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CHOLEKA: 
 
 FACTS AND CONCLUSIONS 
 
 AS TO ITS 
 
 NATURE, PREVENTION, AND TREATMENT. 
 
 EY 
 
 HENRY HARTSHORNE, A.M., M.D., 
 
 MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY; FELLOW OF THE COLLEGE 
 
 OF PHYSICIANS OF PHILADELPHIA; PROFESSOR OF HYGIENE IN 
 
 THE AUXILIARY FACULTY OF MEDICINE IN THE 
 
 UNIVERSITY OF PENNSYLVANIA, ETC. 
 
 PHILADELPHIA: 
 
 J. B. LIPPINCOTT & CO. 
 
 18 06. 
 
 • 
 

 rf 
 
 Entered, according to the Act of Congress, in the year 1866, by 
 
 HENRY HARTSHORNE, A.M., M.D., 
 
 In the Clerk's Office of the District Court of the United States for the 
 Eastern District of Pennsylvania. 
 
 
ON CHOLERA. 
 
 Some experience with Cholera, in this city in 
 1849, 1850, and 1854, and in the latter year at 
 Columbia, Pa., and the perusal of most of what 
 has been written upon the subject, have impressed 
 me with opinions, some of which amount to strong 
 convictions ; the truth of which — if they be true — 
 is so important as to make it justifiable, if not a 
 duty, to give them publication at the present time. 
 
 Without claiming novelty for my views (some 
 of which were published in a medical journal more 
 than ten years ago*), my purpose is to endeavor 
 to give the results of a careful analysis of the 
 facts, and, if possible, an approach to a consistent 
 theory, with direct practical applications. To this 
 end, it will be best to attempt a brief digest of the 
 subject, in a methodical form. 
 
 Principal Synonyms. — Epidemic, Spasmodic, 
 Malignant, Algid, Asiatic, Indian Cholera ; Cho- 
 lera Asphyxia, Mort de Chien ; in India, Vishuchi 
 (vomiting and purging) ; at Bagdad, Haouwa (tor- 
 nado). 
 
 * Philada. Med. Examiner, Aug. 1855; On Animal De- 
 composition as the Chief Promotive Cause of Cholera, etc. 
 
 (3) 
 
ON CHOLERA, 
 
 DEFINITION. 
 
 An acute systemic epidemic disorder (endemic 
 in parts of India), not contagious, but produced 
 under certain local circumstances by an unknown 
 specific cause, which appears to be in rare in- 
 stances and to a very limited degree portable; 
 the symptoms being, in most instances, a premoni- 
 tory, painless, and mostly watery diarrhoea of 
 variable duration, followed by vomiting, also 
 watery, and increased diarrhoea, with weakness, 
 coldness, intense thirst, difficulty of breathing, 
 loss of voice, cold breath, cramps, disappearance 
 of pulse, suppression of the action of the kidneys, 
 restlessness, and a blue or livid and shrunken 
 aspect of the skin ; which symptoms may end in 
 death in from ten minutes to forty -eight hours — 
 in relief and rapid recovery within twelve hours 
 or more — or, in a partial reaction and low fever 
 {chiefly urasmic), the result of which is either 
 death in a few days, or recovery in a week or 
 two. 
 
 APPEAKANCES APTEK DEATH. 
 
 Rigidity occurs soon; sometimes in less than 
 an hour ; generally within two hours. Startling 
 movements of the corpse have been several times 
 noticed ; as of a patient, dead with cholera, slowly 
 
APPEARANCES AFTER DEATH. 5 
 
 lifting both hands over the chest and joining them ; 
 opening the eyes and rolling them downward, etc. 
 Increased heat of the body, cold during the attack, 
 has been sometimes observed after death. Intern- 
 ally, several of the great organs, the brain, spleen, 
 and kidneys at least, are commonly gorged with 
 blood. So are the right cavities of the heart; but 
 the left side of the heart empty or with but little 
 blood, and firmly contracted. The lungs are al- 
 most bloodless. The liver varies in appearance ; 
 but the gall-bladder is almost always full of bile. 
 The urinary bladder is, constantly, greatly con- 
 tracted. The- stomach and intestinal canal are 
 congested, and swollen ; the late Prof. Horner ob- 
 served the frequent throwing off of the " epithelial" 
 lining of the canal ; Bohm, of Germany, confirmed 
 this ; Drs. Parkes, Gull, and Lindsay assert it to be 
 a post-mortem occurrence.* The intestinal glands 
 are found considerably enlarged. The blood 
 has been carefully examined by Drs. Garrod, 
 Schmidt of Dorpat, and others, f Its water and 
 salts transude into the alimentary canal, with 
 some of the albumen and fibrin ; also the contents 
 of the blood-cells transude into the serum. The 
 blood drawn from a vein during life is (as I have 
 seen it) dark, thick, and tarry, scarcely capable of 
 
 * Edinburgh Med. and Surg. Journal, Jan. 1855. 
 f Brit, and For. Medico-Chirurg. Rev., July, 1854. 
 
6 ON CHOLERA. 
 
 flowing. Schmidt found the amount of oxygen in 
 the blood-corpuscles less than half the normal pro- 
 portion. The blood is acid sometimes in cholera ; 
 the reverse of its natural reaction. 
 
 The ganglia of the "sympathetic" system have 
 been often examined, and are frequently changed 
 in appearance; congested, softened, altered in 
 color; but no special change has been shown to 
 belong to them in cholera. 
 
 DIAGNOSIS. 
 
 Common cholera morbus alone {absurd name, 
 hybrid of Latin and Greek; as absurd also is 
 cholera, from the Greek for bile, a cognomen for a 
 disease in which the excreta are remarkable for 
 the absence of bile), when severe, resembles epi- 
 demic cholera so much as to be easily mistaken 
 for it. The collapsed stage of the one, preceding 
 death, is almost identical in appearance with the 
 collapse of the other. But cholera morbus is 
 caused by some irritant of the stomach and bowels, 
 and is clearly an affection of those organs, not a 
 toxaemia or systemic disorder; it is sporadic, not 
 epidemic ; in it the discharges are always bilious 
 at first, and mostly so to the last ; collapse in any 
 degree is rare, and death, under judicious treat- 
 ment very uncommon. In all these things, it 
 differs greatly from Asiatic cholera. 
 
HISTORY. 
 
 HISTOEY* 
 
 Putting aside some possible resemblance to this 
 disease in descriptions of Aretus and one or two 
 other ancient authors, probably the epidemic in 
 France of 1545, " trousse-galant," came more near 
 to it. The earliest distinct account of cholera was 
 that given by Bontius, a Dutch physician of Ba- 
 tavia, 1629. Willis (1684), Morton (1692), and 
 others, described epidemic fluxes and " dysenteries" 
 in England in such terms as strongly to remind us 
 of cholera ; and so did Degner of Nymwegen, in 
 the Netherlands (1T36), and Morgagni in Italy, in 
 1733. Some British physicians (Greenhow, Ait- 
 ken) now believe that cholera may have repeatedly 
 visited England. It appears to me more probable, 
 however, that this opinion is due to an overesti- 
 mate of the resemblance between the autumnal 
 cholera morbus of Great Britain (like our own) and 
 the pestilential disease. 
 
 Certainly cholera must have existed in India for 
 an indefinite time. From 17 8 1-2 dates its extended 
 
 * In this sketch I am chiefly indebted to Dr. A. Brig- 
 ham's Treatise on Cholera, Dr. E. H. Greenhow's and 
 Dr. Gavin Milroy's papers in the Brit, and For. Medico- 
 Chirurg. Review (April, 1856, and October, 1865), and 
 Boudin's Traite de Geographie et de Statistique Mddicales, 
 tome ii. 
 
8 ON CHOLERA. 
 
 prevalence, in a most destructive form ; at Cal- 
 cutta, in Madras, on the Coromandel coast, and in 
 Ceylon. 
 
 In August, 1817, Jessore was the birth-place of 
 the first great migratory epidemic. Shortly after, 
 in Calcutta, 36,000 were attacked in three months. 
 At many military stations, it was very severe. 
 Roads were covered with dead and dying, unable 
 to reach their homes. In November, the grand 
 army of the Marquis of Hastings was devastated 
 by it. Of 90,000 men, in twelve days 9000 had 
 died. On marching the army across a river to dry 
 and elevated ground, the commander was relieved 
 of this otherwise invincible enemy. 
 
 In 1818, the Birnian empire was invaded by 
 cholera; and there and elsewhere in Asia, its 
 ravages were fearful. In 1819, 150,000 died of it 
 in the Presidency of Bombay. It also reached 
 Mauritius, 20° S. latitude, three thousand miles 
 from any place before visited by it. The Island 
 of Bourbon was visited in 1820; as well as the 
 Philippine Islands. In 1821, Borneo and Java 
 were affected ; and a large Persian army was re- 
 pulsed by it from before Bagdad, without a battle. 
 In 1822 its limits were much narrowed, and its 
 destructiveness abated. 
 
 India almost escaped in 1823, but China was 
 ravaged by it; and it extended northwestward, 
 
HISTORY. 
 
 9 
 
 in that year, to Orenbourg, on the Ural, near the 
 borders of Europe and Asia. In 1826 it passed 
 the great wall of China in its northward progress ; 
 but almost left Western Asia. It reappeared in 
 Persia in 1829. 
 
 Orenbourg was revisited in that year, and the 
 epidemic there lasted from August to near the 
 end of February. This city had a population at 
 that time of 11,000, of whom 6000 were soldiers. 
 Those first affected had no communication what- 
 ever with any infected place. 
 
 1831 saw the cholera in the north of Europe, as 
 far as Archangel, near the Arctic Ocean, more than 
 64° N. latitude. It reached Warsaw in April, 
 during an insurrection, and was very fatal. Hun- 
 gary suffered from May to September; losing 
 100,000 of its population. In June, St. Peters- 
 burg, and in September, Moscow, were reached 
 by the pestilence. Berlin had it also for three 
 months and a half, beginning in August. Mecca 
 was attacked during the visitation of throngs of 
 pilgrims, in May; of 50,000, as many as 20,000 
 are said to have perished. In this year, while 
 Hungary was infected, the Austrian s surrounded 
 Vienna by a double cordon militaire; but in vain. 
 The disease began there in August and continued 
 for three months. The southern provinces of 
 Austria and the Khineland were exempt. Con- 
 
10 ON CHOLERA, 
 
 stantinople was affected by it, but not with very 
 great severity. The Turkish government, that 
 year, maintained no quarantine. Cairo suffered 
 dreadfully in 1830-31 ; and so did Smyrna. 
 
 Attacking Hamburg on the 11th of October, 
 1831, it was officially announced at Sunderland, 
 England, October 26th. It had occurred in several 
 cases in England months before. Three or four 
 weeks later it appeared at Newcastle ; and in De- 
 cember, at Haddington, a Scottish town on the 
 Tyne. 
 
 Edinburgh and Glasgow first had cholera in 
 January, 1832; London in February ; Dublin and 
 Paris in March. London then suffered but mod- 
 erately ; Paris terribly — especially in April and 
 May ; 20,000 deaths. 
 
 On the 8th of June, it first invaded our conti- 
 nent, at Quebec ; and within a week, at Montreal. 
 In the same month it was in New York and 
 Albany. Philadelphia had its first cases in July. 
 Between the 1st of July and the 18th of August, 
 New York had reported 5337 cases, with 2068 
 deaths. That city lost 3513 in all.* From the 
 27th of July to August 18th, Philadelphia had 
 1610 cases, with 615 deaths. Boston and Balti- 
 more were moderately affected in August. 
 
 * Dr. A. Clark, Lect. on Cholera. In 1834, New York 
 lost 971; in 1849, 5071*; in 1854, 2509. 
 
HISTORY. 
 
 11 
 
 Detroit, Buffalo, Elizabeth City in North Caro- 
 lina, Wilmington and Newcastle, Delaware, Nor- 
 folk and Portsmouth, Virginia, and New Orleans 
 were the principal of more than fifty towns in the 
 United States reached by cholera in 1832. It had 
 entered twelve different States before September. 
 
 Havana and Mexico were attacked in the spring 
 and summer of 1833. The City of Mexico, not- 
 withstanding its great elevation above the sea, 
 did not escape. 
 
 Portugal was also first visited in that year; 
 Spain but slightly until 1834. Northern Italy 
 was affected in the autumn of the same year. In 
 1835, Alexandria and Malta; in 1836, Rome, 
 Naples, Egypt, and Central America especially 
 suffered. North Germany, South France, Rome, 
 Naples, Sicily, Malta, Egypt, and Syria, in 183T. 
 After that, cholera disappeared from Europe and 
 America for nearly ten years. It still existed, in 
 variable violence and extent, in India. 
 
 In 1847, it ravaged a Russian army west of the 
 Caucasus; and in September returned to Moscow. 
 In 1848, Turkey, Russia, Austria, Prussia, Bel- 
 gium, Holland, Great Britain, and Prance (though 
 not Paris) were successively attacked. Then the 
 cholera showed its power to traverse the sea with- 
 out human aid or agency, by attacking two emi- 
 grant ships, a thousand miles apart, one sixteen 
 and the other twenty-seven days out from Havre, 
 
12 ON CHOLERA. 
 
 when no cholera was prevailing at that port* 
 The cholera-cloud itself also reached New Orleans 
 about the same time, and progressed up the valley 
 of the Mississippi. New York was not affected 
 by the visit of the infected ship ; the disease not 
 occurring again there until May, 1849. 
 
