treatment, doubtless, is one which might win converts, were it not that unfortunately the occasional production of fatal phlebitis is an objection which, in most cases, is almost insurmountable against the employment of venous injection. Hence, at least until a more favorable issue results than has been hitherto obtained, experiments of this kind should not be tried unless in cases considered extreme ; and in suggesting which, we are not, of course, to be limited to the articles indicated of the materia 



112 

TREATMENT OF 

medica. We would further remark, that in submitting to the test of experience any doubtful or heroic method of treatment, which is admitted to be within the recognised principles of medical science, the profession always observes the rule — and which in justice to Dr. Mackintosh we must say he did not forget — to try experiments only in extreme and almost hopeless cases. 

The Sequelae of Cholera. — Whenever complete convalescence is retarded after full reaction is established, the sequelse of cholera usually present themselves in a subdued or subacute form. These are meningitis, cerebritis, pneumonia, hepatitis, icterus, gastro-enteritis, and occasionally symptoms resembling hysteria. 

To successfully combat the consecutive stage of " cholera with collapse," all our caution, experience, and pathological knowledge are required. In the management of the cerebral affections, our remedies are few and simple ; but everything depends upon their judicious application. Here we have to treat a case in which a vast quantity of serum has been lost, leaving the remaining blood in an incrassated state ; and in which a weak cerebral circulation, obstructed by the congestion, is present. 

The indications obviously are — to alter the 



EPIDEMIC CHOLERA. 

113 

incrassated state of the blood, and supply its loss of serum, — thereby enabling it to come into free circulation : second, to control undue action, without depressing the previously weakened vital energies. 

These we may best fulfil by giving liquids, in small quantities, frequently repeated, together with alkalies — milk and water sweetened, tea as ordinarily used, milk and lime water, soda water, fresh spring water, chicken broth; solutions of sesqui-carbonate of soda, bi-carbonate of potash, or iodide of potassium in any convenient vehicle. Should the patient's strength allow it, topical bleeding is frequently of great benefit, as is also blistering the back of the head and neck. When blistering is employed it is probably more likely to be usefully applied in these situations than on the upper part of the head, whilst it does not interfere with a more powerful remedy, the application of cold. 

It should be borne in mind, that cathartics, if administered early in any of the sequelse of cholera, appear to increase the vitiated secretions, and to add considerably to the irritability of the digestive organs. When, however, the activity of the morbid actions has been abated, and the stomach has ceased to evince increased sensibility, aperients 8 



114 

TREATMENT OF 

are used with manifest advantage, but more particularly cathartics in head affections. After the first violence of the cerebral symptoms has been subdued, blisters applied in succession to various parts of the scalp and the upper part of the spine appear to be in many cases extremely beneficial. Although the patient may in the course of the previous treatment have taken a quantity of calomel, nevertheless, when a cathartic is admissible, about the fourth or fifth day of reaction, the succeeding formulae may be employed : — 

R Chlor. Hydr,, gr. viij 

Carb. Calcis, gr. x ; 

Pulv. Aromat.j gr. iij. M. ft. Pulvis, Statim sumendus — 

R Magnesise, 9j ; 

Sulph. 3vj 

Aq. Cinnamomi, 3i ss j Tinct. Sennee Comp., 3iij- M. ft. haustus. 

The draught should be taken three or four hours after having taken the powder. This medicine usually produces a strong cathartic effect, and it is seldom necessary to repeat it. The carbonate of lime, by neutralising the acidity in the prima via, prevents the calomel from being decomposed, and thus irritating the mucous membrane, whilst the draught ensures a purgative effect. 



115 

EPIDEMIC CHOLERA. 

Mercury, to the extent of producing its therapeutic effects upon the constitution, has been strongly recommended, but in many cases the indiscriminate employment of mercury must be injurious ; and we confess, the result of our own observation is that when mercury is useful in head affections, it is chiefly as a purgative, at the same time correcting the biliary secretion and the functions of the digestive organs, which, according to certain modern doctrines, hold so prominent a place in almost every class of diseases. (Dr. Abercrombie.) In the adaptation of the particular remedies to individual cases, we must of course be guided by the age, sex, and habits of the patient, and be particularly regulated by the character of the collapse and the activity of the reaction. 

Pneumonia is a frequent sequel of cholera, generally existing in a latent form, and it is perhaps most difficult to manage. In consequence of the latent nature of this species of pneumonia, it is indeed indispensable that auscultation, as the only true test of its presence, should be used to ascertain the condition of the lungs in every case of reaction ; and when it is ascertained that this complication exists, the most active means to arrest its progress must be forthwith employed. Experience has proved that in these cases bleeding 



116 

TREATMENT OF 

from the arm may not only be had recourse to with perfect safety, but often with very considerable benefit. If, however, the remaining strength will not bear general bleeding, leeches applied to the thorax and cupping may with advantage be substituted ; keeping in mind at the same time that the powers of life are yet weak, and that the reviving state of the patient will not afford to lose much by depletion. The abstraction of blood ought to be regulated very much by the stethoscopic signs, by which frequently both blood and strength will be saved to the patient. On the early and frequent but cautious abstraction of blood, much however will depend. Counter-irritation should be assiduously attended to ; — tincture of iodine, brushed on the thorax over the parts affected every fourth hour until it blisters or excites irritation on the skin, is a very useful application. It acts as a counter-irritant on the surface, while its general physiological action is also obtained. lodine being one of those articles of the materia medica which is readily taken up by the system and quickly eliminated, its twofold action of absorption and elimination, added to its counter-irritant properties when externally applied, make it a remedy of great promise in this affection ; and according to our observation 



EPIDEMIC CHOLERA. 

117 

when thus applied it seems to be a valuable adjunct to the other means of procedure. Warmth to the extremities constantly require to be attended to, and if necessary, frictions with hot terebinth, may be used. 

Although counter-irritation should be effectually sustained, it will be necessary to guard against ulceration or mortification, which, under certain morbid conditions of the constitution of the patient, occasionally occurs in this complication — as, for instance, should anesthesia be present. Now, during the existence of this insensibility of the skin, the absorbent power may be retained ; for while tartar, antim. ointment or blisters, under these circumstances, will not raise the skin or produce a pustular eruption, the stomach by the former, or the urinary organs by the latter, may be still influenced. As soon, however, as the pathological condition which caused this state of things is removed, and the vital energies are restored, the skin recovers its normal sensibility ; but the parts of the tissues impregnated by the tolerated irritants do not participate in the returning vitality, life having been extinguished by the imbibed substance, and thus may mortification or ulceration of those portions of the periphery be induced. Hence we 



118 

TREATMENT OF 

should always limit the duration of the application of blisters and irritants, more especially "the duration of the application without determining irritation." (M. Duparcque.) 

Sesqui-carbonate of soda, bi-carbonate of potash, and iodide of potassium with ipecacuanha, in equal parts of infusion of digitalis and cinnamon water, is generally useful. If the secretion of urine be not increased thereby, a small quantity of spirit, aether, nitros. may be added. Tart, antim., usually so effective in idiopathic, is totally inadmissible as an internal remedy in this form of pneumonia. In those cases where the pulse increases in frequency after bleeding, we have employed with much benefit the succeeding formula : 

R Acid. Hydrocyanici, n\xij ; Tinct. Digitalis, 3ij ; Mucil. Gum. Aca., 3iij; Syrupi Simplicis, 

Aq. Menth. vir., 3ij. M. ft. Mistura. 

One fluid ounce of this mixture may be taken every third or fourth hour until the pulse becomes affected. In the decline of this sequel of cholera we have seen the best results from small doses of calomel and opium. Of course it is necessary that the secretions be attended to, particularly that of the kidneys ; and also that the biliary secretions 



119 

EPIDEMIC CHOLERA. 

be rendered healthy, by mild mercurial aperients. Arrow-root, sago, gruel, with a small quantity of wine, milk and water sweetened, tea, chicken broth, and the like, may be allowed. 

Any treatment more specific in this form of (the choleraic) pneumonia is not practicable. We have tried tart, antim. in enemata, but cannot recommend it ; although it certainly seemed to produce large feculent evacuations, and may, perhaps, with that object be sometimes useful. However, the prostration caused by tart, antim., when taken internally, is a grave objection to its use in this disease. 

Hepatitis. — In allaying the inordinate activity of the liver and excessive secretion of bile, some judgment in taking measures to check the bilious vomiting will be required. Here the bilious discharges tend to relieve the venous congestion of the portal system, and would seem to be the result of a natural effort to remove the excessive secretion of vitiated bile ; the vomiting therefore is of secondary importance in the treatment. Should the patient's strength permit, leeches may be applied to the hepatic region, and the abstraction of blood promoted by the application of cupping-glasses over the leech-bites. This is one of the most certain means of checking excessive 



120 

TREATMENT OF 

action. If, however, the abstraction of blood be deemed improper, counter-irritation may be used, and must be persevered in. The external application of tincture of iodine to the region of the liver as a counter-irritant is frequently of decided advantage, more particularly where it has been preceded by the local abstraction of blood. The vomiting may in the first instance be promoted by giving large draughts of warm water, and a bland emollient enema will be of much use. When the irritability of the stomach is subsiding, the vomiting having run a certain course and is assuming the appearance of being exhausted, manifest advantage is sometimes derived from the following : 

R Acid. Hydrocyanici, TUxij ; Solut. Acet. Morphias, 3j ; Mucil. Gum. Acac, Jiij ; Syrupi Siraplicis, Jj ; 

Aq. Cinnamomi, 3ij- M. ft. Mistura. 

Of this mixture one fluid ounce may be taken every second or third hour. 

When the irritability of the stomach is subdued, soda water, the alkaline mixtures, lime water in new milk, broth, and mild diluents may be freely allowed. The administration of stimulants must in this, as in the other sequelae, entirely depend 



121 

EPIDEMIC CHOLERA. 

upon the general condition of the patient, and should at all times be employed with extreme caution. The excretions from the bowels and the secretion from the kidneys require the same attention in this, as in the former case ; and, if necessary, the 01. Terebinth, enema, and the frictions of the extremities with hot 01. Terebinth, may be used. 

Icterus. — This complication as a consecutive of cholera usually assimilates a head affection. There is stupor with occasional vomiting ; the ejected matters on exposure to the atmosphere generally undergo various changes in colour, dependent upon acidity ; the skin assumes a yellowish-brown hue, the conjunctivse a deep yellow ; the pulse is quick, skin hot ; thirst ; and the secretions are scanty. The abstraction of blood is here frequently of the greatest benefit ; if the strength will not permit general bleeding, the local abstraction of blood from the hepatic region is urgently required ; after which counterirritation should be persevered in for some days. Tincture of iodine applied to the region of the liver is a useful irritant in these cases. Calomel and carb. calcis, followed by an antacid saline purgative — a formula for which will be found in a preceding page — may now be given, and repeated 



122 

TREATMENT OF 

in a day or two, if required. As the bile is in these cases almost always acid, and the secretion of it faulty, the alkalies, conjoined with mercurial aperients, must be greatly relied upon and may be repeatedly employed, care being always had to the strength of the patient to regulate depletion. 

