m -&A; *f f / JJAA^i />■ raw ' /•"■ »6& M^ A . ,.- . .'A • * ' "I fMSPW MmftKm ... £■ ;aA ««*? LIBRARY OF -CONGRESS. /M"' «/«-. Z6 ^%^r r2>4 55 * .K r r • | UNITED STATES OP AMERICA.! .%m tiMm mm V -A - : *n> *■''-• vxnmJm^KMlm* n .in ' * A ^N*nfanjUii- K v w^«4iraHwftSffli i J JrUt ; mm, \» ' Mak $ w# : » ; EPIDEMIC CHOLERA. ALL THE MATERIAL FACTS IN THE HISTORY OF EPIDEMIC CHOLERA: BEING A REPORT OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA, mm m&m m wmimi AND A FULL ACCOUNT OF THE CAUSES, POST MORTEM APPEAR- ANCES, AND TREATMENT OF THE DISEASE. BY JOHN BELL, M. D. Lecturer on the Institutes of Medicine and Medical Jurisprudence, Fellow of the College of Phy- sicians, one of the Vice-Presidents of the Medical Society of Philadelphia, Senior Physician to the Philadelphia Dispensary, &c. &c. AND BY D. FRANCIS CONDIE, M. D. A Corresponding Secretary of the Philadelphia Medical Society, one of the Out-Door Physicians to the Philadelphia Alms House, &cc. &c. ,ry of Cc,:-.^ — ••>►>© © ©""* ' j p ,the entire intestinal tube, seems to be at once emptied of its foecal or solid contents, and an indescribable but. most subduing feeling of exhaustion, sinking, and emptiness is produced. Faintness supervenes, the skin becomes cold, and there is frequently gid- diness, and ringing in the ears; the powers of locomotion are generally soon arrested; spasmodic contractions or twitchings- of the muscles of the fingers and toes are felt; and these affec- tions gradually extend along the limbs, to the trunk of the bodyj they partake both of the clonic and tonic spasm, but the clonic form chiefly prevails. In other words, they consist more gene- rally of permanent contraction than of convulsive movements of the muscular fibres. The pulse, from the first, is small> weak, and accelerated, and, after a certain interval, but es- pecially on the accession of spasms, or of severe vomiting, it * See Appendix, in which precautions, based upon these premonitory symptoms, are given by Drs. Jackson, Meigs, and Harlan, of Philadelphia, after their visit to Montreal. 60 sinks suddenly, so as to be speedily lost in all the external parts. The skin, which, from the commencement of the dis- ease, is below the natural temperature, becomes colder and colder; it is very rarely dry; generally covered with a profuse cold sweat, or with a clammy moisture. In Europeans the skin often assumes a livid hue; the whole surface appears col- lapsed, the lips become blue, the nails present a similar tint, and the skin of the feet and hands becomes much corrugated, and exhibits a sodden appearance; in this state the skin is in- sensible, even to the action of chemical agents; yet the patient generally complains of oppressive heat on the surface, and wishes to throw off the bed clothes; the eyes sink in their orbits and are surrounded with a livid circle; the corneae become flac- cid, the conjunctiva frequently suffused with blood; the fea- tures of the face collapse, and the whole countenance assumes a cadaverous aspect, strikingly characteristic of the disease. There is almost always urgent thirst, and desire for cold drink, although the mouth be not usually parched. The tongue is moist, whitish and cold; a distressing sense of pain, and of burning heat at the epigastrium are common; little or no urine, bile, or saliva is secreted; the voice becomes feeble, hollow, and unnatural; the respiration is oppressed, and generally slow, and the breath of the patient deficient in heat. During the progress of these symptoms the stomach and bowels are very variously affected. After the first discharges by vomiting and purging, however severe these symptoms may be, the matter evacuated is always watery; and in a great pro- portion of cases it is colourless, inodorous, and often homoge- neous. In some it is turbid, resembling muddy water; in others, it is of a yellowish or greenish hue. A very common appearance is that which has been emphatically called the " congee stools" or like rice water, an appearance produced by numerous mucous flakes, floating in the colourless watery, or serous part of the evacuation. The discharges from the stomach, and those from the bowels do not appear to differ, excepting in the former being mixed with portions of the food which may have been eaten. Neither the vomiting nor the purging are symptoms of long continuance; they are either obviated by art, or the body becomes unable to perform the violent actions; and they, together with the spasms, disappear a considerable time before death. If blood be drawn, it is always dark, or almost black, ropy, and generally flows slowly and with difficulty. Towards the close of the attack, jactation, or restlessness, comes on, with evident internal anxiety and distress; and death takes place, 61 often in ten or twelve, generally within eighteen or twenty hours from the commencement of the attack. During all this mortal struggle and commotion in the body, the mind remains clear, and its functions undisturbed, almost to the last moment of existence. The patient, though sunk and overwhelmed, listless, averse to speak; and impatient of dis- turbance, still retains the power of thinking, and of express- ing his thoughts, as long as his organs are obedient to his will; such is the most ordinary course of the Epidemic Cholera, where its tendency to death is not checked by art. Cholera, however, like other diseases, has presented consi- derable variety in its symptoms; thus, it may on one occasion, be distinguished throughout by the absence of vomiting, and by the prevalence of purging; on another, by the excess of vo- miting; and, though more rarely, by the absence of purging. Spasm may be generally present in one instance: in another, it may not be distinguishable. A frequent variety, the worst of all, is, that which is marked by a very slight commotion in the system — in which there is no vomiting, hardly any purging, perhaps