 Paris was reached by it in February of that 
 year, but suffered the worst in June. Lyons now 
 had it for the first time. Tunis and Algiers were 
 visited toward the end of the year. 
 
 In January, 1849, after Memphis, St. Louis, 
 Missouri, was attacked. Chicago, Buffalo, and 
 other towns on the lakes, in May. New York 
 and Philadelphia in the same month. Baltimore 
 had this year only a local epidemic, in July, in 
 the Almshouse ; the restriction of which to one 
 side of the building was very remarkable. As in 
 1832, the mortality in Philadelphia was much less 
 for the population than in New York : 1022 deaths 
 occurred in our city ; New York had a mortality 
 450 per cent, greater, f Canada was reached this 
 time from the westward. 
 
 In 1848-9, the number of deaths from cholera in 
 England and Wales was over fifty-four thousand 
 (54,398); in 1832-3, nearly thirty-one thousand 
 
 * Report on Cholera in the United States, by Dr. James 
 Wynne; and Dr. Gavin Milroy, Brit, and For. Medico- 
 Chirurg. Review, Oct. 1865, p. 444. 
 
 f Dr. J. H. Griscom, Medical Record, March 15th, 1866, 
 p. 35. 
 
HISTORY. 
 
 13 
 
 (30,924). In London,* probably owing to greater 
 attention to sanitary means, the mortality was 
 two-fifths less the second time than the first. Some 
 parts of Southern Rhin eland were visited in 1849; 
 especially the filthy City of Cologne. 
 
 Cholera lingered in various places almost spo- 
 radically, in Europe and America, from 1850 to 
 1854. Canada and the far West (Indiana also 
 had cases every year) suffered the most, in this 
 way, on our continent. In the West, emigrants' 
 camps and military stations seemed especially to 
 furnish its required local conditions. 
 
 In 1853, Persia had it severely ; also some parts 
 of Northern, Central, and Southern Europe (Co- 
 penhagen, Hamburg, Berlin, Piedmont, Lyons, 
 Paris, and Southern Portugal). Before the end 
 of the year it was again in New York, New 
 Orleans, and the West Indies. Mexico had been 
 visited in the spring, and through the summer. 
 
 1854 was still more a cholera year in Europe 
 and in this country. Scarcely any European state 
 or kingdom was exempt. The French, English, 
 and Russian troops suffered from it much in the 
 Crimea. Greece, Italy, Germany, France, Spain, 
 Portugal, in short, all Europe was traversed by it : 
 150,000 died of it in France alone; in England 
 
 * London had 13,098 deaths from cholera in 1849; in 
 1854, about 10,000. 
 
14 
 
 ON CHOLERA. 
 
 and Wales about 20,000. Newfoundland, on 
 our side of the ocean, was reached for the first 
 time in 1854. This was the year of the epidemic 
 at Columbia, Lancaster County, in this State ; so 
 remarkable for the absence of some of the usual 
 promotive conditions of cholera. Our great cities, 
 however, did not suffer nearly so much as in 1849. 
 
 In 1855, the disease was widely spread in Eu- 
 rope, though not very malignant except near the 
 seat of war, before Sebastopol. Egypt and Pales- 
 tine had it also. In Switzerland, which had been 
 slightly touched before, Basle, Geneva, Zurich, 
 and other places now suffered by it. The next 
 year, 1856, still did not witness its withdrawal 
 from Europe. 
 
 Since that period, until 1865, I have no means 
 at hand for tracing the movements of epidemic 
 cholera. Dr. Gavin Milroy says that the countries 
 hitherto exempted have been as follows : Australia, 
 New Zealand, and other islands in the Pacific ; the 
 Cape of Good Hope and adjoining settlements; 
 the coast of Africa from the Cape as far north- 
 ward as the Gambia, and including the islands of 
 St. Helena and Ascension ; the Azores, Bermuda, 
 Iceland, Faroe islands, and also the Orkney and 
 Shetland; the southern half of the. eastern coast 
 of South America, from the Rio Plata inclusive, 
 Cape Horn, and the whole of the western coast 
 of that continent, from the Cape and along the 
 shores of Chili and Peru to Panama. 
 
HISTORY. 
 
 15 
 
 In last year, every one was familiar with the 
 accounts of cholera in Arabia and Egypt in the 
 spring, at Constantinople in July,* and afterward 
 in several parts of Europe, extending, though with 
 but moderate violence, as far as England. While 
 its vast migrations seem to be as capricious or in- 
 calculable as the flight of locusts, two local causes 
 contributed at least to its severity in Mecca and on 
 the Nile. These were the crowds of religious 
 pilgrims at the former place, in the spring, and, in 
 Egypt, the insalubrious circumstances attending 
 the operations at the new Suez Canal. In both, 
 " crowd-poison" was intensified to the greatest de- 
 gree; so that the pest-cause might well find there 
 strength for the renewal of its flight onward to the 
 northwest. In Paris, in 1865, 6383 deaths oc- 
 curred during the late visitation. 
 
 I take from Dr. Brigham's treatise (published in 
 1832) the following table, of the deaths from 
 cholera in 1832, and their proportion to popula- 
 tion : 
 
 
 Population. 
 
 Deaths. 
 
 Equal to 
 
 
 Moscow, 
 
 350,000 
 
 4690 
 
 1 in 74 
 
 • 
 
 Petersburg, 
 
 360,000 
 
 4757 
 
 1 74 
 
 
 Vienna, 
 
 300,000 
 
 11,896 
 
 1 159 
 
 
 Berlin, 
 
 340,000 
 
 1401 
 
 1 242 
 
 
 Hamburg, 
 
 100,000 
 
 446 
 
 1 224 
 
 
 London, 
 
 1,500,000 
 
 1223 
 
 1 1228 
 
 
 * The first case occurred in that city on the 28th of June. 
 
16 
 
 
 ON CHOLERA. 
 
 
 * 
 
 
 Population. 
 
 Deaths. 
 
 
 Equal to 
 
 Edinburgh, 
 
 150,000 
 
 72 
 
 1 
 
 in 2033 
 
 Glasgow, 
 
 180,000 
 
 395 
 
 1 
 
 455 
 
 Hungary, 
 
 8,750,000 
 
 188,000 
 
 1 
 
 46 
 
 Paris, 
 
 800,000 
 
 20,000 
 
 1 
 
 40 
 
 Montreal, 
 
 25,000 
 
 1250 
 
 1 
 
 20 
 
 Quebec, 
 
 22,000 
 
 1790 
 
 1 
 
 12 
 
 New York, 
 
 200,000 
 
 2000 
 
 1 
 
 100 
 
 Albany, 
 
 24,000 
 
 311 
 
 1 
 
 77 
 
 Supposing the population of Philadelphia to 
 have been at that time 150,000, this, with a little 
 over 600 deaths, would give a proportion for our 
 city of 1 in 250 of the inhabitants. In 1849 the 
 ratio was considerably less.* 
 
 It is an important fact in the history of cholera, 
 that before, during, and after the epidemic has 
 visited a place, many cases, greatly exceeding in 
 number those of typical cholera, occur, of diarrhoea, 
 sometimes also with vomiting, not violent, yield- 
 ing easily to treatment. To these the name of 
 cholerine is often given, f 
 
 * Moreau de Jonnes estimates the number attacked as, 
 in France, 1 in 300 of the population ; Russia, 1 in 20 ; 
 Austria, 1 in 30 ; Prussia, 1 in 100 ; Poland, 1 in 32 ; Bel- 
 gium, 1 in 120; Great Britain and Ireland, 1 in 131; Hol- 
 land, 1 in 144; Germany, 1 in 700. 
 
 f The coincidence or anticipation of cholera by epidemic 
 influenza and the potato blight, has been several times 
 noticed. But there is, clearly, no uniformity in any such 
 association. 
 
NATURE. 
 
 IT 
 
 NATTJEE OP CHOLEEA, 
 
 Without discussing opinions at length, it may 
 be asserted that cholera is not at all, like our ordin- 
 ary cholera morbus, a disorder simply of the stom- 
 ach and bowels. Being clearly an acute systemic 
 affection, changes in the blood are proved to occur 
 in it, and may well be believed to be primary; 
 that is, that the morbid cause acts through the 
 blood. But that is not all. 
 
 Cullen placed cholera, in his nosology, in the 
 class neuroses, order spasmi. Many medical ob- 
 servers (Binaghi, Loder, Orton, Delpech, Lizars, 
 Coste, Favell, C. W. Bell, Greenhow, G. Johnson, 
 etc.) consider its principal effects to be referable 
 to disturbed innervation, involving chiefly the 
 ganglionic centres of organic life. Dr. Charles D. 
 Meigs, years ago, graphically called the attack the 
 "cholera squeeze." Yelpeau, of Paris, lately re- 
 peats this, " le mal vous tortille." There, I think, 
 is the pathology of cholera, in one word. As Dr. 
 C. W. Bell says, it is not an adynamic, but a 
 dynamic, or sthenic, collapse. 
 
 The heart, its left side at least, is, after death, 
 contracted. The pulmonary artery and its branches 
 are narrowed, making the lungs pale and anaemic. 
 The gall-bladder is full of bile, but the duct is 
 spasmodically closed, and detains it there. The 
 
18 ON CHOLERA. 
 
 urinary bladder is shrunken to half its size or less. 
 The blood-vessels of the whole alimentary canal 
 press rigidly upon their contained fluid, and force 
 its serum out into the stomach and bowels ; whence 
 it is, by spasmodic ejections, thrown out. The 
 very skin is, by its involuntary muscular fibres, as 
 well as by vascular constriction everywhere, drawn 
 tightly and closely upon the body. The voluntary 
 muscles suffer with cramps. All is cramp, cramp, 
 within and without. The brain is almost in 
 anaesthesia during the collapse — no delirium, but 
 apathy — as from cerebral anaemia. The blood, so 
 compressed, grows thick as tar — it scarcely flows, 
 is not aerated, and cyanosis follows ; — it is detained 
 in the capillary and venous networks of the in- 
 terior organs, in which congestion is found after 
 death. 
 
 Cholera is, then, I say, a poison-spasm ; a gan- 
 glionic tetanus. 
 
 CAUSATION. 
 
 Here we enter, unavoidably, the region of specu- 
 lation. Not, however, without facts to give us 
 hope and promise. By exclusion, we can first see 
 what the cause of cholera is not. 
 
 1. Is it heat, moisture, electricity, ozone, or any 
 modification or combination of the pervading 
 physical forces of nature? Surely not. Those 
 
CAUSATION. 
 
 19 
 
 forces are cosmic, not localized in their operation. 
 Observation would hardly be needed to show that 
 no state of physical conditions marks the presence 
 of a cholera epidemic ; but observation has shown 
 it. Sir Henry Holland* compared the atmospheric 
 conditions of five different places in which cholera 
 was prevailing ; there was no correspondence at 
 all. Barton has found a high dew-point during 
 cholera in New Orleans ; but it prevails often in 
 India where the air is dry. Dr. Moffatt lately has 
 asserted that the equatorial current of moist, ozo- 
 niferous air is fatal to the prevalence of cholera. 
 Berigny, in 1856, thought a deficiency of ozone to 
 coincide with cholera ; but Berigny has, just now, 
 asked and obtained the appointment of a learned 
 commission of the French Academy, to ascertain 
 definitely whether there is such a thing as ozone ! 
 Dr. Hammond, in Kansas, found no ozonometric 
 reaction during cholera; but Prof. Ellet, of New 
 York, proved, in 1849, that there was no constant 
 relation between the two.f Schultze, Yoltolini, 
 and others assert the same conclusion. As to 
 climate, the disease has prevailed from Archangel 
 to the Isle of Bourbon, and from China to Mexico. 
 No telluric causation, therefore, can suffice for it. 
 Elevation has no fixed relation to its occurrence. 
 
 * Medical Notes, Philadelphia ed., p. 349. 
 f Hammond on Hygiene, pp. 164-165. 
 
20 
 
 ON CHOLERA. 
 
 In London, Dr. Fan* found the mortality to be 
 directly in proportion to the lowness of site. But 
 cholera has prevailed 9000 feet above the level of 
 the sea, at Bogota, in 1849 ; ^000 feet, at Enimeneh 
 in Persia, in 1853;* more than once in the City 
 of Mexico, at an elevation of T990 feet; and in a 
 citadel built upon an isolated rock ( Jaragurth, in 
 Bengal), f 1000 feet above the plain. We must 
 explain the influence of lowness of site, as Dr. 
 Baly pointed out, merely as one of the circum- 
 stances which modify the prevalence of cholera; 
 not as accounting for it. 
 
 Coming and going, then, across the earth, from 
 time to time, its cause cannot be conditional 
 merely. Nor, if it were so, could it happen that, 
 among multitudes of persons, in the same spot, 
 " one should be taken and the others left." 
 
 2. If, then, not dynamic or cosmic, this cause, 
 though occult, must be material. Nor could a 
 mineral solid, or liquid, possibly so traverse the 
 earth undetected per se. It must be, if inorganic, 
 volatile, to cross the ocean alone. That it can do 
 so, has been proved in a number of instances. 
 Those of the emigrant ships, New York and 
 Swanton, in 1848, from Havre, have been already 
 alluded to. In 1854, I had direct cognizance of 
 
 * Gavin Milroy, op. cit., p. 449. 
 f Brigham, op. cit., p. 33. 
 
CAUSATION. 
 