As regards the acid reaction of the bile, Dr. Budd, in his work on Diseases of the Liver, observes, " The immediate cause of this acid condition of the bile is most probably decomposition of the bile or of the mucus it contains." He further remarks, that we may expect to find the bile " acid in those cases of jaundice from suppressed secretion, in which the unexpected occurrence of fatal head symptoms, the softened state of the liver after death, and the early putrefaction of the body, evince the existence of some noxious agent which seems to be developed in the system by decomposition of the broken- up hepatic cells, or of the retained elements of the bile." The bile, therefore, may exist in an acid state and be acid when first secreted ; and as it also sometimes is vitiated by containing urea, (Dr. Roupell,) the importance of exciting eliminatory action, and of restoring the normal condition of the biliary as well as the urinary secretions in this, as in every 



EPIDEMIC CHOLEBA. 

123 

case of any of the sequelae of cholera, is quite manifest. 

Where spasm of the biliary duct would seem to cause an obstruction to the exit of the bile and its reabsorption be a consequence, assafoetida, opium, and calomel, in combination, may be employed with good effects, when followed up by the alkaline aperients, &c. The eliminatory action of iodine may be most advantageously obtained in this sequel by external application, and will not interfere with our other more active agents. M. Bonnet has recently published in the Gazette Medicate some interesting observations on the action of iodine. He shows that when iodine is applied to a blistered surface, an ulcer, or to serous membranes, it is largely absorbed and speedily excreted, and may be very soon detected in the urine and saliva. "He considers that it only operates beneficially in proportion to the amount of eliminatory action it gives rise to. *¦ * * * In the diseases in which the iodine proves useful, there is also morbid material to eliminate, and by catalytic action the economy is enabled to effect this by the eliminatory effort excited by the iodine ." {British and Foreign Medico- Chirurgical Review) M. Bonnet recommends for this mode of employment an ointment composed of iodine 



124 

TREATMENT OF 

one part, iodide of potassium two parts, and lard thirty parts. It may in this way be excreted by the urine, according to M. Bonnet, to the extent of fifteen grains daily, without in any way acting injuriously on the general health of the patient. 

Gastro-enteritis. — The consecutive gastroenteritis is not easily managed, particularly where the patient suffered much from previous diarrhoea, because very generally in these cases the mucous membrane has been deprived of some considerable portion of its epithelium, which may be sometimes detected in the peculiar choleraic evacuations from the bowels by the aid of a microscope. (Dr. Bohn, vide Dublin Journal, No 44.) Frequently for the first two or three days the relief obtained by the best-directed treatment is indeed very temporary. In some rare cases general bleeding will greatly expedite the cure; but more usually the abstraction of blood by the application of leeches to the abdomen, and repeated if necessary, is the more prudent and safer course. We prefer the leeches applied to the anus ; a few thus applied have, without much loss of blood, proved most efficacious. Counter-irritation over the abdomen must be assiduously carried out by blisters, croton oil liniment, &c. Should the stomach be irritable, a 



EPIDEMIC CHOLERA. 

125 

draught of warm water, with ten or fifteen grains of ipecacuanha may be given, and followed up by frequently repeated draughts of warm water, in order to clear out the stomach. When this is accomplished the prussic acid mixture, (formula in a preceding page,) conjoined with the 01. Terebinth, enema, or one composed of mucilage of gum arabic four ounces, and tincture of opium forty to sixty minims, may now be employed, often with good results. 

We must not be too anxious to control the diarrhoea, except by means calculated to subdue the inflammation, because the imprudent use of astringents, by untimely suppressing the excretion, may aggravate the disease in the mucous capillaries. 

The vapour bath and terebinthine frictions are useful adjuvants in this complication. 

When the activity of the inflammation is averted, (indicated by the disappearance or diminution of mucus in the stools,) and still the disease is troublesome, astringents may be used — tannin, kino, catechu, logwood, matico, opium, cretaceous mixture, acetate of lead. These may, indeed usually do, require frequent variations in their combinations, as well as in the mode of administering them. After the violence of the 



126 

TREATMENT OF 

inflammatory action subsides, or where from the commencement it assumes a mild form, the greatest benefit is often obtained from the nitric acid mixture and tincture of opium, with or without tincture of kino — the terebinthine enemata and the counter-irritation on the abdomen being simultaneously employed. 

Where there has been reason to apprehend the presence of ulceration low down in the colon and rectum — w T hich is indicated by a feeling of pain or uneasiness referred to the part, the evacuations from the bowels being sudden and impetuous — we have used enemata, composed of from six to twelve grains of nitrate of silver dissolved in four fluid ounces of distilled water, with seemingly considerable advantage. Should the pain be aggravated by this, it will be desirable to follow 7 it immediately with an emollient or an opiate enema. 

The alkalies, calomel and carb. calcis, and the external application of iodine, are equally useful in this type of the sequelse, as in the other complications, in procuring a healthy biliary and urinary secretion, and in altering the condition of the blood and restoring it to its normal state. The remarks, under the heads of the respective forms of the consecutive disease, are fully applicable 



127 

EPIDEMIC CHOLERA. 

in this place, as regards the importance of inducing the secretory functions. 

Typhoid symptoms sometimes manifest themselves, and the strength of the patient requires to be supported. Wine, in these cases, particularly old port, is admissible ; and quina and muriated tincture of iron are recommended. Farinaceous diet with chicken broth may be allowed; and when the patient is recovering, fresh meat, broiled or roast. 

" Pills, containing one or two grains of quinine and half a grain of opium with extract of gentian, have sometimes acted beneficially, not only by imparting vigour and improving the appetite, but also as astringents, even when medicines of this class had been useless." — Thus writes Dr. Symonds, in treating of idiopathic enteritis. In the chronic diarrhoea in which this complication occasionally terminates, we have seen this medicine tried with apparent benefit, and would therefore recommend it in such cases as a useful adjuvant. 

Hysteria. — The general indications of treatment in this form of the sequelae of "cholera with collapse," are in their principles and details the same as those laid down in regard to the other complications of this disease. It is of great consequence in this form, however, to attend to 



128 

TREATMENT OF 

the catamenia and bowels, and to improve the digestive functions. During a paroxysm, plenty of cold air should be admitted to the patient, and a drachm of the aromatic spirits of ammonia, or the same quantity of ammoniated tincture of valerian, may be given in camphor mixture, or in any aromatic water. If the bowels are distended with flatus, "creosote solution" in some cinnamon water is a valuable resource, the nitric acid mixture, — calomel, assafcetida, and opium, followed with laxative medicines, which may be assisted by enemata containing 01. Terebinth, and tincture of assafoetida. Alkaline aperients and bitters, quina, and iron will be serviceable in restoring the functions of the stomach and bowels. Should the symptoms be found to depend on any irregularity of menstruation, our treatment must be modified accordingly. 

In all cases of recovery from the consequences of consecutive reaction in collapsed cholera, after the dejections have assumed a healthy bilious appearance, it will be necessary to persevere in the use of laxatives for some days. In the convalescence from cholera, in any of its types, tonics appear useless unless combined with mild aperients; and the diet must be strictly guarded and well regulated, because upon it the chief reliance must be 



129 

EPIDEMIC CHOLERA. 

placed. Abstinence from crude vegetable matter and articles prone to undergo fermentation must be enjoined, whilst farinaceous diet, broth, fresh meat, and nutritious diluents should be freelyallowed. Exercise in the open air is also useful. 

It should be remembered that, after this disease, it is almost absolutely necessary that convalescents remain for weeks subject to medical inspection ; because there are instances where those who have recovered from the collapsed form of cholera sink under its slow, occult, and lingering effects, in the shape of chronic disease. Beyond a given time, patients in hospital cannot endure the necessary discipline there established — they will not submit to longer confinement, and are impatiently desirous to return to their families. It is to be feared that the shattered condition to which the health is sometimes reduced, by the shock which the constitutional powers had suffered, cannot be repaired, because of the absence of almost every comfort which the poor must endure when they return to their homes. Hence the necessity of vigilance, and of providing for the poor ample means to contend against the circumstances to which we refer. With this object, during the epidemic of 1849, relief was afforded by the guardians of the poor in this locality to 9 



130 

TREATMENT OP 

all those recommended for such by the medical officers, and the result was satisfactory. 

There is one inference which may be legitimately drawn from these pages, and it is one which cannot be too often or too forcibly inculcated. It is that cholera is a continued series of morbid conditions, constituted of distinct phases, each well characterised by definite symptoms, and requiring, according to certain associations of circumstances, frequently opposite modes of treatment. A search after specific remedies would therefore only give evident indications of a reckless intrepidity totally incompatible with a just estimate of professional character, and of a woeful lack of a due regard to the safety of the community. It is well known to those who steadily addict themselves to the pursuit of truth in any line of thought, that disturbance and disappointment frequently arise, notwithstanding their utmost efforts to the contrary, from the incessant intermixture of erroneous ideas allied to the subject of which the mind is labouring to make itself master, and which take their rise from the principle of mental association — therefore, it is of the first importance in the investigation of cholera to exclude altogether the notion of a specific, and to steadily keep before our mind that this disease 



131 

EPIDEMIC CHOLERA. 

must be subject to the same laws of pathological inquiry as are applicable to every other malady, the. peculiar characteristics of cholera consisting in the intense severity of the symptoms, and in the rapidity with which the morbid changes occur. 

ILLUSTRATIVE CASES OE EPIDEMIC CHOLERA. 

The succeeding cases transcribed from the author's notes, taken at the bed-side of the patients, and from the records of 1849 of the Clonmel District Cholera Hospital, although few in number, present well characterised exemplifications of the stages or varieties of the disease, as classified in this treatise. 

Under the treatment which we have in these pages mentioned, we have seen many cases recover which exhibited all the usual symptoms of the most malignant forms of cholera, and even in the very advanced stages of them. The cases which thus terminate favorably hold out every encouragement to persevere in our curative efforts, even though that certain period in the progress of the disease may have passed, beyond which some practitioners are too apt to consider recovery as hopeless. The observations which we have ventured 



132 

ILLUSTRATIVE CASES OF 

to offer upon this formidable but instructive epidemic might be enhanced by such a selection, illustrating as they do the favorable termination of the malady in its various forms and malignance. 