one or two loose stools; no perceptible spasm, no pain of any kind: a mortal coldness, with arrest of circulation, comes on from the beginning, and the patient dies without a struggle. Vomiting is sometimes, as already remarked, entirely ab- sent, or if it has been present, soon ceases from an atonic state of the stomach, under which that organ receives and retains whatever may be poured into it, as if it were really a dead sub- stance. Purging is a more constant symptom than vomiting, and in a large majority of cases, it is the first in the order of occurrence; but being a less striking deviation from a state of health, than vomiting, which instantly arrests the attention, it has usually been spoken of as occurring subsequently to the lat- ter. Purging has been very rarely absent altogether — its absence appears, indeed, to denote a peculiar degree of malignancy in the attack. There is seldom much griping or tenesmus, al- though the calls to the stool are very sudden and irresistible. They also sometimes take place simultaneously with vomiting, spasm, and a suspension of the pulsation at the wrist; as if all these symptoms originated at the instant, from one common cause. In advanced stages of the disease purging generally ceases, but in many cases a discharge of watery fluid takes place on every change of posture. The matters evacuated after the first emptying of the bowels, have been occasionally ob- H 62 served to be greenish or yellowish, turbid, of a frothy appear- ance, like yeast, and sometimes bloody; but by far the most common appearance is, that of pure serum, so thin and colour- less as not to leave a stain on the patient's linen. The next in order of frequency, is the congee-like fluid; the mucus is at times so thoroughly mixed, however, with the serum, as to give the whole the appearance of milk. The quantity of the clear watery fluid, which is sometimes discharged, is very great? and were it uniformly so, it might afford us an easy solution of the debility, thirst, thickness of blood, and other symptoms; but it is unquestionable, that the most fatal and rapid cases, are by no means those which are distinguished by excessive discharges. Death, on the contrary, has ensued in innumerable instances after one or two watery stools, without the develop- ment of any other symptom affecting the natural functions. Collapse has even come on before any evacuation by stool had taken place. The undisturbed state of the mind in this disease, has been the subject of general remark: instances are not wanting of patients being able to walk, and to perform many of their usual avocations, even after the circulation has been so much arrested, that the pulse has not been discerned at the wrist: the cases here alluded to, are those chiefly, in which it has begun by an insidious watery purging: and many lives have been lost in consequence of the patients, under these fallacious appear- ances, not having taken early alarm, and applied for medical aid. In other cases again, the animal functions appear to have been early impaired, and the prostration of strength to have preceded most of the symptoms. The voice, in general, par- takes of the debility prevailing in the other functions; it is usu- ally noticed as being feeble, often almost inaudible. Deafness has also been remarked, in some instances, to have been com- pletely established. Coma does occasionally occur, especially towards the termination of the case, when it is fatal: but deli- rium has seldom, or never been observed, unless as a sequela of Cholera. Spasm has been held to be so essential a feature of the Epi- demic Cholera, as to confer on it a specific name: in so far, however, as relates to the muscles of voluntary motion, and it is 'that description of spasm only to which we now refer, no symptom is more frequently wanting. Spasms of the muscles chiefly accompany those cases in which there is a sensible and violent commotion of the system — hence they are more fre- 63 quently found in cases where Europeans are the subjects of the disease, than when it attacks the natives of India, and in robust patients, more frequently than in the weakly. In the low and most dangerous form of Cholera, whether in the European or Indian, spasm is generally wanting, or is present in a very slight degree. The muscles most commonly affected, are those of the toes and feet, and of the calves of the legs: next to these, the corresponding muscles of the superior extremities, then those of the thighs and arms— and lastly, those of the trunk; producing various distressing sensations to the patient. Dr. Craigie, in his account of the disease as it prevailed in New- burn, (Eng.) says — " The cramps were observed chiefly in the gastrocnemius and soleus of the leg, in the biceps flexor of the thigh, and in the recti of the abdomen. In one or two instances I thought I felt the adductors of the thigh affected; and I think, had I examined a greater number of cases, I should have found this more frequently. But it is remarkable that none of the extensors of the thigh were ever seen cramped; and if those of the foot were affected, they also escaped notice. In the arms I never found the muscles affected with distinct cramps, but only thrown into spasmodic twitches. It is deserving of remark on this point, that in several instances the first indications of cho- leric attacks were twitching of the fingers and toes; and some persons who resisted all the other phenomena of the disease were assailed by this. A man who acted as gardener and man- servant to the Reverend Mr. Edmonston, and whose name has not been put down in my notes, complained, on Sunday the 15th, of twitches of the fingers and hands, for which some gen- tle laxative remedy was in the mean time ordered. The fol- lowing day, about two o'clock, these twitchings had rather in- creased, but not to such an extent as to require very active measures. At four