 21 
 
 such occurrences, in the packet-ships Tonawanda 
 and Tuscarora, Cope's line, between this city and 
 Liverpool. The first was attacked when two 
 weeks at sea, there being no cholera at Liverpool 
 when she started. After a number of days' pre- 
 valence, this vessel neared a large iceberg, which 
 reduced the temperature of the air 30°. The day 
 before the iceberg was met, the largest number of 
 cases occurred ; after that, no new one at all. The 
 epidemic was frozen out. In April, 1866, other 
 instances occurred, to which allusion will be made 
 hereafter. 
 
 Since, then, I say, the cholera cause can travel 
 far over sea, or land, it must be volatile, or ex- 
 tremely mobile. Is it a gas? Chemists have not 
 found such ; but that does not quite disprove it. 
 But the diffusion of all gases through space, 
 aided by the winds, prevents the local accumula- 
 tion of gases everywhere, unless constantly eman- 
 ating from a terrestrial source. Thus the mephitic 
 poison of the celebrated deadly valley of Java, and 
 the carbonic acid stratum of the Cave of Dogs 
 in Italy, are accounted for. No poisonous gas, 
 according to all physical experience, could pos- 
 sibly maintain concentration enough to destroy 
 human life, during weeks and months together, at 
 one place, and then leave it to rest upon another 
 — unless a source of emanation were as migra- 
 tory. As no such mobile source is known, the 
 gaseous hypothesis must explode of itself. 
 
22 ON CHOLERA. 
 
 3. What possibilities, then, are left ? I have 
 observed that, if inorganic, the " cause" in ques- 
 tion must be a gas ; but it has been shown, just 
 now, that no such gas can have existence ; there- 
 fore the cause must be organic in nature. I see 
 no escape from this dilemma, however wanting we 
 are in physical demonstration of the conclusion it 
 brings on. The source^ at least, of the cholera- 
 cause must be organic. 
 
 4. What organic sources are possible for it? 
 Conceivable theories are — I. That it is a contagi- 
 ous effluvium from the bodies of those sick with 
 the disease. II. That it is generated by a pecu- 
 liar chemical change in the excreta, either of the 
 sick or the well. III. That it is a cryptogamous 
 vegetation, a microphyte, requiring certain pecu- 
 liar and only occasional conditions for its ex- 
 istence. IY. That it is minutely animalcular in 
 nature, existing, migrating, and propagating itself 
 only where local circumstances permit. 
 
 I. Is cholera contagious ? The word is vari- 
 ously defined. I follow La Roche and others in 
 regarding a disease as contagious, only, when its 
 cause is a material produced by a morbid process 
 in the bodies of the sick, and generating the same 
 disease in those whom it reaches, either by con- 
 tact or at a short distance through the air. In 
 this sense it is proper to assert most emphatically 
 that cholera has never been shown to be contagi- 
 
CAUSATION. 
 
 23 
 
 ous in a single instance ; while the always difficult 
 negative proof is abundant. Every apparent case 
 of contagion (and such are extremely rare) is 
 susceptible of a different explanation. 
 
 Against contagion we have, especially, the fol- 
 lowing points : 
 
 A. Cholera is often preceded in a place by a 
 considerable increase in the amount of diarrhoea; 
 showing the presence of a general atmospheric 
 cause, the intensification or accumulation of which 
 brings on the epidemic. 
 
 B. It subsides in a locality, after days, weeks, 
 or months, with no constant reference to the num- 
 ber of persons susceptible to it, but obviously in 
 relation to local sanitary conditions. 
 
 G. It attacks, simultaneously, places as far apart 
 as London and Newcastle; and often hundreds 
 the same day in a large city. Thus seven thou- 
 sand perished from it in Paris in eighteen days, in 
 1832. In the Massachusetts State prison, four 
 within an hour, and two hundred and five within 
 forty-eight hours, were attacked. 
 
 D. Cholera is sometimes limited to a part of a 
 town (Oxford, England, according to Drs. Baly 
 and Gull) or even a part of a house ; as at Balti- 
 more in the Almshouse, in 1849. Dr. Buckler 
 then reported its existence, when there was no 
 cholera elsewhere in the city, in one-half of the 
 Almshouse building, in which seventeen fatal cases 
 
24 
 
 ON CHOLERA. 
 
 occurred ; none whatever in the other half, simi- 
 larly occupied. The difference was, that under 
 the walls of the affected side of the house was " a 
 large and foul overflowing cess-pool, whose con- 
 tents mingled with the washings of the dead- 
 house, etc." In several instances, also, it has been 
 confined to a part of a ship.* 
 
 E. An army or other encampment may be 
 affected terribly while in one locality (as with the 
 Marquis of Hastings in India, mentioned before), 
 and then, by a short march, escape from it alto- 
 gether. Such occurrences are frequent and fa- 
 miliar in India. (See S. Clark, Hygiene of the 
 Army in India.) 
 
 F. In Hindostan, where cholera is annually 
 present, the facts are of such a nature that the 
 idea of contagion is scarcely entertained by any 
 medical men or others. Dr. James Johnson 
 wrote, many years ago, that "in India, the con- 
 tagiousness of cholera is denied by ninety-nine out 
 of every hundred medical men." And in a work 
 published in 1864, on the Hygiene of the Army 
 in India (Stewart Clark, M.R.C.S., Inspector- 
 General of Prisons, etc.), I find statements corro- 
 borative of this. For example, the following : 
 
 "After the Hurdwar and other large fairs in 
 India, cholera almost always appears in the vil- 
 
 * E.g. steamers England and Virginia, April, 1866, 
 
 etc. 
 
CAUSATION. 
 
 25 
 
 lages on the lines of roads leading from them ; but 
 the cases are generally confined to people who 
 have been at these fairs. For instance, at Deyrah 
 Doon, about forty miles from Hurdwar, there are 
 often two annual visitations of cholera: viz., one 
 in April or May, confined to individuals returning 
 from the Hurdwar fair ; and one later in the sea- 
 son, of the usual epidemic type, among the gene- 
 ral inhabitants of the town."* 
 
 In the words of Dr. A. Flint, f " compare its 
 course as an epidemic, in this respect, with typhus, 
 small-pox, or scarlet fever !" 
 
 G. Nurses and others brought into contact with 
 cholera patients, even in hospitals, are not more 
 liable than others to the disease. An official re- 
 port to the French government stated that in 1831 ; 
 of over two thousand persons employed in nursing 
 in hospices or hospitals, during an epidemic of 
 cholera (which produced in all eighteen thousand 
 deaths), only one hundred and sixty-four were 
 attacked. At St. Petersburg, 1 nurse in 58 had 
 the cholera ; in Moscow, of 253 persons connected 
 with x>ne hospital, 4 only were affected by it. In 
 the latter city, also,J 587 patients affected with 
 cholera were admitted into a hospital with 860 
 patients, laboring under other diseases, yet not a 
 
 * Op. cit., p. 13, note. f Practice of Medicine, p. 425. 
 % Brigham, op. cit., p. §24. 
 
26 
 
 ON CHOLERA. 
 
 single one of the latter was attacked by cholera. 
 Dr. Alison (himself half a contagionist) recorded 
 the fact* that, in Edinburgh, in 1832 and in 1 848-9, 
 the dissecting-rooms were supplied almost exclu- 
 sively by cholera subjects; and in neither year 
 was there a single case of the disease among the 
 numerous students attending those rooms. Post- 
 mortem examinations have been made freely, by 
 physicians everywhere, during cholera, without 
 any evidence of danger therefrom. 
 
 H. No effort to produce cholera by direct con- 
 tact or otherwise, experimentally, has ever suc- 
 ceeded. Dr. Foy and ten others, at Warsaw, f 
 inoculated themselves with the blood of cholera 
 patients, tasted their dejections, and inhaled their 
 breaths, without receiving the disease. So did the 
 surgeons and medical students at Moscow and 
 Dantzic in 1832; and similar experiments with 
 like results and conclusions were tried by Lizars, 
 Coste, Schmidt, Meyer, Marshall, and others. A 
 late article in the Richmond Medical Journal, by 
 Dr. Houston, mentions that a man in Wheeling, 
 during a cholera epidemic, lay all night in the 
 clothes of another who had just died of the dis- 
 ease ; but was unhurt by it. 
 
 * Brit, and For. Medico-Chirurg. Review, Jan. 1854, 
 p. 22. 
 
 f Gazette M^dicale, 1831, 
 
CAUSATION. 
 
 21 
 
 Dr. Lauer Lindsay* made elaborate experi- 
 mentation with dogs; and thought he had suc- 
 ceeded in giving them cholera. But it does not 
 appear so to me, in reading his account. The 
 dogs were exposed in no case less than seven days 
 to the combined effects of confinement, swallowing 
 and breathing the matters of evacuation and per- 
 spiration of cholera patients. Then the symptoms 
 ought not at all to be regarded as specific, as the 
 discharges were "decidedly biliary, green, and 
 greenish feculent matter," and " emitting an intol- 
 erable stench." Dog No. 1 is also stated to have 
 become somewhat lively and greatly better, after 
 having eaten a quantity of the flesh, fat, and blood 
 of dog No 2, which died on the previous day. 
 The expression of Mr. Marshall, another investi- 
 gator, is clearly correct — that this evidence is still 
 "short of proof" of any contagion belonging to 
 cholera. 
 
 I cannot but anticipate that a similar conclusion 
 would follow a scrutiny of the experiments of like 
 character more recently performed by Thiersch in 
 Munich, and Robin at Paris, f They have made 
 dogs sick by injecting the excreta of cholera pa- 
 tients into the trachea and veins. No wonder! 
 
 * Edinburgh Medical and Surgical Journal, April and 
 October, 1854. 
 
 f London Lancet, Jan. 13th, 1866. 
 
28 ON CHOLERA. 
 
 But, against all this we have the familiar fact that 
 dogs do not get the cholera at all by exposure to 
 the companionship of patients, nor by presence 
 during its epidemic prevalence. Every experi- 
 ment of the kind is simply toxicologieal, not clini- 
 cal or a propos in any sense. 
 
 The influence of drinking water, the occasional 
 occurrence of new cases in hospitals to which 
 cholera patients are admitted,* and all other seem- 
 ing instances of contagious transmission, are, as 
 will be shown hereafter, clearly susceptible of a 
 different explanation, which embraces all the 
 facts. 
 
 I. Cholera does not follow regularly, nor de- 
 pend for its migrations upon, human intercourse. 
 Instances proving this abound in the whole his- 
 tory of it ; a few must suffice us here. 
 
 Whatever the amount of travel, cholera moves 
 with extreme slownessf against the wind. This 
 is especially observable in India ; where, as Orton 
 has recorded, it takes sometimes three months to 
 pass over the distance of a ten days' voyage, not- 
 withstanding constant communication. 
 
 When the epidemic first reached England, in 
 1831, after having been in Berlin and Hamburg, 
 it appeared in Sunderland October 26th. It did 
 
 * Brit. Med Journal, Dec. 9th, 1865. 
 
 I Parkes; vide Aitken's Practice of Med., vol. i. p. 659. 
 
CAUSATION. 
 
 29 
 
 not reach London until February, 1832 ; notwith- 
 standing constant communication between that 
 city and the infected district.* 
 
 One of the Western Islands, beyond the coast 
 of Scotland, on the other hand, was attacked by 
 the disease, although the intercourse between it 
 and the main land was so rare, that the clergyman 
 of the island continued to pray every week for 
 King William the Fourth, for eighteen months 
 after Queen Victoria had ascended the throne, f 
 
 In 1832 and 1848, the town of Annan, nearly 
 equidistant from Carlisle and Dumfries, and right 
 upon the main line of traffic between those towns, 
 escaped cholera altogether, while it prevailed both 
 at Dumfries and Caiiisle.J 
 
 I repeat, that these are only instances of a large 
 class of facts, which show a capriciousness in the 
 career of cholera epidemics, altogether adverse to 
 the supposition that it is either contagious or in 
 any way dependent for transmission upon human 
 intercourse. 
 
 But the advocates of the view just now most 
 prevalent, urge that on all occasions cholera has 
 crossed the ocean only in ships. Each by each of 
 
 * G. Milroy, Brit, and For. Medico-Chirurg. Review, 
 Oct. 1865, p. 438. 
 
 j- Aitken, op. cit., p. 650. 
 
 % Edinburgh Monthly Journal of Med. Sci., April, 1854. 
 
30 
 
 ON CHOLERA. 
 
 the asserted instances of this has been or could be 
 met and shown to be quite unproven. A single 
 case of such disproval would establish for us the 
 important proposition, that cholera certainly does 
 not depend for its migrations upon human agen- 
 cies or contingencies. 
 
 What do we say of the New York and Swanton, 
 vessels, in 1848? They have been already alluded 
 to on a previous page. I say, first, that there 
 was no cholera at Havre when they started, nor 
 for some time before ; Dr. James Wynne* and 
 Dr. Gavin Milroyf being my authorities for the 
 statement. 
 
 Secondly, I regard it as a decisive fact, that in 
 all the accounts of the voyage of these vessels 
 referred to, one is said to have been sixteen and 
 the other twenty -seven days out at sea before any 
 cholera occurred on board. 
 
 Now what, according to the strictest contagion- 
 ists, as well as those who believe in the theory 
 of excretory fermentation (Pettenkofer), is the 
 time of incubation of the cholera poison ? Budd,J 
 Niemeyer, and Greifswald make it from six hours 
 to three days; Kierulf,§ of Bergen, from one to 
 
 * Report on Cholera in the United States, 
 f Brit, and For. Medico-Chirurg. Review, Oct. 1865. 
 J Association Journal, 1854 ; Memoranda on Asiatic 
 Cholera, 1865. 
 