Though pre-eminently important to the observer, records of mere details seldom are perused, and indeed afford comparatively little instruction. We have therefore and for the sake of brevity omitted much of the narration of the symptoms ; but we hope that we have sufficiently although succinctly described the diagnostic traits, the change of symptoms in the course of the treatment, and the effects of our remedial agents. 

The first two cases will show the affection arrested in the early stage ; and may be offered in elucidation of the type which we designate " Choleraic Invasion!' The third and fourth cases will illustrate the favorable termination of the disease, with the symptoms which we characterise — "Cholerine / while the others are characteristic of the more advanced period, or malignant form, of "Cholera with collapse," in which the affection is too often considered as hopeless. 

Case 1. — Henry Kean, set. 16, Mary Street, admitted into hospital 21st April, 1849, at 11 o'clock, a.m. Reports that he was taken ill the 



133 

EPIDEMIC CHOLERA. 

previous night — that he retired to bed perfectly well and awoke during the night with chilliness, tremor, and vomited — that he soon after felt pain in the upper part of his belly, and was afraid of cholera, as several in his neighbourhood had been attacked ; but he did not wish to alarm his friends, and made no complaint until 8 o'clock this morning. States that his bowels were frequently moved during the night and morning, and that he took some medicine. 

11 o'clock, a.m. — Pulse small, not easily compressible, and quick, 108 ; countenance flushed, eyes dull, languid, and rather sunken ; tongue white and warm ; heat of body and head, natural; extremities cold and blue ; complains of burning pain at the epigastrium. Has just now suddenly and without nausea discharged from the stomach whey -like matter, — is thirsty, but took no drink for some hours, as he rejected during the morning after each time that he drank, but now wishes for cold water; bowels were not freed since 1 0 o'clock. 

Venesectio ad gxij statim. R Chlorid. Hydrarg., gr. x; 

Pulv. Opii, gr. ij, M. ft. Pil. ij. Statim sumendus. Be Solutionis Creosotse, 3ss ; 

Misturse Camphoree, gvj. M. ft. Mistura. Sumantur cochlearea ij ampla q. q. hora. 



134 

ILLUSTRATIVE CASES OF 

2 o'clock, p.m. — Had two watery motions from the bowels, one immediately before and the other just after taking the pills. Vomited twice, but did not throw up the pills. Pulse more full, now easily compressible, 86. No sleep, but is calm, and inclined for sleep. 

Pergat. Mistura, 

8 o'clock, p.m. — Better ; pulse natural, pain at epigastrium much relieved, vomited but once since last report; bowels not moved since 2 o'clock, p.m. 

Pergat. Mistura sumat. 3 tia q. q. hora. 

April 22d, 8 o'clock. — Had a good night, slept — perspired much during the night; skin soft and warm, pulse 80, natural; pain at epigastrium altogether gone ; no vomiting since last report ; passed urine ; bowels freed this morning, some solid faeces passed with greenish liquid matter, — had pain in passing from the bowels. 

The creosote solution to be discontinued, and the following draught to be taken immediately : 

Be Olei Bicini 

Tinct. Eliei Comp., aa 3iij. ; Mist. Camphorse, 3j. M. ft. haustus. 



135 

EPIDEMIC CHOLERA, 

2 o'clock, p.m. — Passed dark-green faeculent matter from the bowels with, some pain, and a quantity of watery matter — also passed urine. 

R Chlorid. Hydrarg., gr. ij ; 

Carb. Calcis, gr. x. M. ft. Pulvis. Statim sumendus. 

8 o'clock, p.m. — Heat of skin natural, pulse 84, extremities warm. Bowels were moved twice, of a more healthy colour — no pain — tongue clean ; passed urine each time he had a motion from the bowels ; took some broth with a relish, sits up in bed, and says he is a great deal improved. 

To have milk and water, sweetened and warmed, as drink, at pleasure. 

April 23^, 8 o'clock, a.m. Had a good night, slept, and is convalescent. 

Case 2. — Ellen Dunlay, set, 30, nurse in fever wards of hospital. Reports that she first complained six hours since of a faintish feeling, accompanied with a cold chill through her whole person. Her bowels and stomach soon after became disturbed, and both were discharged. A violent cramp of the stomach (as she describes it) soon succeeded, and for which she applied hot flannels with relief. She lay upon a bed, and took some warm tea. 



136 

ILLUSTRATIVE CASES OF 

The pain at the epigastrium soon returned, and she rejected the tea. Prostration of strength and restlessness now supervened, and the resident medical gentleman was to see her. She was forthwith removed to the Cholera wards, and presented the following symptoms : 

Admitted Aug. sth, 1849, at 10 o'clock, p.m. Pulse at the wrist small, easily compressible, and quick, 120; body warm, extremities cold and blue ; tongue white, rather cold ; jactitation, tossing her hands outside the bedclothes and above her head, and constantly expressing, " Oh, what ails me !" Sudden vomiting without nausea, and a burning heat at the epigastrium ; shrunken features, the countenance pallid, and expressive of distress. 

To be placed in the vapour bath for ten minutes, and the following powder to be given immediately, and followed with ten drops of creosote solution in an ounce of spearmint water. 

R Chlor. Hydrarg., gr. viij ; 

Pulv. Opii, gr. ij; 

Tanninse, gr. iij. M. ft. Pulvis. 

When removed from the bath into a warmed bed, the following enema to be given ; and the creosote solution to be continued every hour, and after each time she vomits. 



137 

EPIDEMIC CHOLERA. 

R Olei Terebinth., gij. 

Olivar., 3j- 

Aq. Calid., Jiss. M. ft. Enema. 

12 o'clock, midnight. — Tongue warm, pulse more full, soft, 110; extremities warm, jactitation relieved, less alarm; vomited twice since last report, but not so distressing and violent ; pain at epigastrium better ; wishes for cold water. 

Be Pulv. Assafoetidae, gr. viij ; Ext. Opii, gr. $ ; 

Chlor. Hydrarg., gr. ij. M. ft. Pil. ij. Habeat sex tales — Sumantur duse q. q. hora. 

Ten drops of the creosote solution to be taken in an ounce of spearmint water after each dose of the pills. 

Aug. Qtk, 5 o'clock, a.m. — Better; slept for some hours — pulse 90, full and soft ; a warm perspiration is now diffused over the body ; no pain, no vomiting or purging since about 2 o'clock, when a fseculent stool was passed, as was also some urine. 

Pergat. 

10 o'clock, a.m. — Reaction, moderate; pulse as at last report, but irregular ; respiration natural, skin soft and warm; fulness of the abdomen, slight tenderness on pressure over the 



138 

ILLUSTRATIVE CASES OF 

duodenum; bowels moved twice, dark bilious matter with some pain ; passed urine. 

R Acid. Nitric. DiL, sj ; Misturse Camphorse, 3viij ; Tiuct. Opii, ial. M. ft. Mistura. 

Sumantur cochl. ij ampl. 2 da q. q. hora. 

2 o'clock, p.m. — Pulse 80, regular ; the fulness of the abdomen relieved, bowels slightly moved, and passed much flatus ; the character of the stool more natural. 

Pergat. Mistura. 

Allowed some broth, as she wishes for some. 

8 o'clock, p.m. — Pulse same as last report; the fulness and tenderness of abdomen are altogether gone ; liked her broth, sits up in bed, and says she is greatly relieved. 

Pergat. Mistura. 

Aug. Ith, 10 o'clock, a.m. — Had a good night, slept. Convalescent. 

Case 3. — James Keefe, set. 60, labourer, Sherlock's Lane. Had been, in 1832, a porter at the Cholera Hospital, Admitted Bth April, 1849, at 9 o'clock, p.m. Reports, that about 8 



139 

EPIDEMIC CHOLERA. 

o'clock, p.m., he was perfectly well, and was standing at the entrance to the lane down which he resides, talking with others of his acquaintance, when he was suddenly first attacked with violent cramps in the legs, thighs, fingers, and forearms, and soon after with vomiting. Says that he was previously in good health, and had no premonitory symptoms whatever. We visited him soon after being attacked, and he then complained of a burning pain at the epigastrium ; most violent cramps in extremities and abdomen ; and extreme jactitation — the involuntary tossing from one side to the other in the passage to the lane in which he lay was such that the people around him were not able to prevent the violence he sustained from the flinging about of his person ; and in consequence, when we first saw him he was bleeding at the mouth, and his face in parts was slightly bruised, from being knocked against the ground and walls of the passage or lane. The pulse was small, rapid, and scarcely perceptible ; surface of the body and extremities cold, hands livid, tongue warm ; vomiting suddenly, and with force. Having given him immediately twenty drops of the creosote solution and forty of tincture of opium in a little cold water, we caused him to be removed to the hospital. 



140 

ILLUSTRATIVE CASES OF 

9 o'clock, p.m. — In hospital. Pulse 140, small and weak, jactitation, and violent cramps ; has now vomited sero-albuminous fluid, countenance livid, shrunken, and contused marks on forehead and cheeks ; tongue warm and moist 

The abdomen and spine to be rubbed with hot oil of turpentine immediately j after which the patient to be rolled in warm blankets, and heat to be applied generally. The patient to take a scruple of Calomel forthwith, and two of the following pills every half-hour, with one ounce of Camphor mixture after each dose of the pills. 

R Pulv. Assafoetidsej gr. x ; Ext. Opii, gr. ss. M. ft. Pil. ij. 

12 o'clock, midnight. — Tongue warm, white, and moist ; pulse more full, 106; body warm, extremities not so cold ; jactitation has ceased, cramps less severe, and not so frequent ; vomited but once since last report j purged three times, small in quantity and liquid; passed no urine; thirst moderate. 

R Pulv. Assafostidse, 3j ; Ext. Opii Aq., gr iij ; Olei Cinnamomi, TT\iv. 

M. ft. Pil. xij. Sumatur una ut antea. 

An ounce of Camphor mixture to be taken 



141 

EPIDEMIC CHOLERA. 

every half-hour with one of the above pills. To have sweetened milk and water in small quantities, frequently repeated, if he wishes for drink. 

April 9tk, 2 o'clock, a.m. — Is now calm ; pulse 100, distinct and regular; extremities warm ; no vomiting since last report ; cramps but once, and then limited to the calves of the legs, and not severe ; apparently much relieved. 

Let him proceed with the pills and Camphor mixture. 

8 o'clock, a.m. — Cramps and vomiting have ceased ; purged twice since last visit, the last discharge from the bowels fseculent ; pulse 90, full ; extremities warm ; the body warm and moist with perspiration. The patient is now in a sound sleep, and not disturbed by our noiseless examination. 