 § Aitken, Practice of Medicine, vol. ii. p. 657. 
 
CAUSATION. 
 
 31 
 
 four days; Rilliet, Madin, Weissbrod, Hielman, 
 and others, twelve hours to eight days. 
 
 How absurd, therefore, to endeavor to construe 
 the case of the Swanton as one in which the 
 cholera was transported from Havre to New 
 Orleans by that ship ! The arrival of the New 
 York at the port of that name was not followed 
 by the infection of that city. I would say, that 
 the arrival of the epidemic at New Orleans simply 
 coincided, pretty nearly, with that of the Swanton; 
 which had been overtaken by it on its way. While 
 these pages are being written (April, 1866) two 
 analogous cases are attracting attention ; those of 
 the steamers England and Virginia, from Liver- 
 pool; attacked by cholera when five and eight 
 days out.* 
 
 J. But something must be said of the authenti- 
 cated instances where transportation by persons 
 seems to have occurred. With a good deal of re- 
 search, I have been able to collect together only 
 the following, as allowable in evidence. 
 
 Certain cases mentioned by Dr. Jameson, in the 
 Bengal Report, in 1824. 
 
 Eight persons taking cholera at Toulon, shortly 
 
 * Some conjecture that German emigrants must have 
 brought the disease to the England and Virginia; but, if 
 so, why did they not likewise infect Liverpool ? 
 
32 ON CHOLERA. 
 
 after the arrival there of the frigate Melpomene f 
 from Lisbon, with cholera on board, in 1833.* No 
 other cholera cases occurred at Toulon for two 
 years. 
 
 A woman attacked at Edinburgh, in 1832, when 
 no cholera prevailed there, after nursing her son, 
 who got the disease at Musselburg and came home 
 sick with it.f 
 
 Some instances mentioned by Dr. Simpson 
 (Edin. Med. and Surg. Journal, April, 1838, and 
 Edin. Monthly Med. Journal, 1849), quoted with 
 only partial details by Dr. Alison (Brit, and For. 
 Medico-Chirurg. Review, Jan. 1854). 
 
 Three women took cholera after washing the 
 clothes of some sailors who had died of cholera, 
 at Banff, Moray Firth, Scotland, 1832.J 
 
 Two men died of cholera, in 1849, at Campbell- 
 town, Scotland, after the arrival of a woman from 
 Glasgow, with some blankets which had been used 
 by her sister-in-law who died of cholera. The 
 disease then existed nowhere else within fifty 
 miles (Dr. Robertson, Edin. Monthly Journal, 
 August, 1849). 
 
 Several instances are given by Dr. Berg, in his 
 
 * London Medical Times, N. S., vol. iii. p. 515. 
 f Ten days afterward cholera became epidemic in Edin- 
 burgh. 
 
 t Alison, loc. citafc. 
 
CAUSATION. 
 
 33 
 
 Treatise on the Cholera in Sweden, in 1850; of 
 which I have not details. 
 
 One case is narrated by Dr. S. H. Dickson, in 
 Charleston, 1832 (Am. Journal of Med. Sciences, 
 vol. xiii. p. 309). 
 
 The outbreak of cholera at Arbroath, in Scot- 
 land, in 1853, described by Dr. T. Traill (Aitken, 
 op. citat , p. 656). Some instances in the Nor- 
 wegian Reports of 1850-53. Others in the Report 
 of the College of Physicians of London, 1854. A 
 few cited from a Bengal Report, 1853, by Dr. 
 Aitken.* 
 
 A few cases mentioned by Boudin in his " Traite 
 de Geographie et de Statistique Medicales" (tome 
 ii. p. 37 4), viz.: 
 
 Three- persons in the commune of Masles, in 
 France, affected, in 1849, subsequently to the 
 arrival of a person who visited Paris while cholera 
 was prevailing there, returned to Masles, became 
 ill, and died of cholera. 
 
 One person, in the same year, in the commune 
 of Conde, attacked after handling the clothes of a 
 woman who had died of cholera ; there being no 
 other cases at Conde at the time. 
 
 Three individuals, in the same year, affected at 
 Aubees, after the arrival there of a person from 
 
 * Practice, p. 656. 
 
 2 
 
34 ON CHOLERA. 
 
 Courville, where cholera prevailed, that .person 
 becoming ill and dying of cholera after his arrival. 
 
 According to M. Bucquoy,* two wet-nurses, 
 going from Paris to Peronne, and falling ill there 
 with cholera (1865), communicated the disease to 
 eight other persons ; some of whom died. 
 
 In Dr. Burrall's recent work on Cholera, received 
 since the above was written, several other exam- 
 ples of an analogous kind are given. 
 
 All of these, together, would count, I suppose, 
 since 181?, possibly fifty or a hundred individuals, 
 who might be acknowledged to have taken cho- 
 lera, in immediate sequence upon exposure to con- 
 tact with the persons or clothing of cholera pa- 
 tients, in localities not at the time under the epi- 
 demic influence. 
 
 Granted, then, that such was the case. They 
 are, clearly, exceptional instances. If cholera was 
 in any proper sense contagious, could the instan- 
 tise crucis possibly be so few and hard to find or 
 prove ? No ! But how do we account for these ? 
 On the principle of fomites; of occasional, very 
 rare, carrying of the cause of cholera, the " germs" 
 of it, in clothing, merchandise, or by the person of 
 a human being ; as one might carry skippers on a 
 
 * Discussions of Parisian Hospital Med. Society ; Phila- 
 delphia Med. News and Library, Feb. 1866, p. 22. 
 
CAUSATION. 
 
 35 
 
 piece of cheese in his pocket, or a paper of flower- 
 seeds in his carpet-bag. 
 
 Practically, what is the difference between this 
 and contagion ? Much, indeed ! When the cause 
 of the disease is a somatic {bodily) contagion, no 
 prevention of it is available, except the total and 
 remote avoidance of those persons who have it, 
 and of things which have been in contact with 
 them. When the cause is an eatfra-soniatic infec- 
 tion, depending, for its production, multiplication, 
 and transportation, on local and atmospheric con- 
 ditions, not personal — then those conditions may 
 be met preventively; and the very rare carry- 
 ing power of fomites may be reduced to nullity, 
 by sanitary precautions. Against contagion, we 
 would have only quarantine ; a most "lame and 
 impotent " defence. Against infection, we have 
 the amply sufficient measures of sanitary police 
 and management. 
 
 Contagion, as a theory, would explain only a 
 minority of the facts concerning cholera, and is 
 not required to explain them. Infection will ex- 
 plain all. 
 
 Let me here state briefly the main facts in refer- 
 ence to the three vessels which have reached our 
 shores within a few months, having cholera on 
 board. 
 
 The Atalanta arrived off New York on the 2d 
 of November last, with emigrants, from Havre. 
 
36 
 
 ON CHOLERA. 
 
 In the steerage there were a number of cases of 
 cholera during the voyage; none at all in the 
 cabin. 
 
 The steamer England reached Halifax April 
 8th (the present month) from Liverpool, with 
 1202 passengers, chiefly emigrants, Irish and Ger- 
 man. When five days out, she was attacked with 
 cholera. The disease did not then exist, and has 
 not since (as shown by a number of arrivals from 
 that port later) existed at Liverpool. It was, on 
 the voyage and at the quarantine, confined entirely 
 to the steerage.* 
 
 The Virginia arrived, also from Liverpool, April 
 18th, at New York quarantine station. She had 
 1043 passengers, 14 saloon and 1029 steerage, most 
 of the latter being German and Dutch. Leaving 
 Liverpool on the 4th, on the 12th cholera broke 
 out among the steerage passengers, in the " orlop," 
 below the deck and beneath the water line : 37 
 died during the voyage. After reaching quaran- 
 tine, being detained there, the disease increased, 
 but still was exclusively confined to the steerage 
 passengers. 
 
 Now, how did these vessels get the cholera ? 
 
 * Eight passengers escaped from the England, and one 
 died of cholera at Halifax ; without any other cases fol- 
 lowing there. Dr. Slayter, of Halifax, went on board of 
 the vessel, took the disease, and died of it. 
 
CAUSATION. 31 
 
 Not at Liverpool, for there was none there. Did 
 German emigrants bring it on board ? If they 
 could have, why, as they stopped at Liverpool, 
 did they not infest that city also ? But yester- 
 day (April 30th), a steamer arrived direct from 
 Hamburg, with no tidings at all of cholera in Ger- 
 many. Dr. E. B. Dalton, Sanitary Superintendent 
 of New York, and Dr. Elisha Harris, a distin- 
 guished sanitarian, went officially on board the 
 Virginia, and carefully questioned v the passengers 
 in regard to their original starting-places. They 
 had none of them knowledge of any epidemic in 
 any place they came from or through. The near- 
 est possible approach to anything whatever of the 
 kind was said to be that, "during the past ivinter, 
 the disease had appeared in certain towns in Sax- 
 ony, near which some of them had resided !" 
 
 Determined, indeed, must any one be to insist 
 upon the communication theory, who will account, 
 by a vicinity dating back to "last winter," for an 
 epidemic commencing out at sea, in April, which, 
 yet, in neither of three ships successively so af- 
 fected (including the Atalanta of November), can 
 be or has been communicated from the steerage to 
 the cabin of the same vessel ! So palpable was 
 the contrast of safety and of infection between the 
 saloon — spacious, clean, and well aired — and the 
 steerage — crowded, close, and unwholesome — that 
 the cabin passengers on one of those vessels pre- 
 
38 
 
 ON CHOLERA. 
 
 ferred to remain upon it, in their apartments, to 
 being removed elsewhere, in the immediate and in- 
 salubrious company of the emigrants among whom 
 the disease had proved so destructive. 
 
 These cases appear to me extremely important, 
 as explicable, clearly and consistently, only upon 
 the view that the cholera-cause has the power of 
 migration across the sea ; a crowded vessel, like a 
 filthy city on land, affording the local conditions 
 for its manifestation, propagation, and extension. 
 
 Wishing to give fall legitimate effect to all that 
 can be asserted of a different tenor from what I 
 maintain, I quote the following from Dr. Harris, 
 in a recent report:* 
 
 "In studying the history of fourteen epidemics 
 of cholera that have occurred within the walls of 
 our New York quarantine establishment, the 
 writer has seen abundant evidence of the infec- 
 tious agency of the sick and their 'rice-water 7 
 evacuations. 
 
 " Concerning these repeated outbreaks of chol- 
 era at quarantine, it should be stated, that while 
 they proved how fatally infectious the cholera poi- 
 son may become in the midst of crowded hospi- 
 tals and public institutions, they have utterly failed 
 
 * Report on Epidemic Cholera by the Council of Hy- 
 giene and Public Health of the Citizens' Association of 
 New York. November, 1866. 
 
CAUSATION. 
 
 39 
 
 to prove that from the same exclusive cause — viz., 
 the contagion of the cholera evacuations — a world- 
 wide epidemic could be caused. These outbreaks 
 did prove, however, that the stools and besmeared 
 clothing of the sick with cholera can, under cer- 
 tain circumstances, propagate the disease ; while, 
 on the other hand, a series of events at quaran- 
 tine and in the city demonstrated, that, for the 
 production of a wide-spread epidemic, other im- 
 portant causes than the presence of the rice-water 
 stools and vomitings must be present. " 
 
 II. Let us now examine, briefly, the theories 
 which connect the propagation of cholera exclu- 
 sively with the discharges of those who have the 
 disease. They are, that of the late Dr. Snow, of 
 England, and those of Pettenkofer and Thiersch, 
 of Munich. 
 
 Snow's theory was, that a poison is generated 
 by the morbid process of the cholera attack ; which 
 poison passes from the bowels of the patient ; that 
 this poison is conveyed by the water which ab- 
 sorbs it from the tainted atmosphere about him ; 
 and thus, through " continuous molecular change," 
 it taints destructively the systems of those who 
 drink such water, or the water of streams polluted 
 by sewage or drainage into which cholera excre- 
 ments pass. 
 
 It has already, I consider, been shown — 1st, that 
 there are facts which this theory will not account 
 
40 
 
 ON CHOLERA. 
 
 for; and, 2dly, that all the facts (many as they 
 are) proving the important influence of drinking 
 water over the mortality of cholera, can be ex- 
 plained as well upon another, wider view. 
 
 Pettenkofer's theory is much like Snow's ; but 
 he supposes the poison not to pass as such from 
 the bowels of the patient ; but that it is produced 
 by a sort of post-excretory fermentation, which re- 
 quires several days of time, and is effected in the 
 water beneath the surface of the ground. He 
 makes a very large estimate of the importance of 
 the soil and substrata of a place in determining 
 its liability to cholera. He denies that it can ever 
 prevail over rock. 
 
 On this I would remark — 1st, that it has pre- 
 vailed upon rocky sites ;* 2dly, that this theory 
 cannot, any more than Dr. Snow's, explain all the 
 facts ; 3dly, that a theory which will account for 
 all other facts, will also explain those on which he 
 relies. 
 
 Dr. Parkes and others seem ready to make use 
 of a recent modification of Pettenkofer's views, 
 which is certainly convenient and ingenious. This 
 is, the hypothesis that the "germs" of cholera 
 poison, once produced, are not destroyed for some 
 
 * See Brit, and For. Medico-Chir. Review, Jan. 1857, p. 
 66; also, Brigham on Cholera, p. 33; Drasche, Die Epi- 
 demische Cholera, Vienna, 1860; Kiehl, Ueber den Ur- 
 sprung und die Veihutung der Senciien, etc., Berlin, 1865. 
 
CAUSATION. 
 
 41 
 
 time by desiccation ; that the tainted faecal mat- 
 ters, though formed in water, may become dry 
 enough to be carried, as dust, through the air. 
 
 This is, I believe, at the present moment, the 
 theory which has the greatest number of influen- 
 tial advocates in England ; and some elsewhere. 
 
 I ask, can it be imagined that such cholera dust 
 (if not endowed with the vitality of microphytic 
 sporules or animalcular ova) could multiply as the 
 cholera cause must, or could be swept over the 
 ocean far enough to reach a vessel two weeks and 
 more from the shore it had left ? 
 
 The parenthetical words of this last sentence 
 imply the direction in which my reasonings (and, 
 I hope, those of my reader also) are, by exclusion, 
 impelled. 
 
 III. An organic nature, that of a living organ- 
 ism, is thus suggested as most probably belonging 
 to this undiscovered cause. The combination of 
 persistent identity, with extensive mobility, can, 
 I think, be no otherwise explained. I regard this 
 as not at all a vague conjecture, the mere resort 
 of ignorance ; but as a logically obtained scientific 
 hypothesis ; needing but little, if anything, to make 
 it a theory worthy of universal adoption and appli- 
 cation. It has been, in such a sense, considered 
 seriously by such careful reasoners as Sir H. Hol- 
 land, Prof. Alison, and Prof. Max Pettenkofer. 
 
 I repeat the question — can it be imagined that 
 
42 ON CHOLERA. 
 
 an excrementitious "dust," not organic or vitalized 
 at all, should multiply itself so as to account for 
 the world-wide spread of cholera ? 
 
 If it could, observe then the other horn of the 
 delemma ; how could it ever cease doing so ; how 
 could cholera ever stop, until the human race was 
 destroyed ? At all events, how could it disappear 
 as it does, after visitation, from Europe and Amer- 
 ica, for long terms of years ? 
 
 Variability in reproduction, under complex and 
 partly unrecognized causes, is a characteristic of 
 animal and vegetable life. This would account 
 for such facts, and this alone. 
 
 The organic theory has been asserted in two 
 forms:* the vegetative or microphytic, and the 
 
 * Vide Holland's Med. Notes and Reflections; Essay on 
 the Hypothesis of Insect Life as a Cause of Disease. I 
 cite from this work the following curious facts : 
 
 " The Hessian fly, on its first appearance in America, 
 afforded a singular example of slow progressiva movement. 
 First observed in Long Island, in 1776, it proceeded into 
 the interior, at the rate of ten or fifteen miles in the year, 
 destroying all the wheat in its progress. The spread of 
 the Blatta orientalis in northern Europe is another fact of 
 a similar kind." 
 
 "In October, 1836, a vast swarm of minute aphides 
 passed over a wide district in Cheshire, Derbyshire, and 
 other counties. The air was so thickly filled with them, 
 that the clothes and faces of persons walking out of doors 
 were completely covered. From observations taken, the 
 
CAUSATION. 
 
 43 
 
 animalcular. The first is not set aside by any 
 positive facts ; but it does not explain any more 
 than the second ; while the remarkable mobility 
 or migratory power of the mysterious agent in 
 question points rather to the animalcular theory. 
 
 IY. To this, then, we are brought at last ; with 
 only one other alternative, as, not a substitute, but 
 an amendment for it. I mean the view advanced 
 recently by two members of the Philadelphia 
 Academy of Natural Sciences, the late Dr. Wilson 
 and J. Cassin ;* that reason exists for distinguish- 
 ing a third kingdom of nature, besides animals 
 and plants ; for which they propose the name of 
 Primolia. If such organisms as sponges, many 
 infusoria, volvocineae, diatoms, and desmidise, have 
 attributes neither animal nor vegetable, and yet 
 clearly organic, it is evident that our previous 
 classifications of natural forms are incomplete. 
 
 superficial extent of the mass must have been at least 
 twelve miles in one direction by five miles in another ; but 
 detached notices from other places make it certain that the 
 continuous swarm was much more widely spread. No 
 proof was obtained as to its rate of movement ; but Man- 
 chester was infested for two or three successive days. 
 Wherever generated, there is cause to suppose that the 
 swarm was in transit from one place to another, and pos- 
 sibly brought nearer to the earth by some peculiar state 
 of the atmosphere." 
 * Proceedings of Acad. Nat. Sciences of Philadelphia. 
 
44 ON CHOLERA. 
 
 So are our observations. With each increase 
 in their means and facilities, come new discoveries. 
 No limit to microscopic, any more than to tele- 
 scopic possibilities. Because we have not found 
 any peculiar cholera animalcules, or primalia, it 
 does not at all follow that they have no existence. 
 
 The chief haunt and residence of cholera being 
 in warm or hot climates, with luxuriance of or- 
 ganic development, this is strongly in favor of the 
 hypothesis. So is its general prevalence in tem- 
 perate regions during the warmer part of the 
 year.* 
 
 Against it, we have two facts especially ; as fol- 
 lows: 
 
 Firstly, cholera has, on a few occasions, prevailed 
 in cool or cold latitudes ; as in winter in the north 
 of England, and the north of Russia. As to this, 
 it has been recorded that the winter of 1831-32, 
 when it existed in the north of England, was, as 
 shown by Mr. Losh's Meteorological Journal,f 
 exceptionally mild. In Russia, also, the summer 
 of 1830 was oppressively warm, and the disease 
 began at Moscow in September. In the cities of 
 northern Russia, moreover, the domestic habits of 
 
 * September has had, altogether, the greatest number of 
 deaths. Vide Brigham on Cholera; G. Milroy, loc. cit., 
 etc. 
 
 f Brit, and For. Medico- Chirurg. Review, April, 1856, 
 p. 304. 
 
CAUSATION. 45 
 
 the population, in heating their houses, maintain a 
 sort of green-house, or internal warm climate, 
 throughout the winter. Thus, any " germs" trans- 
 ported thither in the summer or autumn, if other 
 favoring circumstances were present (as they 
 are), might well be kept alive. Moreover, as Dr. 
 Routh has shown, the poorer Russians throw out 
 everything around their houses ; and then melt 
 the snow for their drinking water. 
 
 It may be incidentally mentioned, that the me- 
 teorological conditions most frequently coinciding 
 with the outbreak and continuance of cholera, are, 
 those of moderately high temperature, and stag- 
 nation, or deficiency of atmospheric change or 
 movement.* 
 
 Secondly y it has been very plausibly assertedf 
 that no parasite, invading or residing in the human 
 body, ever causes violent or destructive acute 
 disease; but only slow local disorders. Before 
 trichiniasis attracted the attention now drawn to 
 it, this statement had more weight than now. Of 
 animal or vegetable parasites there had been, per- 
 haps, before, only one record of any that had en- 
 dangered life by residence in or upon the body ; 
 that of the mycetoma, or disease produced by a 
 
 * Glaisher, Meterology of London during cholera, etc.; 
 T. H. Greenhow, loc. cit. 
 f J. Simon, Lectures on General Pathology. 
 
46 ON CHOLERA. 
 
 peculiar fungous vegetation attaching itself to the 
 limbs, in India, as described by Dr. Carter, of 
 Bombay. And the effects of this were slow; no 
 acute systemic malady was produced. But the 
 lives destroyed by trichinae lately in some of the 
 German towns afford instances of importance. It 
 is especially notable that these last parasites seem 
 to act by numbers; a few may be detected in the 
 flesh of animals or men, without serious injury to 
 either ; it is by multitude that they disturb seri- 
 ously or even kill. 
 
 However, the "organic" theory does not require 
 parasitic action to make it possible. Life is only 
 predicated as an attribute of the cholera-cause in 
 accounting for its variable multiplication and mi- 
 grations. Its mode of action upon the human 
 body is a separate question. It is most probable 
 that it is not by parasitic residence ; but by enter- 
 ing the system as an organic poisonous material. 
 For the action of such material, of animal origin, 
 abundance of analogy exists ; as in the toxic effects 
 of cantharides, of in sect- stings, venom of serpents, 
 and of rabid animals ; of dissecting wounds, and 
 spoiled meat or sausage used as food. 
 
 My theory, then, is as follows : That the cause 
 of cholera is a (yet undiscovered) protozoon, or 
 primal organism, of extreme individual minute- 
 ness ; which, on entering the human body, affects 
 it as an organic poison. That the varying quan- 
 
CAUSATION. 47 
 
 tity or number of these organisms may in different 
 cases account (along with individual predisposi- 
 tions and exposures) for the unequal violence of dif- 
 ferent epidemics ; as in the case of trichiniasis. Cho- 
 leraic diarrhoea or cholerine, so frequent before as 
 well as during and after the prevalence of cholera, 
 may in some instances at least be explained by the 
 action upon the alimentary canal only, of a mini- 
 mum quantity of the cause. The dreadful fatality 
 of some Indian seasons, is on the same view re- 
 ferred to an extreme accumulation of it. 
 
 A most important part of the theory is, further, 
 that which concerns promotive causation. What 
 conditions favor and maintain in life, multiplica- 
 tion and migration, this ens primalis f 
 
 All the facts answer, as I believe, that animal 
 matter in a state of rapid and foul decomposition, 
 putrefaction, along with moderately high (not the 
 highest) temperature, and ordinary moisture, will 
 afford those conditions ; and that nothing else is 
 required to explain the whole history of the pro- 
 pagation and extension of cholera. Nothing, I 
 mean, but the admission of the existence of the 
 "protozoon," which in ova or in maturity, or 
 both, may fly "on the wings of the wind;" or be 
 conveyed to less distances by water; and, with 
 these the above-named conditions of its vital main- 
 tenance, as its food and " habitation. '? 
 
 It is, in my mind, obvious that this theory will 
 
48 * ON CHOLERA. 
 
 explain all the facts. I believe, also, that some 
 well-known facts can be explained by it alone. 
 
 As to the general facts, I can scarcely do better 
 than repeat, with some extension, words written 
 eleven years ago, and referred to at the beginning 
 of this essay.* 
 
 The Gangetic delta being the great focus or 
 centre of cholera, certain traits in the usages and 
 circumstances of that locality and its population 
 have a direct bearing upon the subject. Among 
 these may be named the peculiarity of the inhab- 
 itants in disposing of the dead. Most of them 
 either burn the bodies, and this very imperfectly, 
 or throw them into the Ganges or its tributary 
 streams; that river being held to be sacred ■ — a 
 gateway to heaven. In the Hooghly river, Stewart 
 Clark says,f he has seen "upwards of fifty dead 
 human bodies, besides numbers of carcasses of 
 lower animals, floating within sight at one time." 
 At Allahabad, at the junction of the Ganges and 
 the Jumna, many persons drown themselves as 
 devotees, and others are often drowned by the 
 pressure of crowds immersing themselves in the 
 sacred spot. J The worship of Juggernauth has 
 
 * On Animal Decomposition, etc. By H. Hartshorne, 
 M.D. Philadelphia Med. Examiner, August, 1855. 
 f Hygiene of the Army in India, p. 63. 
 % Stocqueler, Handbook of India, p. 366. 
 
CAUSATION. ' 49 
 
 produced a greater mortality still. The average 
 of pilgrims annually visiting the temple of this 
 deity was, a few years since, 120,000. Of these, 
 thousands die from famine, fatigue, and exposure, 
 and are left on the road to rot. 
 
 The annual wide overflow of the Ganges, and 
 its withdrawal in the dry season, must increase 
 the amount of animal decomposition. The Nile 
 also inundates, every year, the land of Egypt. 
 How is it, then, that cholera has but half a dozen 
 times invaded the latter country, while always at 
 home in India ? I conceive the difference to have 
 a twofold, and yet very simple explanation. The 
 climate of Egypt is proverbially dry, from the 
 vicinity of the great deserts. Decomposition there 
 meets with its minimum of rapidity. The skin 
 of an Ibis, shot for me in Upper Egypt, simply 
 cleaned without anything antiseptic, and hung up 
 on the deck of a boat in the sunshine, kept for 
 two weeks without any odor or other sign of 
 putrefaction. 
 
 Further, the inhabitants of Egypt neither bury 
 nor drown themselves from superstition in the 
 river Nile. If their habits were not, in some lo- 
 calities, especially when crowded away from their 
 homes, uncleanly, there ought, and would, I be- 
 lieve, never be any cholera in Egypt. 
 
 The Hindoos, however, must be inconceivably 
 filthy in many ways. S. Rogers, F.R.S., a British 
 
50 
 
 ON CHOLERA. 
 
 army surgeon, gives the following example, in a 
 Report on Cholera in Madras : 
 
 " The Coom river nearly encircles the village of 
 Chintandrepett. This river was made a privy of 
 ' by hundreds of natives, daily ; when the water be- 
 came low, the smell was most offensive. In the 
 hot weather, an attack of cholera was the certain 
 result, the only victims being those residing with- 
 in a short distance of its banks. " 
 
 In Europe and the United States, as well as in 
 India, influences belonging to closely aggregated 
 communities have always been observed to dis- 
 play a power to propagate cholera. It comes 
 most often, stays longest, and is most destructive, 
 in the densest and filthiest cities, and in the worst 
 quarters of those cities. In even the densely pop - 
 ulated country of Holland, Suermann found the 
 mortality to be 1*54 in 1000 in rural districts; in 
 the towns, 8*93 in 1000. Moscow, Paris, Mar- 
 seilles, Liverpool, Manchester, Edinburgh, New 
 York, and Quebec have had great mortality from 
 it. That of Moscow, in 1832-33, was 1 death 
 from cholera in 32 of the whole population. 
 