To omit the pills, and when he awakes let him have the following draught : 

R Olei Hicini 

Tinct. Rkei Comp., aa Jss ; Mistura Camphorse, §j. M. ft. haustus 

12 o'clock, noon. — Reaction; pulse 94, soft; tongue foul; skin hot; passed a large fseculent evacuation of a dark-green colour ; complains much of pain in the abdomen, which is 



142 

ILLUSTRATIVE CASES OF 

rather distended — the pain is little increased on pressure. 

The 01. Terebinth, enemata to be administered immediately. A blister to be applied to the epigastrium; and one of the following powders to be given every hour : 

R Chlor. Hydrarg., gr. 5 ; Carb. Calcis, gr. xv ; 

Pulv. Zingiberis, gr. iij. M. ft. Pulvis. Habeat sex tales. 

8 o'clock, p.m. — Pulse 90, full; respiration natural; purged twice since last report, the discharges not so fseculent, and not so dark in colour as those passed previously, — passed urine each time ; the pain in bowels is less urgent, and not increased upon much pressure. 

To repeat the last powders, and to take one every hour for four doses. 

April 10, 3 o'clock, a.m. — Better. Pulse 84, natural; skin warm and soft; tongue clean and moist ; bowels freed once since last report, no pain, the faeces of a yellowish-brown colour; passed urine; slept since 10 o'clock last evening. Sits up now in bed and says he is quite well. 

8 o'clock, a.m. — Had a good night, slept well, and was not out of bed but once to pass urine. Convalescent. 



143 

EPIDEMIC CHOLERA. 

In reference to this case it may be remarked that though the violence of the spasms and excessive jactitation were the symptoms which demanded most attention, yet the sudden prostration and rapid sinking were nearly equally urgent. The decided advantage of early treatment is manifest; and it may be mentioned that this patient did not take an alcoholic stimulant of any sort ; — his drink consisted of sweetened warmmilk and water. Hence the reaction was moderate, and easily controlled. This we have had frequent occasions in our experience to observe, as a pleasing result of the omission of alcoholic stimulants in our plan of treatment. 

Case 4. — Thomas Molloy, set. 30, shopman, Main Street. Admitted 10th May, 184 9. Reports that he complained of diarrhoea for two days, and with vomiting and cramps for six hours, before he was removed to the hospital ; but for which he was under medical treatment. 

11 o'clock, a.m. — In hospital. Pulse rapid, small, and scarcely perceptible ; skin cold, extremities blue and shrivelled ; tongue warm, foul ; much dullness, countenance shrunken ; vomiting and purging of whey-like fluid have just now occurred, the discharge from the bowels resembles 



144 

ILLUSTRATIVE CASES OF 

whey in which much curd had been broken up, and is inodorous ; slight cramps, chiefly confined to the calves of the legs; intense thirst, and wishes for cold water. 

The entire body and extremities to be well rubbed with hot oil of turpentine, by means of flannel cloths. The spine to be afterwards rubbed with an embrocation composed of equal parts of 01. Terebinth, and compound liniment of Ammonia. Twelve grains of Calomel, and six grains of Aromatic powder, mixed in a small quantity of moistened sugar, to be given immediately. 

Twenty minims of the "Creosote solution" to be taken in an ounce of spearmint water every hour, and after each time the patient vomits ; and the following enema to be administered immediately, and repeated if the first be quickly rejected : 

R Acet. Plumbi, 9j ; 

Acet. Distillat., Jj ; 

Aquae Distill. Calid., §ij. M. ft. Enema. 

4 o'clock, p.m. — Pulse 120, more distinct; skin warm ; no cramps since .1 o'clock ; vomiting not so frequent ; has taken much drink of milk and water sweetened and warmed ; bowels three times moved since the second enema, which was 



145 

EPIDEMIC CHOLERA. 

repeated an hour after the first ; passed no urine since admitted, the bladder not distended; the dulness is not increased ; no pain in the head ; pupils natural ; eyes sunken. 

The " Creosote solution" and mint water to be continued. 

May Wth, 6 o'clock, a.m. — Pulse 120, distinct; body warm, extremities rather cold no vomiting since last report ; purged twice, liquid discharges ; dulness, verging more towards stupor ; passed no urine ; abdomen free from distension ; little thirst ; no cramps of extremities. 

R Chlor. Hydrarg., gr. iss ; Sacchari, gr. iij. M. ft. Pulvis. 

Habeat sex tales— *Sumatur una 2 da q. q. hora. 

10 o'clock, a.m. — Pulse 130, distinct; skin warm ; stupor more apparent ; vomiting has not returned ; purging once, liquid ; passed no urine. 

To have diluents at pleasure. A blister to be applied immediately to the back of the neck, and also one to the epigastrium. To continue the Calomel powders. 

12 o'clock, noon. — Pulse, 110, distinct -, stupor not so marked ; extremities warm ; bowels moved three times, the last stool almost black and fetid ; 10 



146 

ILLUSTEATIVE CASES OF 

no urine. The blisters are felt by the patient, and are to remain on until the next visit. 

To omit the "Creosote solution;" and to have an ounce of lime water in a wine-glassful of new milk every half hour. The acetate of lead enemata to be repeated. 

4 o'clock, p.m. — Pulse 110, full; tongue foul, and red at the top ; stupor less ; skin warm. 

The blisters to be removed ; and to continue the lime-water and milk. To have diluents at pleasure. 

11 o'clock, p.m.— Pulse 1 00, soft ; tongue foul, rather cold ; extremities cold, body rather cold ; wished for cold water, and drank largely of it a short time since j no vomiting ; purged once, with a burning pain, the stool dark and not quite liquid, faeculent; stupor less than at last report; thinks he passed urine, but is not certain. 

The body and extremities to be well rubbed with hot oil of turpentine. One of the following powders to be taken every hour : — 

R Chlor. Hydrarg., gr. ij ; 

Pulv. Opii, gr. |j 

Pulv. Aromat. gr. iij. M. ft. Pulvis 

To have four of such powders. 

May 12th, 9 o'clock, a.m. — Reaction ; pulse 



147 

EPIDEMIC CHOLERA. 

96, soft ; tongue dry ; skin warm ; bowels moved twice during the night, the faeces dark-bilious colour; passed little urine; is troubled with hiccough. 

R Liq. Mther. Oleos., 3ss ; Mist. Camphorse, Jj ; 

Syrupi Simplicis, 3j. M. ft. haustus. Statim. sumendus. 

11 o'clock, p.m. — Pulse 90, full; head hot, body and extremities warm ; bowels moved three times since morning, bilious; passed a small quantity of urine. 

To have the usual diluents, and to apply sulphuric aether to the forehead, allowing it to evaporate. 

May Y&th, 8 o'clock, a.m. — Had an uneasy night, in consequence of the bowels being frequently moved ; the discharges large and liquid, but bilious ; pulse 110, small, and easily compressible ; feels weak, and complains of pain in the head. 

A small blister to be applied to each temple. The acetate of lead enemata to be repeated ; and one of the following powders to be given every hour for four doses :—: — 

R Chlor. Hydr., gr.j ; 

Carb. Calcis, gr. viiij. M. ft. Pulvis. 



148 

ILLUSTRATIVE CASES OF 

2 o'clock, p.m. — Pulse 100; tongue moist, not so foul ; head hot, stupor less marked, pain not relieved by the blisters ; thirst ; passed no urine since last report. 

To have diluents repeatedly. To apply sulphuric aether as before. 

10 o'clock, p.m. — Pulse 100; tongue as at last report ; head better ; no pain ; bowels twice moved since last visit, dark-coloured, fetid ; passed a little urine not long since. 

Pergat. 

May I4<th, 9 o'clock, a.m. — Pulse 86, soft; was frequently disturbed during the night, caused by the acrid discharges from the bowels ; otherwise improved. 

ft Pulv. Taiminae, 9j ; 

Aq. Calid, gij. M. ft. Enema. 

To be employed immediately ; and one of the following powders to be given every third hour, for three doses : 

R Pulv. Tanninae 

Hydr. cum. Creta, aa gr. iij. M. ft. Pulvis. 

10 o'clock, p.m. — Pulse 90, irregular; bowels moved once since morning, the faeces still of the 



149 

EPIDEMIC CHOLERA. 

same character ; head symptoms relieved little thirst, but wishes for some tea. 

To have some tea. 

May \§th, 9 o'clock, a.m. — Pulse same as at last report; tongue foul, moist; bowels moved twice during the night, with some pain, the faeces still of a dark-green colour. 

To have an ounce of lime water in a wineglassful of new milk every hour. To have tea and toast for breakfast. 

2 o'clock, p.m.— Pulse 96, irregular, weak ; tongue foul, moist; bowels moved once since morning, of the same character; dulness more apparent than yesterday; head, body, and extremities equally warm ; some hiccough, since last visit ; passed no urine since yesterday. 

To have broth once, and the other diluents at pleasure. To take an ounce of the following mixture every second hour : 

R Bicarb. Potassse, 3ij ; lodid. Pofcassii, 9ij ; Aq. Menth. Vir., > Spiritus iEther. Nitros., Jss ; Syrupi Simplicis, §j. M. ft. Mistura. 

10 o'clock, p.m. — Pulse 90, regular; bowels moved once since last report, still dark coloured ; 



150 

ILLUSTRATIVE CASES OF 

passed urine at the time, and once since. Dulness is considerably less than for the last few days. 

To proceed with the mixture, and diluents as before. 

May 16tk, 9 o'clock, a.m. — Better. Had a good night ; pulse 80 ; bowels not moved during the night, but had a motion this morning which is natural ; passed urine three or four times since last report, which, he says, "he did freely." 

To have tea and toast for breakfast, and mutton broth once in the course of the day. The other diluents as usual. 

To repeat the last mixture. 

10 o'clock, p.m. — Is much improved, and says — " he is all right." Pulse 80 ; tongue clean ; bowels not moved since last report; liked his broth, and hopes he will be allowed some meat to-morrow ; passed urine twice since last report. 

Pergat. 

May 17 th, 9 o'clock, a.m. — Had a good night, and is convalescent. 

Case 5. — Mary Harrington, act. 40, Kerry Road, a poor unemployed. Admitted August 2d, 1849, at 10 o'clock, a.m. Reports that she was attacked with a purging of the contents of the 



151 

EPIDEMIC CHOLERA. 

bowels two days since, which changed to a watery purging on yesterday — that she was seized with vomiting in the course of last night, and with cramps about 4 o'clock this morning. States that she took nothing but boiled milk yesterday, and drank cold water frequently this morning, as she was very thirsty, and had no means to procure any other drink ; but the moment she swallowed it, she was attacked with the vomiting. 