 Dr. Baly says, in his " Report" upon cholera in 
 England, that "in the evidence received, lowness 
 of site is not very prominently set forth among 
 the unfavorable sanitary conditions; being, in 
 fact, specifically mentioned only five times ; while, 
 out of 68 places where cholera raged, bad ventila- 
 
 
CAUSATION. 51 
 
 tion and overcrowding of houses are mentioned 
 fifty-four times, defective drainage twenty-eight 
 times, cess-pools, open sewers, etc., sixteen times." 
 
 Three prisons at Wakefield, all on one plot of 
 ground, seventeen acres in extent, differed* in chol- 
 era mortality precisely in proportion to their re- 
 spective sanitary conditions. Stewart Clark men- 
 tions corresponding facts in India. This author 
 also mentions a case narrated by Dr. Thompson, 
 in which cholera affected one side only of a ship, 
 which was foul ; the disorder ceasing when purifi- 
 cation was effected. 
 
 Very important testimony exists as to the influ- 
 ence of the drinking water of localities. Having 
 shown that Dr. Snow's theory is insufficient, we 
 find such testimony available still in regard to the 
 propagating and extending power of animal con- 
 tamination. Thus, Bethlehem Hospital, supplied 
 by an artesian well, had, in 1849, among 400 in- 
 mates, no case of cholera. It was the only large 
 lunatic hospital in London which escaped ; as it 
 was the only one supplied with spring water. In 
 the districts of London supplied from the Thames 
 above the entrance of the sewers, the mortality 
 ranged from 8 to 33 in 10,000 of the inhabitants; 
 in those supplied from below the entrance of the 
 sewers, from 28 to 205 in the same number. 
 
 * Baly, op. cit, p. 20. 
 
52 
 
 ON CHOLERA. 
 
 
 In this country, Dr. James Wynne's report* 
 affords, upon almost every page, matter of exactly 
 the same purport as the above. In St.. Louis, 
 Louisville, Buffalo, New York, Philadelphia, Bos- 
 ton, etc., similar facts were recorded. It is unne- 
 cessary to extract them, they are now so familiar 
 and so commonly accepted. 
 
 All of Pettenkofer's and Thiersch's observations, 
 in regard to subsoil accumulation and transit, and 
 fgecal fermentation after discharge, range them- 
 selves now naturally under the one general fact 
 which they exemplify, viz., that animal decompo- 
 sition is the one great promotive cause of cholera ; 
 to which heat and moisture, etc. are merely ad- 
 juncts. 
 
 But, that which suggested first to me this opin- 
 ion was, the singular history of the outbreak at 
 Columbia, Lancaster County, Penn., in Septem- 
 ber, 1854. Cholera had never visited that town 
 before. It is not large or populous, in a rural 
 site, on the Susquehanna, not densely built enough 
 to exclude malarial fevers. Why should it have 
 cholera at all ? 
 
 Visiting the town, with other physicians of our 
 city, during the epidemic, I learned that an ex- 
 ceeding drought had reduced the channel of the 
 river to an unusually low ebb, and that, in its bed, 
 
 * Presented to Parliament, and published in 1852. 
 
CAUSATION. 53 
 
 a short space above the town, a number of car- 
 casses of sheep and other animals, thrown from 
 the railroad trains, etc., were putrefying rankly in 
 the sun. A reservoir which supplied many of the 
 people with drinking water was filled from the 
 river not far from that spot, and the wind blew 
 from it directly over the town. The first subsi- 
 dence in the disease, we were afterward told, at- 
 tended a decided change in the wind. 
 
 At Pittsburg, shortly after the above events, a 
 similar epidemic occurred. A gentleman on a visit 
 to that locality not many days before the disease 
 broke out, informed me that the same condition of 
 the river existed there, with a like abundance of 
 accumulated putrefying animal matter, exposed 
 to the sun. 
 
 In Rhode Island, in the autumn of the same 
 year, I was informed that the local existence of 
 cholera in a few spots, otherwise very healthy, 
 might be traced, in coincidence at least, with a 
 practice not uncommon along the shore of the sea 
 or bays, of dragging up fish in quantities by nets, 
 and spreading them out to rot for manure. 
 
 Enough, then, of these facts and of their argu- 
 ment. There remains the great practical ques- 
 tion, which they ought to help us to solve — what 
 are the best measures ,for the local exclusion or 
 prevention of cholera ? 
 
54 
 
 ON CHOLERA. 
 
 PBEVENTION. 
 
 Quarantine is now urged by some, and appears 
 to be even contemplated by the Government as a 
 part of its duty. Is it available ? Will it do any 
 good ? I say, no. Theoretically, if the views ad- 
 vocated in the preceding pages are correct, it falls 
 to the ground of course. But we have more than 
 that to say against it. It never has succeeded; 
 and never can. Let us look at the facts. 
 
 I take the following from Dr. Brigham's work 
 on cholera, published in 1832 :* 
 
 " In Russia, immense lines of troops were formed 
 for arresting its progress ; St. Petersburg was en- 
 tirely surrounded by cordons sanitaires; but all 
 these regulations, enforced by a powerful despotic 
 government, were unable to prevent the approach 
 and the spread of the cholera throughout the Rus- 
 sian Empire. The efforts of Austria were equally 
 unavailing ; for in a short time the disease passed 
 her triple cordons and invaded the country from 
 Poland. Prussia employed sixty thousand of her 
 best troops to enforce her rigorous restrictions, and 
 travellers bear testimony to their severity. And 
 what (says the American Journal of Medical Sci- 
 ences, May, 1832) have been , the results ? An im- 
 mense expenditure of money, the suspension of 
 commerce, a stop put to industry, multitudes de- 
 
 * P. 302. 
 
PREVENTION. 55 
 
 prived of the means of acquiring subsistence, and 
 whole families plunged into misery and rendered 
 favorable subjects for the disease ; but no stop to its 
 extension ; on the contrary, its progress was ren- 
 dered more fatal. As an instance of this, Breslau 
 may serve as an illustration and a warning to 
 other cities. That city contained 90,000 inhab- 
 itants, active, commercial, and industrious,- many 
 of them manufacturers and artisans. A quaran- 
 tine of twenty days, with difficulties almost insur- 
 mountable which it entailed, was established at 
 the borders of the province, and maintained with 
 a rigor which might serve as a model to other na- 
 tions. But, in the midst of this apparent security, 
 a woman living in a damp part of the town was 
 attacked by the cholera, and in a few days the 
 disease spread. The most minute researches on 
 the part of the public authorities could not dis- 
 cover any communication between this woman 
 and any stranger or goods suspected of being in- 
 fected. But when the disease spread, the authori- 
 ties saw too late the deep injury which their sani- 
 tary measures had inflicted ; a multitude of fami- 
 lies, and thousands of individuals, were plunged 
 into extreme misery, for the sudden cessation of 
 commerce, and consequent suspension of labor, had 
 deprived them of the means of subsistence. 
 
 " Taught by sad and lamentable experience, 
 Russia, Austria, and Prussia withdrew their cor- 
 dons, and acknowledged not only their inutility, 
 
56 ON CHOLERA. 
 
 but that they are productive of immense evils. 
 Indeed, all the nations of Europe are (1832) aban- 
 doning severe quarantine regulations." 
 
 Dr. Alison, of Edinburgh, wrote thus in 1854 :* 
 
 " It is a fact that cholera has made its way, not 
 uniformly, but very generally, in spite of cordons 
 and quarantine regulations." 
 
 Dr. Gavin Milroy, one of the ablest and most 
 industrious sanitarians of our time, published, 
 about the same year, an essay with this title: 
 11 The Cholera not to be Arrested by Quarantine." 
 A writer in the Brit, and For. Medico- Chirurg. 
 Review (July, 1861) cites from that and many 
 other authentic sources facts of great interest bear- 
 ing on the subject. This is his account of the state 
 of quarantine in different countries : 
 
 "What is most remarkable in the quarantine 
 regulations of different countries at present, is the 
 fact of their want of accordance ; hardly any two 
 being alike. Another noticeable point is, that, the 
 more liberal the government of a country gene- 
 rally, and the freer its institutions, the fewer and 
 less stringent are the quarantine restrictions. In 
 the Baltic States, in Sweden, Denmark, Prussia, 
 Holland, the regulations formally enacted may be 
 considered almost as a dead letter ; so in Belgium, 
 where they are rather nominally than really in 
 force. In the United States of America, each 
 
 *Brit. and Foreign Medico-Chirurg. Review, Jan. 1854. 
 
 
PREVENTION. 57 
 
 State of the Union has its own code ; all of them, 
 according to a resolution of the Quarantine Con- 
 vention held at Philadelphia in 1857, inefficient 
 and often prejudicial to the interests of the com- 
 munity. In Chili and Peru, and along the whole 
 western coast of South America, the tendency is 
 to disregard all quarantine regulations, as inter- 
 fering with the freedom of commerce. In that 
 anarchical country, Mexico, quarantine is under no 
 legislation, the Board of Health having unlimited 
 power, which it sometimes exercises most tyran- 
 nically. In the South of Europe, in the old king- 
 dom of the Two Sicilies, the codes are, or were, 
 most elaborate and rigorous. In France and Sar- 
 dinia, they have of late years undergone revisal ; 
 and yet, though somewhat improved, they are still 
 open to great objection ; fortunately, however, they 
 are mildly enforced. In the Ottoman dominions — 
 including Egypt, in which, little before 1840, there 
 were no quarantine restrictions — a system has 
 been established as elaborate as could well be con- 
 trived, and as inefficient as can well be imagined, 
 being totally in opposition to the feelings and 
 habits of the people."* 
 
 All are familiar with the entrance of cholera 
 from Arabia into Egypt, and afterward Europe, 
 
 * At Marseilles, in France, the people are said to have 
 lately, under panic, asked for the restoration of the quar- 
 antine. 
 
58 ON CHOLERA. 
 
 in the spring and summer of 1865. All existing 
 regulations clearly failed then. We cannot but be 
 astonished that, at the late " Cholera Conven- 
 tion," held at the instigation, and almost under 
 the dictation, of the French Emperor, increased 
 rigor of quarantine should have been (against the 
 remonstrance of a number of delegates, it is true) 
 insisted upon as the desideratum hereafter. What- 
 ever validity such an enactment may have in 
 political relations, let us hope that it will have 
 none whatever in a scientific aspect ; as it contra- 
 dicts facts, reason, and true expediency. 
 
 The inefficiency of quarantine is a matter of 
 demonstration. As the author just quoted re- 
 marks,* " quarantine, even when rigidly enforced, 
 has not kept out diseases of the contagious nature 
 of which there is no question ; such as small-pox, 
 and other exanthemata. In Malta, for instance, 
 we are assured on good authority, that in the 
 short space of seven years, 1829-1835, in spite of 
 quarantine regulations for their exclusion, that 
 island was twice invaded by small-pox, one epi- 
 demic proving fatal to 1500 persons out of a popu- 
 lation of 114,000 ; and also hj measles, scarlatina, 
 and hooping-cough. Yet at Malta the quarantine 
 system has been enforced very regularly, and under 
 more favorable circumstances as to efficiency than 
 anywhere else." 
 
 * Review, p. 40. 
 
 
PREVENTION. 59 
 
 Quarantine, if sound in theory even, could not 
 avail, never has availed in practice. Its infraction 
 for smuggling and other inducements, is every- 
 where constant and notorious ; this cannot be pre- 
 vented. Macaulay (History of England, vol. v. p. 
 52) states that when a contraband trade was, in 
 the time of William III., carried on between 
 France and England on the southeastern coast, 
 " it was a common saying among the inhabitants, 
 that if a gallows were set up every quarter of a 
 mile along the coast, the trade would still go on 
 briskly." 
 
 One might think the history of blockade-run- 
 ning, during the late rebellion in this country, 
 might afford ample illustration and confirmation of 
 this. Vain, indeed, would be the attempt to close 
 our coast against the introduction of cholera, were 
 it as contagious as small-pox, or as plague was 
 once imagined to be.* 
 
 The evils of quarantine are great, almost incal- 
 culable. Sir John Bowring, speaking in the House 
 of Commons in 1841, gave it as his belief that the 
 losses from quarantine in the Mediterranean alone 
 were not less than two or three millions sterling 
 a year. 
 
 But what if, instead of preserving, quarantine 
 
 * The Governor of Eupatoria is said to have wished the 
 British and French troops to undergo quarantine, at the 
 opening of the Crimean war! 
 

 60 ON CHOLERA. 
 
 actually involves, often, sacrifice of life? No 
 doubt this has many times occurred. With yellow 
 fever, the quarantine epidemic in New York har- 
 bor, a few years ago, exemplified this. In various 
 quarters reports of travellers show the miseries 
 and dangers of the lazaretto, and of the confine- 
 ment on the vessel detained. 
 
 What more do we need to show this than the 
 very recent instance of the steamer England, at 
 Halifax? Forty passengers, one account says 
 fifty (out of 1202), died on this vessel during the 
 voyage. She was prohibited from entering port ; 
 all were detained on board, and, by April 14th, 
 130 more deaths occurred ! In all, 159 died while 
 in quarantine. If the twelve hundred passengers 
 had been landed and scattered, I, for one, doubt 
 the occurrence of the disease in a dozen of their 
 number ; especially as it was reported as altogether 
 confined to the steerage. 
 