August %d y 11 o'clock, a.m. — Pulse not perceptible at the wrists and temples ; tongue foul, clammy, and cold; body cold and moist; extremities deadly cold, blue, and shrivelled ; head rather warm ; voice a whisper, scarcely intelligible; no vomiting, since 9 o'clock; no cramps of extremities ; perfectly collapsed. 

To be placed in the vapour-bath for five minutes ; to be given immediately the following powder : 

R Chlor. Hydrarg., gr. viij ; 

Pulv. Opii, gr. ij ; 

— Tannmse, gr. iij. M. ft. Pulvis. 

When taken from the bath to be assiduously rubbed with hot oil of turpentine; and after being put into a warmed bed, the 01. Terebinth, enema to be administered, which, if it be soon 



152 

ILLUSTRATIVE CASES OF 

rejected, must be repeated. To have the usual diluents at pleasure, but in small quantities. 

1 o'clock, p.m. — Pulse scarcely perceptible; tongue warm ; body warm ; extremities cold and blue; retained the enema ; no vomiting; passed no urine; thirsty; likes the milk and water diluent. 

R Pulv. Assafoetidee, gr. viij ; Ext. Opii, gr. ss ; Chlorid. Hydrarg., gr. ij. M. ft. Pil. ij — habeat sex tales — Sumantur ij, q. q. hora. 

R Solut. Creosotse, n\x in 3j Aq, Menth. Yir. 2 da q. q. hora. 

8 o'clock, p.m. — Calm. Pulse perceptible, 140; tongue foul, warm; body warm, moist; passed, at 2 o'clock, a liquid motion from the bowels, which is sero-albuminous ; has had a short time since a bilious motion, dark and fetid; and passed some urine; thirst increased; no vomiting. 

To continue the Creosote solution and mint water. To have diluents at pleasure. 

12 o'clock, midnight. — Sleeping — not to be disturbed; extremities warm; pulse 100, distinct. 

Pergat. 



153 

EPIDEMIC CHOLERA. 

August 3c?, 6 o'clock, a.m. — Reaction. Pulse 120, full; tongue foul, moist; heat of skin natural ; hands have lost the blue colour ; bowels freed twice since last visit, bilious, fseculent ; no flatulence, abdomen not distended; respiration natural. 

To omit the Creosote, and to have diluents. 

11 o'clock, a.m. — Pulse 100, full, soft; tongue foul, moist ; extremities warm ; bowels moved frequently, in large quantity of a darkgreen colour, fseculent, and with some pain; passed urine. 

R Acid. NitriciDil., 3j; 

Aq. Menth. Vir., Jvj ; 

Tinct. Opii, 9ij; 

Syrupi Simplicis/3j- M. ft. Mistura. Sumantur coch. ij, ampla 2 da q. q. bora. 

And the following enema to be administered immediately : 

R Olei Terebinth., |ij ; — Olivar., §j ; Aq. Calid., Jij. M. ft. Enema. 

2 o'clock, p.m. — Pulse 96 ; tongue moist, improved ; retained the enema ; feels better, an d wishes for food. 

To have some broth and toast. To continue 



154 

ILLUSTRATIVE CASES OF 

the acid mixture ; and to have the usual diluents at pleasure. 

8 o'clock, p.m. — Pulse as at last report; tongue clean ; heat of skin natural, moist ; passed the enema about 4 o'clock this evening, with some rather solid bilious faeces; no pain; no distension of abdomen ; passed urine. Liked her broth, and asks for some tea. 

To have some tea and toast; and to continue the acid mixture. 

August 4ttk, 9 o'clock, a.m. — Pulse 80 ; had a good night, slept ; bowels moved once since last visit ; and passed urine at the same time. 

Convalescent. 

What makes this case interesting is, that when admitted into the hospital, it presented but little to hope that any curative means could be effectually employed, the patient seeming to be almost moribund. It is also remarkable because of the convalescence being so abrupt and decided, presenting all the characteristics of a crisis, as in the ordinary fevers. This abrupt termination occurs frequently, and sometimes in cases of the apparently most malignant type. We therefore believe that it is never too, late to attempt to save the life of the afflicted patient. 



155 

EPIDEMIC CHOLERA. 

Case 6. — Ellen Kennedy, act. 36, servant ; was brought from the country district. Admitted April 28th, 1849, at 2 o'clock, p.m. Reports that four days since she came to town to dispose of some articles, and on her return to the country was that night first attacked with a purging, which the following day became very frequent and watery ; that all day, notwithstanding the bowel complaint, she attended to her employment, and became very weak; that her mistress gave her some castor oil on a little warm punch, after which she got worse ; that she drank a good deal of boiled milk, but the bowel complaint continued for three days before she vomited ; that about twelve hours since she first complained of cramps, which alarmed the family, who said she had the cholera, and they had her sent to the hospital. 

2 o'clock, p.m. — Pulse at wrists and temples imperceptible, carotids 130, small; tongue foul, moist, and cold; skin cold, extremities cold, hands blue and shrivelled ; no vomiting for some time ; just purged, the discharge sero-albuminous; passed no urine ; thirsty. 

The hot oil of turpentine frictions of the whole body and extremities to be assiduously employed immediately, and repeated in an hour. To be rolled in warm blankets afterwards, and artificial 



156 

ILLUSTRATIVE CASES OF 

heat to be applied to the extremities and along the spine. A mustard cataplasm to be applied to the epigastrium; and fifteen grains of calomel to be given on a little sugar, and a draught, consisting of twenty-five minims of tincture of opium, and one ounce of camphor mixture. The following enema to be administered immediately : 

R Acet. Plumbi, 9ij; 

Acid. Acet., 3j ; 

Aq. Distillat. CalicL, Jij. M. ft. Enema, 

4 o'clock, p.m. — Pulse at the wrist scarcely perceptible, rapid, irregular; skin cold, tongue cold; retained the medicines, but has just now vomited the milk and water diluent ; wishes for cold water. 

To have the usual diluents only in small quantities, but may be frequently given. 

Two table-spoonfuls of the following mixture to be taken every hour, and after each time the patient vomits : 

R Solut. Creosotae, 3ij ; Misturse Camphorae, » Tinct. Opii, 3j. M. ft. Mistura. 

7 o'clock, p.m. — Pulse perceptible, 110, small ; tongue warm, body warm, extremities artificially 



157 

EPIDEMIC CHOLERA. 

warmed; bowels moved twice since last report, the discharge liquid; passed no urine; vomited but once ; respiration quickened, 34 ; slight dulness on percussion at the right side of the thorax; respiratory murmur small, but audible at the left side, marked by a dry rale on the right. 

A large blister to be applied immediately to the thorax. 

The turpentine friction of the whole body to be repeated, and to continue the mixture. 

11 o'clock, p.m. — Pulse 120, easily compressible, regular; tongue dry, warm; body warm, extremities rather warm; no vomiting; purged twice since last report ; liquid motion ; no urine ; respiration 30, respiratory murmur more audible in both lungs than at last report ; blister is felt by patient, and is now acting. 

To omit the Creosote mixture. To have the usual diluents at pleasure, and to remove the blister in two hours. 

April 29tfi, 9 o'clock, a.m. — Reaction. Had a good night, pulse 100, soft; respiration better; bowels not moved since the blister was taken off; passed a little urine this morning, with some pain; no vomiting. 

To have some tea and toast, and the usual diluents at pleasure. 



158 

ILLUSTRATIVE CASES OP 

1 o'clock, p.m. — Pulse 100, soft; tongue foul, moist; heat of skin natural; respiration 25, respiratory murmur distinct in both lungs ; bowels freed once since last report, of a dark bilious fseculent matter, with much flatus ; abdomen distended. 

To have some broth once, and the usual diluents at pleasure. 

To take an ounce of the following mixture every hour : 

ft Acid. Nitric. Dil., 3j ; 

Misturae Camphorse, 3viij. M. ft. Mist. 

8 o'clock, p.m. — Pulse 90, regular, soft ; tongue moist; bowels freed three times since morning of dark-coloured, fseculent matter; respiratory organs relieved ; passed urine. 

To have some tea and toast 

To continue the mixture. 

April 30t/i, 8 o'clock, a.m. — Pulse as at last report; tongue foul; bowels freed three times during the night; slept at intervals; passed urine. 

To have tea and toast for breakfast. 

To continue the acid mixture. 

8 o'clock, p.m. — Pulse 110, easily compressible ; tongue foul, moist ; bowels freed once since morning ; passed no urine ; skin warm. 



159 

EPIDEMIC CHOLERA. 

To have the usual diluents at pleasure. 

To continue the mixture. 

May Ist, 9 o'clock, a.m. — Pulse 100, soft; tongue foul ; skin warm ; bowels freed twice, with some pain this morning, faeces dark colour, fetid ; had a restless night; passed urine this morning; feels weak. 

To omit the acid mixture, and to have the usual diluents. 

2 o'clock, p.m. — Pulse 100, soft ; tongue moist; bowels freed twice since last report; abdomen distended; skin cool, lower extremities cold; vomiting bilious matter; respiration natural; passed urine. 

To have some tea, and the usual diluents in small quantities frequently repeated. 

To take an ounce of the creosote, opium and camphor mixture as before, every hour. 

The lower extremities to be assiduously rubbed with hot oil of turpentine immediately, arid to be repeated in an hour. 

8 o'clock, p.m. — Pulse as at last report; vomited but twice since ; bowels not freed since last visit; body and extremities warm; abdomen less distended; no pain. 

Pergat. Mistura. 



160 

ILLUSTRATIVE CASES OF 

May 2d, 8 o'clock, a.m. — Pulse 96, soft; tongue moist ; bowels freed once in the night, and at the same time vomited; bowels freed this morning again, each discharge is bilious; no pain; skin warm; passed urine this morning; slept a few hours. 

To have some tea and toast, as she wishes for some. 

To continue the mixture. 

3 o'clock, p.m. — Pulse same as at last report ; tongue moist ; extremities warm ; bowels not moved since last visit; vomited bilious matter, just now ; no flatulence ; no pain ; passed urine about an hour since. 

To take the mixture every second hour. 

To have diluents at pleasure. 

11 o'clock, p.m. — Same as at last report 

To continue the mixture every second hour. 

To have the usual diluents, in small quantities, frequently repeated. 

May 3d, 8 o'clock. — Pulse 90, soft; tongue clean; skin warm; slept better last night than usual; was not out of bed during the night; bowels freed once since last report ; vomited twice, bilious ; passed urine ; says she is well, wishes for some broth ; and inquired of nurse when she was brought to the hospital. 



EPIDEMIC CHOLERA. 

161 

To have tea and toast for breakfast. 

To take the mixture every three hours. 

1 o'clock, p.xM. — Pulse as at last report ; tongue clean and moist; bowels moved not long since, natural, no pain or flatulence; feels better, but weak. 

To have broth and toast. 

To continue the mixture. 

8 o'clock, p.m. — Pulse 86, soft; tongue moist; bowels not moved since last visit ; liked her broth, and wishes for some tea. 

To have some tea and toast. 

May 4stk, 9 o'clock, a.m.- — Had a good night, slept, and is convalescent. 

As regards this case, it may be remarked how important it is, at the very moment as it were of reaction, to attend to the state of the lungs, and at once to take cautious measures for their relief. 

Here also we may observe that none of the alcoholic stimuli were employed, — the creosote, opium, and camphor mixture best answering the indications, and appearing to successfully aid the efforts of nature in this case. In very many instances of patients treated at their own homes, we have relied greatly upon this formula, always having previously administered one full dose 

li 



162 

ILLUSTRATIVE CASES OF 

of calomel and of opium; and our experience enables us to say that the results of the practice was very satisfactory in almost every case where the ordinary alcoholic stimulants were omitted. 

Case 7. — Judith Sulivan, set. 63, was brought by her son from the country district. Admitted September 26th, 1849, at 4 o'clock, p.m. Reports that she first complained on the 22d inst. with purging of watery matter from her bowels, which continued for three days before she was attacked with vomiting and cramps • which latter commenced about sixteen hours since. States that she took castor oil twice, but derived no benefit from it; and drank a great quantity of milk before the vomiting commenced ; and since then, she became excessively thirsty, and preferred cold water, of which she drank freely, but immediately vomited it, with, as she expresses it, a " sudden jerk." 

4 o'clock, p.m. — Pulse at the wrists and temples imperceptible ; tongue cold, foul ; body cold ; extremities deadly cold and blue ; voice a whisper ; great prostration ; fseces passed from the bowels as she was being brought into the wards ; perfectly collapsed. 



163 

EPIDEMIC CHOLERA. 

R Chlor. Hydrarg., 9j ; Pulv. Opii; 

Tanninae, aa gr. iij. M. ft. Pulvis— statim sumendus. 

To be placed in the vapour bath for five minutes; after which the whole body and extremities to be assiduously rubbed with hot oil of turpentine; to be rolled in warm blankets, and artificial heat to be applied to the spine, epigastrium, and extremities. 

The 01. Terebinth, enema to be employed immediately after the frictions. 

To have the usual diluents in small quantities. 

7 o'clock, p.m. — Pulse imperceptible ; tongue foul, not cold; skin not so cold; no vomiting since she came to the hospital ; purged twice ; did not retain the enema, which was, as usual, repeated immediately, and is still retained ; passed no urine ; cramps. 

To have one of the assafcetida, opium, and calomel pills every hour, for six doses ; and eight minims of the " Creosote solution," in an ounce of spearmint water, after each pill. 

The spine and epigastrium to be rubbed with an embrocation composed of two parts of 01. Terebinth, and one part of liquor ammonise fortior. 

10 o'clock, p.m. — Pulse scarcely perceptible; 



164 

ILLUSTRATIVE CASES OF 

tongue warm ; body warm ; extremities rather cold j no vomiting ; spasms have ceased ; bowels moved once since last report, liquid. 

To continue the pills and " Creosote solution/ 5 but to be taken Only every third hour, for four doses. 

To have the usual diluents at pleasure. 

Sept. 27th, 6 o'clock, a.m. — Reaction. Slept at intervals during the night ; pulse distinct, 110, soft ; tongue foul, moist ; skin warm ; much dulness; feels weakly ; passed dark feculent matter from bowels ; no pain, no flatulence. 

Pergat. To have tea and toast. 

11 o'clock, a.m. — Pulse distinct, irregular, and slow ; tongue warm, still foul ; skin warm ; oppression at the prsecordia, respiratory murmur audible, no dulness on percussion of the thorax; cerebral functions heavy and dull; bowels not moved since last report; passed no urine since she came to the hospital, and does not remember when she last passed any. 

To omit the former medicine, and to commence the following : 

R Magnesise, 313 ; 

Bicarb. Potassae, 3iij ; 

Aq. Menth. Yir., %v ; 

Spiritus JEther. Nitros., Jss. M. ft. Mistura. St. 3j tertia q. q. hora. 



165 

EPIDEMIC CHOLERA. 

To have the usual diluents at pleasure. 

8 o'clock, p.m. — Pulse 80, small, irregular; tongue foul, moist ; oppression at prsecordia rather relieved ; respiration natural ; passed a small quantity of urine, and some bilious matter from bowels ; cerebral functions dull, as at last report. 

To continue the alkaline mixture. 

To have tea and toast, and the diluents at pleasure. 

Sept. 2&tk, 10 o'clock, a.m.- — All the symptoms are improved, but the cerebral dulness is about the same; and the kidneys are not secreting much urine. 

To have broth once and the other diluents at pleasure. 

To continue the mixture. 

8 o'clock, p.m. — Pulse 96, full, regular ; tongue moist; slept occasionally during the night, with loud sonorous breathing ; passed no urine during the night; bowels moved twice, liquid, but bilious. 

To continue the same as yesterday. 

8 o'clock, p.m. — Passed a small quantity of urine since morning; bowels not moved since last report ; in other respects the same as at last visit. 

Pergat. 



166 

ILLUSTRATIVE CASES OF 

Sept. 30^, 11 o'clock, a.m. — Bowels moved once this morning; passed urine at the time, passed none during the night ; slept quieter last night ; in all other respects the same as yesterday. 

Pergat. ut heri. 

8 o'clock, p.m. — Pulse 84, full, soft; tongue clean, moist ; heat of body, head, and extremities natural; bowels moved once since last report; passed no urine at the time, but passed a small quantity since; cerebral symptoms have disappeared; asks for some tea; says she is quite well. 

To have some tea and toast 

To continue the mixture. 

October Ist, 11 o'clock, a.m.' — Had a good night. Is slowly improving; pulse 86, soft; tongue moist ; bowels moved twice since last report, bilious ; the kidneys are now secreting, passed urine four times since last visit ; cerebral functions are more active. 

To have some broth and toast for dinner, and the diluents at pleasure. 

To continue the mixture. 

8 o'clock, p.m. — Pulse 80, full, soft ; tongue clean ; passed urine twice since morning ; bowels moved once, liquid and bilious j no pain. 



167 

EPIDEMIC CHOLERA. 

October 2d, 11 o'clock, a.m. — Slept all night, and is convalescent. 

We may observe in reference to this case, that the oppression at the prsecordia, the obstructed circulation, and the consequent cerebral disturbance which presented at the period of reaction, seemed to have been caused by the incrassated state of the blood ; and we have further remarked in our notes of this case, that all the symptoms gradually disappeared under the alkaline and diuretic treatment in the same degree as the functions of the kidneys progressed in improvement. 

It will be remarked, that in 'the treatment of the foregoing cases preparations of ammonia and alcoholic stimulants form no part of the plan. 

According to our experience, ammonia and alcoholic preparations are, if not quite inadmissible, at least very doubtful remedies, in the collapsed or congested varieties in particular. Alcoholic preparations and ammonia operate injuriously either by exciting and accelerating the heart's action, thereby forcing into the already partially-gorged vessels a portion of the blood as yet fluid in circulation, which, mixing with the stagnant blood in those parts, assumes the same character, or 



168 

ILLUSTRATIVE GASES OF 

by their de-oxidising property 1 effecting an obstruction to the elimination of the decomposing organic compounds, which have already accumulated to a poisonous extent within the system. In this manner the circle of the general circulation is progressively narrowed, and the congestion increased by the injudicious employment of powerful stimulants. 

Case No. 4 will show that the indications of practice in cholera will be best fulfilled by preventing excessive congestion from taking place in any one organ ; and in the attainment of which, we shall be greatly aided by avoiding those stimulants which are known to excite the circulation to accelerated action. In observing this rule, and in applying with caution our remedies to combat any morbid local activity that might present after reaction, and to restore the healthy organic functions in conformity with general principles, the successful treatment of epidemic cholera we conceive to consist. 

The result of our experience of the effects of alcoholic stimulants in the treatment of cholera, will be more satisfactory as well as more interesting by giving the statistics bearing upon the point ; and as the operation of remedies are most 

1 Vide p. 52. 



169 

EPIDEMIC CHOLERA. 

instructive when observed in collapsed cases, these we have definitively selected from the records for 1849 of the Clonmel Cholera Hospital. 

The following is the result of the collapsed cases treated with and without stimulants in the hospital during the respective months of the appearance of epidemic cholera at Clonmel in 1849 t 

Ist Month. 

24 died who got alcoholic stimulants. 8 died who got none. 

2 recovered who got alcoholic stimulants. 7 recovered who got none. 

U Month. 

20 died who got alcoholic stimulants. 15 died who got none. 

1 recovered who got alcoholic stimulants. 15 recovered who got none. 

Bd Month. 

6 died who got alcoholic stimulants. 3 died who got none. 

None recovered who got alcoholic stimulants. 11 recovered who got none. 



170 

ILLUSTRATIVE CASES OF 

4>th Month. 

No alcoholic stimulants given. 2 died and 6 recovered. 

Wi Month. 

No alcoholic stimulants given. 3 died and 7 recovered. 

(sth Month. 

4 died who got alcoholic stimulants. 11 died who got none. 

None recdvered who got alcoholic stimulants. 7 recovered who got none. 

Ith Month. 

No alcoholic stimulant employed. 3 recovered, none died. 

It may be here mentioned that of the 11 collapsed cases of deaths, which occurred in the 6th Month, and were treated without alcoholic stimulants, 6 were so far advanced in the collapsed stage, that 4 of them died within six hours, the other 2 within ten hours. 

As regards the general result in reference to 



171 

EPIDEMIC CHOLERA. 

this topic, we may mention that the statistics from the hospital records show that in the treatment of 353 patients, alcoholic stimulants were employed in 113 cases, and in 240 cases they were not used in any form. The total number of deaths was 132. Of this number, in 80 cases alcoholic stimulants were employed, and in 52 cases they were not used. We also find that 188 patients recovered who got no alcoholic stimulants in any form, and 33 recovered who used alcoholic stimulants ; but of these 33 cases, it is necessary to remark that - only three were collapsed on admission, and that in the majority of the other 30 cases the alcoholic preparations (wine and whiskey) were administered in small quantities mixed up in arrow-root jelly, and therefore acted rather as food than as stimulants. 

MEANS OF PREVENTING EPIDEMIC CHOLERA. 