 Were such measures sure to preserve from the 
 epidemic the whole people of our continent, a 
 hecatomb like this might find excuse. In face of 
 facts, I regard it as a barbarity. Pelissier, in 
 Algiers, was thought a monster, for suffocating a 
 band of guerrillas in a cave ; but what is this case 
 of the England more like, except in motive ? It 
 is closing up hundreds of people for death; as 
 though one might lock the doors, and bar the 
 windows, against all escape of a thousand people 
 from a burning church ; such as that of which we 
 
PREVENTION. 61 
 
 read so harrowing an account, some time back, in 
 South America. 
 
 As I write, the papers have account of another 
 steamer, the Virginia, with over 1000 passengers, 
 attacked in the same latitude and longitude. A 
 striking confirmation of the view I have advanced. 
 
 But it will be said or asked, would you abolish 
 all quarantine — abandon all inspection of ships 
 whatever? No; I would not. But I would 
 abandon altogether the whole theory of quaran- 
 tine, as against cholera most particularly. 
 
 Ships should be inspected on approaching ports, 
 because they may have unsanitary conditions in- 
 tensified in them, on a scale sufficiently large to be 
 important. This is, or should be, a part of sani- 
 tary police. Nor should it (and here is a great 
 point of difference) include any restriction of per- 
 sons; at the most, longer than enough for cleans- 
 ing of the body and of the clothing, and purifica- 
 tion of merchandise, by fresh air, and possibly by 
 some disinfecting process in certain cases. 
 
 I insist that Sanitary Police includes the 
 sum total of available measures for the prevention 
 of cholera in any place. 
 
 On this ground, the measures required are obvi- 
 ous, and familiar. The thorough and frequent 
 cleansing of all streets, alleys, courts, wharves, 
 and vessels, private and public buildings, and 
 empty lots ; the abatement of all nuisances ; daily 
 
62 ON CHOLERA. 
 
 removal of offal ; efficient sewerage ; and conser- 
 vancy, i.e. the cleansing, ventilation, and disinfec- 
 tion of cess-pools and water-closets. Among all 
 signs of danger of the location of cholera, none is 
 more significant than the privy odor. Let it be 
 everywhere annihilated. Lime, charcoal, dry earth, 
 chloride of lime, Labarraque's chloride of soda, 
 liquid coal tar, chloride of zinc, and sulphate of 
 iron are about the most available of disinfectants. 
 
 The fresh white-washing of cellars is useful; 
 thorough ventilation and drying of them and of 
 all parts of habitations, still more so. Chloride of 
 lime may be placed, in a saucer, in any suspected 
 room or other locality in a house. The same, in 
 the solid form, or solution of green vitriol, may be 
 thrown daily into a foul privy ; and, during cholera 
 time, especially in the case of patients with the 
 disease, every water-closet and vessel used may 
 and should be disinfected constantly, by a dilute 
 solution of chloride of zinc, chloride of soda, per- 
 manganate of potassa, or carbolic acid. The im- 
 mediate removal of all discharges from the sick- 
 room, their disinfection and transportation to the 
 safest possible place of elimination, ought to be 
 imperatively maintained. All foul clothing must 
 be promptly washed, or, if very bad, disinfected or 
 burned. 
 
 These precautions have been proved to be capa- 
 ble of essentially limiting and mitigating the preva- 
 lence of epidemics. 
 
PERSONAL PREVENTION 63 
 
 PEBSONAL PBEVENTION. 
 
 One principle will suffice here : to keep the 
 system at par ; neither above its level of excite- 
 ment, nor below that of its due strength. 
 
 For this, regularity of life is required, in work, 
 diet, mental movements, and all indulgences. The 
 popular errors most common are, one, to suppose 
 that living on rice or rice-water, avoiding fruits or 
 vegetables, etc. , will be preventive ; another, to • 
 think constant alcoholic stimulation beneficial for 
 that end. Both are certainly wrong. 
 
 In 1832 and 1849, the late Dr. Joseph Harts- 
 home, my father, then in very large practice, 
 allowed in his family all its usual variety of food : 
 boiled corn, peaches, watermelons, cantelopes, etc., 
 everything but cucumbers; and no cholera re- 
 sulted from the liberty. My own subsequent ex- 
 perience justifies the practice. Of course care is 
 always needed as to quality and quantity. 
 
 Of all those most likely to die when attacked by 
 this disease, the drunkard stands first, according 
 to all records. Nor is he one whit less apt to be 
 attacked than others. Temperance, in all things, 
 is essential to safety during epidemics of every 
 kind. 
 
64 ON CHOLERA. 
 
 TEEATMENT. 
 
 To discuss all the modes of management pro- 
 posed for cholera, would make a volume larger 
 than this is meant to be. I shall merely enumerate 
 those which have attracted the most attention; 
 and then give my view as to what is so well sus- 
 tained as to be worthy of further trial and some 
 confidence. 
 • 1. Bleeding. — This was largely practiced in 
 India, in 1818-1825, by Corbyn, Scot, Annesley, 
 and others. Without entering upon any argu- 
 ment about it, I will simply say, that (as Dr. 
 Brigham's quotations show) as many positive 
 facts have been asserted on behalf of the success 
 of blood-letting as of any other remedy in cholera. 
 My father bled in several cases in 1832, and had 
 confidence in the treatment, as "the most effectu- 
 ally antispasmodic." In 1849 I bled in one case 
 (a boy of twelve years of age), in incipient col- 
 lapse. The blood at first was thick and black as 
 tar ; in a few minutes it flowed more freely, and 
 the patient recovered. I confess that the only 
 thing which makes it unlikely that I will ever try 
 or advise the repetition of this practice is, the 
 want of courage to stem the overwhelming tide of 
 professional and popular opposition now existing 
 against it. In this timidity I may be wrong ; if 
 
TREATMENT, 
 
 65 
 
 so, another generation may afford the demonstra- 
 tion of what is right, in such a way that no one 
 can gainsay it. 
 
 2. Calomel. — This, too, was an old East Indian 
 remedy. Suggested by the almost universal ab- 
 sence of bile in the discharges, which was thought 
 to indicate the need of stimulation of the torpid 
 liver, it has been more largely given than any 
 other medicine in cholera. 
 
 Unhesitatingly, I hold the opinion that calomel 
 is of no earthly use in cholera. The argument in 
 its favor, from the absence of bile in the stools, is 
 rebutted by the fact of its abundance in the gall- 
 bladder ; while the clinical experience quoted for 
 its success is accounted for by the addition to it, 
 almost always, of opium, in the prescription. Nor 
 is the amount of success with it, even then, great. 
 Such is Dr. Gull's conclusion, based upon the ex- 
 amination of a great mass of evidence, given in 
 his report.* 
 
 Dr. Ayre, a British practitioner of some note, 
 gave prominence to a modification of the old calo- 
 mel treatment (in which twenty grains were some- 
 times given at once), by prescribing a grain of 
 calomel every five minutes during the attack. 
 
 3. Saline Treatment. — Dr. Stevens, of Jamaica, 
 proposed this, upon the view that the main patho- 
 
 * Report, etc. of Drs. Baly and Gull, already cited. 
 
 3 
 
66 ON CHOLERA. 
 
 logical .element in cholera was the loss of salts 
 from the blood in the discharges. After the gen- 
 eral failure of saline solutions (of common salt, car- 
 bonate and phosphate of soda, etc.), given by the 
 mouth, had been conceded, Dr. Mackintosh, of 
 Edinburgh, and others, tried the method of injection 
 into the veins (half an ounce of common salt, and 
 four scruples of sesquicarbon ate of soda, dissolved 
 in ten pints of water, at 105° to 120° Fahrenheit). 
 Under this plan, resorted to during collapse, of 
 156 patients in Dr. Mackintosh's hands, only 
 twenty-five recovered. Remarkably improvement, 
 almost like a resurrection, appeared in several, who 
 afterward fell again into collapse, and died. The 
 suggestion has been recently made, that it may 
 have been the temperature of the injected liquid 
 which produced the benefit, so promising and yet 
 transient. 
 
 4. Eliminative Treatment. — Dr. George John- 
 son, of London, has urged this with especial vigor. 
 The castor-oil medication of cholera owes its trial 
 to him. Some recent lectures of his on the pa- 
 thology and treatment of the disorder give a full 
 and very intelligent exposition of his views. A 
 prominent idea with him is, that the general col- 
 lapse is due especially to anaemia of the lungs, 
 owing to spasmodic contraction of the pulmonary 
 artery and its branches. I regard this as only a 
 part of the universal arterial (and other) involun- 
 
TREATMENT. 
 
 61 
 
 tary muscular spasm, belonging to what I have 
 called the ganglionic tetanus of the collapse. But 
 the essential feature of Dr. Johnson's pathology 
 is the opinion that, the disease being toxemic, a 
 morbid poison exists which must be eliminated 
 from the blood ; and that the discharges are the 
 media of this elimination. Therefore, the vomit- 
 ing and diarrhoea are salutary or relieving ; and 
 ought to be rather encouraged than checked. He 
 goes even so far as to repudiate the commonly 
 accepted belief, that " premonitory diarrhoea" or 
 " cholerine " ought to be checked ; considering it a 
 fallacy to assert that those who are relieved of 
 such symptoms by mild treatment were really, or 
 would have been, cases of cholera at all. 
 
 I am entirely unable, from observation or reflec- 
 tion, to assent to these views. They have very 
 few advocates or supporters, besides the distin- 
 guished physician whose name and ability com- 
 mand for them at present careful consideration. 
 It is true that patients have died of cholera with- 
 out vomiting or purging. I saw in 1849 a woman 
 in collapse (from which she recovered) for several 
 hours without either; and many such cases are 
 on record ; though, in some, after death, the in- 
 testines have been found to be distended with 
 the rice-water liquid. But the checking of the 
 discharges is almost always the sign of the im- 
 provement and recovery of the patient. And we 
 
68 
 
 ON CHOLERA. 
 
 cannot, on Dr. Johnson's dictum, set aside or 
 quash all the accumulated evidence, in Europe 
 and in this country,* which shows that it is de- 
 sirable and important to check all watery diar- 
 rhoeas in cholera time — such fluxes having been 
 proved to be often premonitory of cholera attacks. 
 
 5. Ice to the Spine. — Dr. John Chapman's ice- 
 bags threaten to become the "pathy " or therapy 
 of the day, with those who are zealous and ven- 
 turesome in experimental practice. Upon reasons 
 of a physiological nature, not appropriate for dis- 
 cussion here, I disbelieve altogether in the theory 
 of his therapeutics. In his pamphlet upon " Diar- 
 rhoea and Cholera," lately published, he gives but 
 one case of the latter disease, and does not say 
 whether the patient recovered or died. 
 
 As ice is so useful when internally given in cho- 
 lera, it may be safe and beneficial when applied to 
 the spine. Not having seen it tried, I am not 
 prepared to deny the possibility. It is one of the 
 experiments to consider, in so desperate a disease. 
 But, if it should hereafter prove useful, I should 
 explain that result quite otherwise than Dr. Chap- 
 man has done, in part at least. 
 
 6. Sulphuric Acid. — Dr. Cox, of England, after- 
 
 * See Lectures on Cholera, by Prof. A. Clark, of New 
 York ; Report to the Royal College of Physicians, 1854 ; 
 also, Madin, Briquet and Mignot, etc. 
 
TREATMENT. 
 
 69 
 
 ward Mr. Buxton and Dr. Fuller, and very re- 
 cently Dr. Jules Worms, of Paris, have especially 
 recommended dilute sulphuric acid in all stages of 
 cholera. Many others especially report well of its 
 action in the premonitory diarrhoea. Such an 
 action would comport perfectly with the view I 
 have taken of the organic nature of the poison of 
 cholera ; sulphuric acid being so potent a destroyer 
 of everything organic, except such mirabilia as 
 the Acarus Crossii. 
 
 Dr. Worms' treatment (based on the results in 
 238 cases of cholera, and 150 of cholerine, in 
 1865) is as follows: For prodromic diarrhoea, he 
 makes a "mineral lemonade," of about half a 
 drachm of concentrated sulphuric acid to a pint 
 or more of sweetened decoction of salep (arrow- 
 root would do as well). The patient is to take of 
 this every hour a wineglassful, till relieved. 
 
 For confirmed cholera, the patient being kept in 
 complete repose, there is administered every half 
 hour a glass of a similar lemonade, of the strength 
 (about) of a drachm to the pint ; ice and wine also 
 being allowed ad libitum. 
 
 7. Opium in large doses. — This practice had 
 once many advocates ; now they are few. Prof. 
 Austin Flint, of New York, is one of them ; at 
 least morphia is advised by him, in full dose, 
 repeated if required. A great deal of evidence of 
 the insufficiency of such a plan has been published ; 
 
70 ON CHOLERA. 
 
 although it is not worse than several other me- 
 thods. Letting alone would probably be better. 
 The secondary fever is apt to be more severe and 
 more often fatal after treatment of the attack by 
 large doses either of opiates or stimulants. Large 
 quantities of brandy (I add, by the way) have 
 been often used, with no good results. 
 
 Statistics are given, as follows, of the results of 
 some of the most common modes of practice in 
 cholera, by practitioners in Great Britain, as re- 
 ported to the " Treatment Committee of the Medi- 
 cal Council of the Board of Health," 1854-55. 
 
 Taking all grades of the disease, the deaths 
 were — 
 
 Per Cent. 
 