A malady the remote or exciting cause of which may still be said to be almost inscrutable, or involved in mysterious obscurity, affords but slender grounds for a prophylactic code; the 



172 

MEANS OF PREVENTING 

attempt must therefore be . imperfect, perhaps futile; yet the author, willing to render this treatise as complete as his experience will admit, is induced to submit the succeeding suggestions as a code the observance of which may prevent the propagation of this, and indeed of all infectious diseases. 

Doubtless, a knowledge of the mode in which nature protects from disease would be an important point gained. But the utter annihilation of the sources of infectious and epidemic diseases would be the greatest triumph of art. The chief means of prophylaxis is perhaps to be found in a perfect system of public hygiene. In the social instincts of animal communities, numerous illustrations of which are afforded by natural history, the great protecting instinct points out the adoption of personal cleanliness as the surest hygienic means ; and it would appear that this instinct, if we may so call it, of personal cleanliness in animals, is but another manifestation of the wise economy of nature in providing for the depuration of the blood. Thus pursuing nature's laws, we behold the same operation of a beneficient principle is incessantly influencing the whole creation, and these furnish to man the best precedents to follow, and to be acquainted with 



173 

EPIDEMIC CHOLERA. 

winch constitutes the utmost extent of human knowledge. 

In accordance with certain modern views it is believed that quina is an antidote to the malarious element of disease; and this encourages a hope that an antidote to the fcecal and oc/detic miasms exists, and will yet be discovered, since the experience of the antidotal properties of quina renders it extremely probable that nature has, and will yield such an antidote. In the experience of the French physicians in the treatment of the paludal fevers of Algeria, (vide British and Foreign Medico- Cldrurgical Review, October, 1852,) no remedy so constantly maintained its position as an antidote to the malarious poison as quina. In the " pernicious" forms of malarious fevers in which the poison acts so intensely on the nervous system, that the paroxysm is not unlike an attack of epidemic cholera, the quina is held to be the only known antidote, " the first, the last, almost the only thought of the physician should be sulphate of quina. This is the remedy for the disease, and only this." Cases are recorded in which quina effectually arrested an attack of abdominal typhus, as well as the ochletic yellow fever ; but in other cases it seemed only to modify the phenomena. In explanation of 



174 

MEANS OF PREVENTING 

this partial action it is suggested that, as these diseases are of the complex group, it may be assumed that " while the malarious element may be neutralised by the quina, the fcecal or the ockletic or specific poison may remain uninfluenced," and that "if powerless over the miasmatic'element, the counteraction of the malarious is a great point gained." Dr. Wood, in his recent Treatise on the Practice of Medicine, sustains these views : " Quina is administered in the United States not alone for the cure of all forms of intermittents, but it is employed with great success in the typhus class of diseases ; nor is the presence of local inflammation, if it be of a low type, a contra-indicant — cerebral inflammation alone contra-indicating its use. When typhoid pneumonia supervenes upon or becomes complicated with intermittent fever," Dr. Wood has seen the happiest effects result from quina, administered as soon as possible, and without waiting for a distinct intermission. " Not only is the intermittent interrupted, but the inflammation itself puts on a more favorable character It would be better, however, to give the quina as a prophylactic, rather than a curative agent." In the British and Foreign Medico- Chirurgical Beview, Dr. Laycock remarks — " There is a destruc- 



175 

EPIDEMIC CHOLERA. 

tive class of infectious and contagions fevers, especially those of ochletic origin, as epidemic cholera and yellow fever, which derive much of their fatal energy from the previous entry of the malarious poison into the blood, so that the way to disarm them of their virulence and render the attack milder and safer is to administer quinine as a prophylactic. This plan," he continues, "we adopted during the cholera epidemic with marked success." As regards the efficacy of quina as a curative agent in the treatment, or as a prophylactic against cholera, we do not choose to express an opinion, but prefer to let further investigation and more extended experience decide. 

In the absence of demonstrative proof of the non-contagibility of cholera during the prevalence of its epidemic influence, whatever that influence might be, 1 and impressed with the many startling if not convincing facts which have presented themselves to our notice, evidently tending towards the attesting of its contagibility, we trust that we shall best perform what we have imposed upon ourselves in treating of this part of our subject, by in a manner assuming that the principle of contagibility, at least while the epidemic influence prevails in a locality, is already re- 

1 Vide pp. 15, 19, 32, 42. 



176 

MEANS OF PREVENTING 

cognised by the profession. This course we conceive, in the present state of our knowledge, is the only prudent one to follow, because even should it be an erroneous one, no injury can arise from its adoption ; and we believe it to be a step in the right direction. 

If the attendants about a person labouring under cholera observe but a few rules, they will very rarely, scarcely ever, suffer from its attack — even admitting that, during the epidemic prevalence, cholera is an infectious disease. 

The first and perhaps the greatest of these is to establish a free ventilation, — to cause all foul or offensive substances to be removed as soon as possible,— to be as much to windward of the patient as they can,— to avoid bending over the body, or inhaling the exhalations from the patient, and to wash their mouths frequently with a weak solution of chloride of soda and water — (an ounce of the former solution to a quart of cold water.) The innocuousness of virus in the alimentary canal is a doctrine recently advanced, and although we can readily admit the possibility that the force of chemical action in the assimilative process may decompose the specific virus, yet it cannot be objected to wash, &c. The next in importance is to live moderately, eat light and easily digestible 



177 

EPIDEMIC CHOLERA. 

food,— to avoid cathartic medicine,— to take their usual quantity of rest, sometime in the twentyfour hours,— and to sprinkle the apartment occasionally with a solution of chloride of zinc or of lime. We have some faith in the vapour of oil of turpentine — when thus presented to the lungs, it appears to be readily absorbed into the system ; and as 01. Terebinth, is as quickly eliminated, the two-fold action of absorption and elimination seems to be of some considerable efficacy in arousing without exciting the cerebro-ganglionic nervous system. We therefore think it may be prophylactic (?) as well as useful in the treatment of cholera patients. It should always be kept in a hot state in the wards of a cholera hospital, and in the chambers of private patients affected with this disease; because as an external application its employment frequently repeated is generally of great service, and its vapour is thereby diffused immediately around the patient, and the atmosphere of the apartments is therewith impregnated. It would be injudicious to advise against the use of camphor, rosemary, or other aromatic substances, or to ridicule the possessing or carrying about the person any amulet, since whatever inspires confidence in the mind contributes to the security of the body. 

12 



178 

MEANS OP PREVENTING 

As safety from danger depends chiefly on the strict observance of cleanliness and the free admission of pure air, the chamber-door of a patient ill of cholera, more especially in badly-ventilated houses and in the habitations of the poor, should never be kept shut ; a window in the room ought to be very generally kept open during the day, and it ought to be occasionally opened in the night. Such observances would be highly useful both to the patient and the nurse, but are more particularly important previous to the arrival of any visitor. 

For obvious reasons the bed-curtains should be removed, or should never be drawn close round the patient, but only on the side next the light, to shade the eyes. 

Utensils, soiled cloths, and the like, should be frequently changed, immediately immersed in cold water, and when taken out of it washed clean. 

All discharges from the patient should be instantly removed ; and the floor round the patient's bed be rubbed clean frequently in the day, with a wet mop or cloth. 

Visitors and attendants should avoid the current of the patient's breath, the air, or effluvia, or exhalation which ascends from his person, as well as the vapour arising from all evacuations. When 



179 

EPIDEMIC CHOLERA. 

medical or other duties require a visitor or a nurse to be placed in those situations, a temporary suspension of respiration should be observed. 

An enervated condition of the constitution or a debilitated state of the body in which the blood is charged with decomposing matters, is it appears indispensable when exposed to the exciting cause to contract any epidemic as well as any infectious disease ; if then we ask what are the most frequent causes of this state of health ? we find that functional derangement of the digestive organs, conjoined to mental anxiety, fatigue, and discontent, not only tends to but is perhaps the most general and constant cause in the production of this enervated and debilitated condition. It is true that cholera much more frequently attacks the poor, doubtless because they have not the advantage of comfortable, clean, well- ventilated dwellings, and suffer from many other privations, but the malady is often milder in its type in them, because they are not fed or nurtured upon rich, high-seasoned, and therefore improper diet. The gentry and persons in comfortable circumstances might be exposed to the exciting cause of cholera, or to infection, with more impunity than the lower classes, but should they catch the disease, the danger or fatality to them is nearly tenfold. 



180 

MEANS OF PREVENTING 

We are convinced from observation and experience, that organic disease is engendered in the system, and that we become predisposed to cholera, and to all other epidemics and infectious maladies, more from neglect of our mode of living, than perhaps from any other cause. Hence it appears necessary to awaken in the public mind a sense of the importance of carefully attending at all times, but more especially during the prevalence of cholera or any other fatal epidemic to proper diet and habits of living. Every one knows that the body derives its sustenance from the food taken into the stomach ; if that food be not of a wholesome quality, if it be taken in too large or in too small quantities, or otherwise improperly, so that the stomach and organs connected with digestion be disarranged, therefore unfit to receive it, and consequently unable to fulfil their offices, surely it is impossible that the body can be able to perform its allotted functions, and resist the abnormal condition of the elemental forces, or successfully oppose those external influences which constitute the remote or exciting cause of epidemic and infectious diseases. 

The effect of particular food, even upon the mind, is known to every one ; and if we look to the different countries within our immediate 



181 

EPIDEMIC CHOLERA. 

sphere of observation, we may be able to trace how far the peculiarities of character spring from the mode of living of their inhabitants. 

Our food, then, at all times should be of an easily digestible and nutritious quality, taken moderately and at proper intervals, never eating to the full extent of our appetite, rather leaving off with a relish for more. An excessive quantity of animal food is as injurious to health as too much vegetable; we should say the rule is, one part of the former to two of the latter, taking care that the vegetables are well boiled, and that they are not of the flatulent kind. We ought to abstain as much as possible from all fermented and spirituous liquors. We do not mean to advise those who have acquired the habit of taking a few glasses of wine or a little brandy or whiskey punch after dinner to abruptly lay it aside, because in the event of doing so the system might feel the want of the stimulus it had been accustomed to, and therefore we would apprehend injurious consequences to arise, more particularly if discontinued during the prevalence of epidemic cholera. The stomach may be truly said to answer for the body, what that indefinite thing — conscience — does for the mind; and hence it would be desirable that more attention be given to its 



182 

MEANS OF PREVENTING 

promptings and requirements. In fact, volumes have been, and doubtless might again be written on articles of diet ; but as it is more than doubtful that an attempt will ever be made to write a volume for every man, and as different things agree and disagree with different persons, and with the same person at different times, the whole principles of diet may be summed up in an axiom : — Observe what agrees best with you, and use that in moderation. The advice, upon regimen, of a celebrated physician to his patients, is also entitled to consideration — " Keep your head cool, by temperance ; your feet warm, by exercise ; your mind at ease, and your bowels regular, and defy * *. 

The effect of the mind on the various functions of the body is indeed generally known and admitted to be great. Anxiety, fear, and the depressing passions, are all predisposing causes ; they therefore should be avoided as much as possible, by gay and cheerful society, and pleasing pursuits and amusements. We should endeavour to remove, or at least alleviate, mental distress; shun the haunts of debauchery, and be careful not to induce in any way fatigue or exhaustion. 

" The Precautions and Instructions" issued in 1848 by the Irish Commissioners of Health, 



183 

EPIDEMIC CHOLERA. 

may, in reference to the topic before us, be with propriety here annexed; we will therefore be permitted to borrow from their circular the following instructions, which, we assume, will aptly form the final page of a treatise like the present. 

" Shun damp and low situations, and if possible quit dwellings in such places during the prevalence of cholera ; keep your houses and rooms dry, and the windows and doors open, as much and as long as the weather will permit : there can scarcely be too much ventilation. An abundant supply of fresh air is as necessary during the night as in the day, and pure air is as requisite for the support of life and health as good food. 

"Remove all stagnant water and dung-heaps from around your dwellings, and clean out your sewers without delay. Do these things at once, without waiting for the outbreak of the disease. It will be unsafe, and it will be too late to undertake them when cholera shall have broken out. 

" Avoid chills ; do not wear wet clothes a moment longer than can be avoided. Wear a flannel belt round the stomach and loins ; make use of plain wholesome food, in the solid rather than in the liquid form ; abstain from fruit, raw and ill-cooked vegetables, pastry, smoked and 



184 

PREVENTING EPIDEMIC CHOLERA. 

hard salted meats, and salted fish, pork, cider, stale or sour malt drinks, pickles, and all articles of diet that from experience are known to have a purgative effect. 

" Avoid purgative medicines, particularly castor oil, seidlitz powders, and salts. 

a Be very careful that the water used as drink is of good quality. 

"Abstain from stimulants, unless prescribed as remedies under medical advice. In former visitations of cholera, many persons, both rich and poor, resorted to the use of stimulants — wine, whiskey, brandy, &c, under the false impression, that what was sometimes useful as a cure, was also good as a preventive. This is a great error; stimulants, frequently taken, or taken in excess, are followed by collapse, which predisposes to the disease; and the general health, moreover, is seriously and permanently injured by the practice. In fine, shun damp places, particularly for sleeping ; breathe pure air; observe cleanliness; keep the surface of the body warm; use wholesome plain food; live temperately; preserve as much as possible a state of general good health, and you will have adopted the best safeguards against cholera." 



INDEX. 

PAGE 

Abnormal state of the " cosmic forces" ... ... 32-44 Accidental creation of the " acarus Crossii" ... 40 Acetate of lead as enemata ... ... 100 Action of electricity on dew ... ... 26 Alchemic power of assimilation ... ... 28 Alcoholic preparations and ammonia not approved as remedies ... ... ... ... 167 Anaesthesia, counter-irritation dangerous in ... ... 117 Animalcule in the sero-lymphous discharges from cholera patients ... ... ... 33-38 Animal heat, phenomenon of ... ... ... 47 Brodie and Chossat's experiments on 48 De la Eiva's hypothesis on ... ... ib. Artificial generation ... ... ... 35 Atmospheric influence indispensable for the development oflife ... ... ... ... 38 Atomic theory, Daubeny's views of ... ... 34 Auscultation, the only true test of pneumonia . . . 115 Axiom expressive of the principles of diet ... ... 182 Bile acid in consecutive icterus ... ... 122 Bloodletting in cholera ... ... 81-85-87-95-113-116 



186 

INDEX 

£AGE 

Bonnet's, M., on the action of iodine ... ... 123 Budd's, Dr., reasons assigned for acid bile . . . 122 Calomel, its action in cholera ... ... 98 Carpenter's, Dr., views of organic substances ... 34 Cathartic, when admissible ... ... ... 113 Cause of failure of Dr. Mackintosh's experiments 43-111 Cerebro-nervous system, divisions of ... ... 44 Cerebro-nervous system, dynamic action of ... 32 Chemico-electric actions, disturbance of ... 46 law ... ... ... 41 Cholera, absence of the saline constituents of the blood, an. effect oi ... ... ... 43-109 appearance after death from ... ... 69 arguments in favour of the contagibility of 15-32 author's inference as to the contagibility of 20-24-32-175 date of first appearance of ... ... 2 definition of ... ... ... 55 difficulty of marking the origin of ... 3 Dr. Johnson's view of suppression of the secretion of urine in ... ... ... 103 effects of fear at the approach of ... ... 6 empiricism most fatal in ... ... 108 English and Irish boards of health on ... 14 exciting cause of ... ... ... 43 hospital, Clonmel, statistics of ... 54-67-169 illustrative cases of ... ... 132 importance of early treatment of ... ... 9 in children ... ... ... 65 invasion of ... ... ?. 59 means of preventing ... .... 171 mortality less in 1849 than in 1832 ... 8 mortality of ... ... ... 4 non-contagious views of ... ... 10-23 no stage hopeless ... ... ... 154 origin of morbid actions in ... ... 46-49 



187 

INDEX 

PAGB 

Cholera, plan of inspection during prevalence of ... 9 predisposing cause of ... ... ... 49 prognosis in ..... ... ... 65 rate of progression of ... ... ... 4 spasm, the cause of suppression of the secretion from kidneys in ... „ . 102 subject to the same laws of pathological inquiry as other diseases ... ... ... 131 symptoms of ... ... ... 56 tendency to relapse in ... ... 94 the nature of ... ... ... 130 treatment of ... ... ... 76 various names of ... ... 1 varying aspects of ... ... ... 56 venous injection in ... ... ... 109 with collapse ... ... ... 61 with collapse, treatment of ... ... 95 " Choleraic invasion," indications of treatment ... 79 " Cholerine," indications of treatment ... 84 Circular of Irish Commissioners of Health ... ... 183 Consecutive cerebral affections, treatment of ... 112 gastro-enteritis, treatment of ... 124 hepatitis, treatment of ... ... 119 hysteria, treatment of ... ... 127 icterus, treatment of ... ... 121 pneumonia, treatment of ... ... 115 Contagion and infection ... ... ... 16-24 Contagion, explanation of the arguments for ... 18 Convalescence from the sequelae of collapse ... 128 Convalescents, necessity for medical inspection of ... 129 Counter-irritation, M. Duparcque's views of ?. 117 Creosote solution, modus operandi of ... ...90-106 Daubeny's atomic theory ... .... 34 Diet, the principles of ... ... ... 180 Douche baili ... ... ... ... 108 



188 

INDEX 

PAGE 

Duparque, M. on counter-irritation ... ... 117 Dumas and Bonnet's experiments on the blood with an alkaline iodide ... ... ... 105 Dumas and Prevost on the action of electricity on albumen 35 Electric and nervous forces, not identical ... ... 29 Electricity, action on dew of ... ... ... 26 action on albumen ... ... ... 35 identity of all the species of ... 27 light, caloric, and life, relation of ... 26 Mr. Weekes' experiments with ... 41 Elements of organic substances ... ... 34 Enemata of 01. Terebinth. ... ... ... 88 of acetate of lead ... ... 100 of tart, antimon. ... ... ... 119 Entozoa, generation of ... ... ... 37 Epidemic influence, nature of ... ... 26-32-42 Epiricism, more particularly dangerous in cholera 108 Existence, functions essential to .... ... 45 Experiments, Rengger's ... ... ... 30 Brodie and Chossat's ... ... 48 cause of failure of Dr. Mackintosh's 43- Dumas and Bonnet's ... ... 105 Mackintosh's ... ... ... 109 Weekes 3 ... ... ... . 41 Pissiparous generation ... ... ... 34 Formula for " creosote solution" ... ... 89 Dr. Stevens' ... ... ... 104 Dr. Symond's ... ... ... 127 for a cathartic ... ... ... 114 for an alkaline and diuretic ... ... 105 for assafoetida, opium, and calomel for hydrocyanic acid mixture . . . 118-120 for matico mixture ... ... 92 for nitric acid mixture ... ... 93 



189 

INDEX 

PAGE 

Formula for nitric acid and opium ... ... 106 for 01. Terebinth, enemata ... ... 81 Functions essential to existence ... ... 45 General result of treatment, alcoholic stimulants forming part ... ... ... ... 171 Impure air, danger from habitual respiration of ... 18 Infusoria, the primitive production ... ... 38 Inorganic matter, properties of ... ... 39 Invariable generation from ova, opinions on ... 37 lodine, action on the blood ... ... 105 its two-fold action ... ... ... 116 manner of employing ... ... 116-123 physiological action of ... ... 123 Kidneys, suppression of secretion from ... 102 Mercury, indiscriminate use injudicious ... ... 115 Modified plan of Dr. Stevens's treatment . . . 109 " Morbus cseli," the abnormal " cosmic force" ... 25 Nervous and electric forces not identical ... 29 Nervous force permeates the organic structures ... 32 Nucleated cells the basis of vegetable and animal substances 33 01. Terebinth., therapeutic effects and physiological action of 82 01. Terebinth., vapour of ... ... ... 177 Opium, action of ... ... ... 97 Organic forces, Passavant's views of ... ... 27 and inorganic creation, sustained from identical sources ... ... ... 29 sether reacts upon inorganic forces ... 31 creation by law ... ... ... 38 life, a modification of the "cosmic force" 29 substances, elements of ... ... 34 



190 

INDEX 

PAGE 

Pneumonia, a frequent sequel of collapse ... ... 115 Prevost and Dumas, electric action on albumen ... 35 Prophylactic code ... ... ... 171 Sequelae of cholera ... ... ... 63-112 appearances after death from ... 73 treatment of the ... ... 112 Simultaneous action of curative agents ... 85 " Spirit of animation," modification of Darwin's theory of 31 Statistics as regards alcoholic stimulants ... ... 169 predisposition .... ... 55 prognosis ... ... 67 Typhoid symptoms, treatment of ... ... 127 liberations in the colon and rectum ... ... 126 Urea, excess of, in the blood ... ... 103 discovered in the bile by Dr. Roupell ... 122 Urine, suppression of the secretion of ... 102 complete suppression of, Dr. Prout's view ... ib. suppression of, caused by spasm ... ib. Dr. Johnson's view ... ... 103 

C. AND J. ADLAHD, PRINTERS, BARTHOLOMEW CLOSE.