 With Eliminants 71-7 
 
 Stimulants 54 
 
 Calomel and Opium . . . .36-2 
 Chalk and Opium . . . . 20-3 
 
 Of collapsed cases, the mortality was — 
 
 Per Cent. 
 With Calomel and Opium . . . .59-2 
 Larger doses of Calomel . . 60-9 
 
 Salines 62-9 
 
 Chalk and Opium . . . . 63-2 
 Calomel, small doses . . .73-9 
 
 Castor Oil 77-6 
 
 Sulphuric Acid . . . .78-9 
 
 Much is uncertain, obviously, in such statistics, 
 without further account of dosage, circumstances, 
 
TREATMENT. fl 
 
 etc. But this seems to follow ; that neither treat- 
 ment has much to boast of success. 
 
 8. Treatment by antispasmodics and mild 
 stimulants, in small doses at short intervals ; 
 with ice, and external frictions, etc. — In 1849, 
 my first two cases of cholera were fatal; although 
 assiduously watched, each for a day and a 
 night. The third, I saw with the late Dr. Wm. 
 E. Horner, Professor of Anatomy in the Univer- 
 sity of Pennsylvania. I left the treatment to him. 
 He sat down by the bedside of the patient — a 
 man, blue, cold, and with a scarcely perceptible 
 pulse, copiously vomited and purged, with rice- 
 water. Having ordered ice,* Dr. Horner took 
 from his pocket a vial containing a mixture of 
 chloroform, oil of camphor, and laudanum ; which 
 he gave in sweetened ice-water, in small doses, 
 every Jive minutes by the watch. Each dose was 
 followed by a piece of ice. 
 
 Soon the vomiting diminished, afterward the 
 diarrhoea, and in an hour and a half the veins on 
 the back of the hand began to fill up, and the 
 blood to return in them more rapidly after pres- 
 sure. Diminishing the frequency of the doses, we 
 left him, an hour later, evidently convalescent. 
 When I saw him after several hours again, he was 
 
 * Ice was used, and lauded, in cholera, by the celebrated 
 Broussais, in 1882, 
 
?2 ON CHOLERA. 
 
 sitting up in bed, at ease, and so changed, that I 
 doubted at first his identity. No secondary fever 
 followed ; he was cured. 
 
 Naturally, I repeated this treatment in all my 
 subsequent cases, some of which were of extreme 
 severity; and with gratifying success. The 
 memorandum-book of the number of these cases 
 has, to my present regret, been mislaid. After 
 the treatment of Prof. Horner had been adopted, 
 however, I saw no death, except in the instance 
 of a drunkard, two or three hours in collapse be- 
 fore any medical treatment began. 
 
 Should I be attacked with cholera, such is the 
 treatment I desire. Conscientiously I believe, 
 that nothing else will afford a better chance of 
 recovery. I merely altered Prof. Horner's mix- 
 ture to a tincture, for better presei^ation ; adding 
 some minor adjuvants. This recipe will be given 
 directly. Frictions and sinapisms may also be 
 added. The great merits of this plan are its anti- 
 spasmodic nature, and the administering of small 
 doses at very short intervals. This is eminently 
 demanded in cholera. Phthisis may be a com- 
 plaint of years ; hooping-cough, of months ; ty- 
 phus, of weeks ; pneumonia, of days ; but chol- 
 era must be numbered by its hours, half hours, 
 or even minutes. 
 
 Having reached, then, this conclusion, I may 
 
 
TREATMENT. 73 
 
 add, that a rationale for such a treatment is dis- 
 cernible. I only follow many good authorities in 
 the opinion that cholera is, symptomatically and 
 pathologically, a poison-spasm, or tetanus of the 
 ganglionic system. Taken early, that condition 
 may be prevented, by mild opiates and stimulants, 
 in the premonitory stage. Later, while any medi- 
 cines will act, these will do the most. What is 
 needed in confirmation of this explanation, more, 
 than is given by the action of quinine in prevent- 
 ing an anticipated chill, or, of the same, in full 
 quininization, curing the paroxysmal disease (a 
 toxaemic neurosis) of intermittent ? An antagon- 
 istic influence against that which so perturbs in- 
 nervation throughout the body ; such is the whole 
 definition that we can give of the remedial power 
 shown in either case. 
 
 Let me be more specific in reference to treat- 
 ment. Premonitory diarrhoea is very generally 
 admitted to be present in a majority of cases of 
 cholera.* In the East Indies, many writers, of 
 different dates (Lawrie, 1832, Stewart Clark, 
 1864, etc.), assert such a stage to be an exception 
 instead of the rule. But, in India, they have a 
 premonitory or incipient stage of another kind; 
 
 * Barraut asserts fixed contraction of the pupil to be 
 the first prodromic sign; M. Worms makes the same state- 
 ment in regard to albuminuria. 
 
74 
 
 ON CHOLERA. 
 
 characterized by great languor or depression, with 
 restlessness, and sometimes ringing in the ears, 
 occurring mostly in the night. Stewart Clark 
 states* that, in this stage, a mild opiate ("with a 
 little calomel or blue pill "), with a cup of warm 
 tea or a small dose of a diffusible stimulant, as a 
 few grains of carbonate of ammonia, or a little 
 weak warm brandy and water, will arrest the at- 
 tack in a great portion of cases otherwise to be- 
 come serious. 
 
 Such symptoms, as well as diarrhoea, should be 
 noticed here, during a cholera epidemic ; and I be- 
 lieve the same treatment will meet both. Rest, 
 warmth, and mild, composing, but gently stimulat- 
 ing draughts ; paregoric, aromatic spirit of ammo- 
 nia, tincture of ginger, lavender, etc., with a mus- 
 tard-plaster over the abdomen, and a hot mustard 
 foot-bath if coldness of the body increase, or vom- 
 iting begin ; such are safe, and I believe will be 
 efficient remedies. The above may be called the 
 first or prodromic stage, f 
 
 The next has been well called, by Prof. A. 
 Clark, the rice-water stage. For that, the treat- 
 ment I have described as given to me by Prof. 
 
 * Hygiene of the Army in India, p. 12. 
 
 f The recently published experience of Dr. Hamlin, in 
 Constantinople, confirms the importance of the above 
 early treatment. 
 
TREATMENT. 75 
 
 Horner is particularly adapted. My recipe, based 
 upon his, is as follows : 
 
 R. — Chloroform, et 
 Tinct. Opii et 
 Sp. Camph. et 
 
 Sp. Amnion. Aromat, aa f 3jss ; 
 Creasot. gtt. iij ; 
 01. Cinnamom. gtt. viij; 
 Sp. Vin. Gall, fgij.— M. 
 
 Dissolve a teaspoonful of this in a wineglassful 
 of ice-water; and give of that two teaspoonfuls 
 every five minutes; followed each time by a lump 
 of ice.* 
 
 Friction of the limbs with brandy and red pep- 
 per will be, along with large mustard-plasters on 
 the back and pit of the stomach, useful to promote 
 reaction. 
 
 The third stage is that of absolute collapse; 
 blue, pulseless, shrunken, voiceless. Should a case 
 go on, in spite of the above-mentioned treatment, 
 into this state, what else can be done ? All now 
 
 * I take from Dr. Aitken's Practice the followhig recipe, 
 much used and approved in India and England : R. — 01. 
 Anisi, 01. Cajeput., 01. Juniperi, aa gss; iEther, gss; 
 Liq. Acid. Halleri {i. e. one part concentrated sulphuric 
 acid to three parts of rectified spirit), £ss ; Tinct. Cinnam., 
 gij. — M. Dose, 10 drops every \ of an hour, in a table- 
 spoonful of water. 
 
 
76 
 
 ON CHOLERA. 
 
 seems to be desperate experimentation.* Let the 
 ice-bags be tried, and judge them by the trial. I 
 would also try belladonna internally, as an antag- 
 onist of vascular spasm. Leclerc, of Tours, intro- 
 duced it in 1854; Barraut, of Mauritius, used it 
 (£ grain every half hour), and reported success. 
 He also employed hypodermic injections of sul- 
 phate of atropia. This should be tried again in 
 bad cases. So might be, as was suggested by me 
 in 1855, warm baths of infusion of stramonium 
 (Jamestown weed) leaves; on the same indica- 
 tion. Also, the injection of hot liquids into the 
 rectum ; the warm bath (hot baths cause distress 
 in the collapse), with carbonate of ammonia 
 added, as used sometimes in malignant scarlet 
 fever (West) in children ; or, the warm mustard 
 bath. Hot airf bathing, if practicable, in the 
 manner so praised of late by Erasmus Wilson and 
 others, would be worth trying ; and so would even 
 the inhalation of nitrous oxide. Let us confess 
 honestly, for it is wise to do so, our art is here 
 very weak ; fifty per cent, or more of collapsed 
 cases die; shall we not endeavor to discover new 
 
 * Duchaussoy and Vernois assert the non-absorption of 
 medicines given by the stomach during the collapse ; but 
 Magendie proved that a very slow absorption does occur. 
 
 f Dr. George Johnson states that he has seen the hot- 
 air bath used without success. 
 
TREATMENT. 71 
 
 resources ? All honor to those who, at the risk 
 of their own lives, contend yet, with so forlorn a 
 hope, and so little glory to be won. There is 
 room yet for, and possibility of obtaining, a final 
 triumph. 
 
 Two words remain still to be said, with short 
 comment: house to house visitation, and houses 
 of refuge. These are measures of great conse- 
 quence, shown to be of value during cholera epi- 
 demics. The latter, especially, is of notable im- 
 portance ; that is, the establishment of houses of 
 refuge in salubrious places, into which persons 
 from tainted districts most liable to the disease 
 may be received, on the occurrence there of the 
 
 first cases. 
 
 ■ 
 
 That there are such tainted districts, has been 
 amply proven. Thus, Dr. Laycock has shown 
 that in York, England, the first death from chol- 
 era occurred in the spot where plague had been 
 traditionally the worst, in a badly-drained district. 
 In Edinburgh, the first case in 1848 occurred in 
 the same house as did the first in 1832. In Hol- 
 land, at the town of Groningen, in 1832 and 1848 
 but two houses in the better part of the town 
 were attacked ; the same houses exactly in both 
 epidemics. 
 
 Dr. Alison reports that in the first three months 
 of the epidemic at Edinburgh, in 1832, 353 per- 
 sons were taken in at Houses of Refuge, from TO 
 
IS 
 
 ON CHOLERA. 
 
 tainted districts, houses, and rooms in which de- 
 cided cases or deaths had occurred. Of these, 
 only 15 took the disease, and 7 died after removal. 
 Of the 346 thus surviving brief exposure, it is very 
 probable that more than half would have died had 
 they remained in the midst of the infection. At 
 Glasgow, in 1849, 401 persons were taken into 
 Houses of Refuge from tainted districts; only 19 
 of these took the disease and but 5 died. At Ox- 
 ford, England, the same year, of TO persons so 
 taken in, none died. The London Board of Health, 
 in its " General Report," gives the fact that of 1691 
 of whom the Board had accounts as taken into 
 Houses of Refuge, but 33 were attacked, with only 
 10 deaths. These numbers would have been 
 larger, but for the very common unwillingness of 
 poor and ignorant people to leave their homes, 
 chiefly from want of confidence in the greater 
 safety of so doing. Could this be overcome, I 
 have no doubt that an immense saving of life 
 might be produced by Houses of Refuge, allowing 
 also the places which are proved " foci of infection" 
 to be thoroughly purified at once. 
 
 House to house visitation, by sanitary inspec- 
 tors to abate nuisances, small and great, and by 
 medical men to treat premonitory symptoms, 
 might also have great preventive value. The 
 establishment of cholera hospitals may be made 
 necessary when the number of cases is great, espe- 
 
TREATMENT. 79 
 
 daily as the greatest proportion always happens 
 among the poor, who are ill provided for attend- 
 ance at their homes. 
 
 There should be no panic about cholera ; espe- 
 cially in Philadelphia. Let our authorities do 
 their full duty, in sanitary measures of local im- 
 provement and renovation ; let them give to our 
 city its pristine cleanliness, and cholera may reach 
 and sweep across the continent without a case oc- 
 curring here. Baltimore has had such an immu- 
 nity more than once. And, in our worst visitation, 
 the mortality has not been very great. Pear, 
 moreover, aggravates the danger. 
 
 While, if it come, those who can leave as well as 
 not, will, undoubtedly, be most safe in the open 
 country, for those whose duties keep them in the 
 city, courage and equanimity are not only becom- 
 ing but expedient. 
 
 There is but slight exaggeration in the prover- 
 bial assertion, that " Pestilence kills thousands, 
 but Fear tens of thousands." Above all, let us 
 hope that no mistaken terror of contagion will 
 ever lead to the extreme barbarity of desertion of 
 the sick or neglect of the dead. 
 
 Cholera is not, after all, a hard death to die. 
 To me, it appears one of the easiest modes of exit 
 from the world. 
 
K 
 
 CHOLEEA: 
 
 FACTS AND CONCLUSIONS 
 
 AS TO ITS 
 
 NATURE, PREVENTION, AND TREATMENT. 
 
 BY 
 
 HENRY HARTSHORNE, A.M., M.D., 
 
 MEMBER OF, THE AMERICAN PHILOSOPHICAL SOCIETY; FELLOW OF THE COLLEGE 
 
 OF PHYSICIANS OF PHILADELPHIA; PROFESSOR OF HYGIENE IN 
 
 THE AUXILIARY FACULTY OF MEDICINE IN THE 
 
 UNIVERSITY OF PENNSYLVANIA, ETC. 
 
 I 
 
 PHILADELPHIA: 
 
 J. B. LIPPINCOTT & CO. 
 
 1866. 
 
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