o'clock, as we were quitting the village, he ran up to Mr. Fife's carriage to say, that he had been, since two, attacked with several loose stools, and to request assist- ance, which was immediately ordered for him." Of all the symptoms of Cholera, none is so invariably pre- sent, nor indeed so truly essential and destructive, as the im- mediate sinking of the circulation. It must, nevertheless, be ad- mitted, that, where instant remedial measures have been suc- cessfully practised, this symptom may not have developed itself, and that there are even cases where an excited vascular action has been observed to accompany the first perturbation of the sys- 64. tern in Cholera. Some intelligent practitioners have enter- tained doubts whether such cases belong indeed to this disease: it is, however, to be remembered, that these are precisely the cases which yield most certainly and readily to appropriate re- medies, and it consequently follows, that the physician can sel- dom have an opportunity of observing whether or not this form of Cholera will pass into a more aggravated stage. Cases however, have occurred, in which such degeneration has taken place, and it has then been followed by death. The symptoms of excitement have likewise principally occurred among sol- diers, in whom an effect upon the circulation may have been produced by the quantity of ardent spirits they are in the habit of drinking daily. The period at which a marked diminution of vascular action takes place, is somewhat various — the pulse sometimes keeps up tolerably for several hours, though very rarely: it more ge- nerally becomes small and accelerated at an early stage, and on the accession of spasm or vomiting, suddenly ceases to be dis- tinguishable in the extremities. The length of time during which a patient will sometimes live in a pulseless state, is ex- traordinary. Thirst and sense of heat, or burning in the region of the stomach, are generally connected together, and form very pro- minent and constant symptoms of Cholera^ yet not only in indi- vidual cases, but even in epidemic visitations, these symptoms have often been altogether wanting. Even when they are present, in the highest degree, the mouth is not parched, nor the tongue often dry$ on the contrary, there seems in general no want of moisture in these parts. The sense of thirst seems to subdue all other feelings — cold water is constantly craved and eagerly swallowed. The state of the skin is cold, generally clammy, and often co- vered with profuse cold sweats: nevertheless, varieties occur in this, as in other symptoms of Cholera— the skin is some- times observed to be dry, though coldj and sometimes of a na- tural, and even in some rare cases, of preternatural warmth. An increase of temperature has been repeatedly observed to take place just before deathj but the development of heat ap- pears to be confined then to the trunk and headj and, in almost all cases, this partial development of heat is found to be a fatal symptom: it is entirely unconnected with any restoration of the energy of the blood-vessels, or any improvement in the function of respiration. Often at a very early stage of Cholera, leeches 65 cannot draw blood from the skin; when the sweat is thin, it is usually poured out in large quantities from the whole surface of the body, but when thick or clammy, it is more partial, and generally confined to the trunk and head. The action of the vapour and hot baths, seems unquestionably to increase the exudation or secretion from the skin: and the application of dry heat, as the natural temperature of the skin augments, ap- pears to restrain these discharges. The perspiration or mois- ture is often free from odour; at other times it has a fetid, sour, or curdy smell, which has been said to be peculiarly disagree- able, and to " hang about the nostrils" of the byestander. That remarkable shrinking of the features of the face, which has acquired the emphatic term of the " true Cholera counte- nance," appears in every case not quickly cut short by medi- cine. This expression of countenance, which conveys so truly that of death itself, connot be mistaken, and by an attentive ob- server it will be perceived that a similar shrinking takes place throughout the limbs, and all the projecting parts of the body. Respiration is not usually interrupted in the early stages of Cholera. In many cases terminating in death, respiration has gone on in its mechanical part, with little or no interruption, excepting that it becomes more and more slow. Numerous cases, on the other hand, are noticed, occurring especially in Europeans, where the interruption of respiration was most dis- tressing, and could only be compared to the most violent at- tacks of asthma. Although the breath is stated, in many re- ports, to have been deficient in heat, it is not clear that this is a general symptom, nor is it understood that this coldness is more particularly observed in cases of difficult and laborious respiration, than in those where the function seemed to be at least mechanically performed without interruption. No symptoms of Cholera are so uniform in their appearance and progress, as those connected with the blood and its circu- lation. It is established by undoubted evidence^ that the blood of patients attacked with Cholera, is of an unnaturally dark colour and thick consistence. These changes in the circulation of the blood, are likewise fully proved to be in direct ratio with the duration of the disease. In a great majority of the reports of the physicians in India, it is stated unequivocally, that after a certain quantity of dark and thick blood has been abstracted, it is usual for its colour to become lighter, and its consistency less thick, and for the cir- culation to revive — such appearances always affording ground 66 for a proportionally favourable opinion as to the termination of the case. In many instances, however, no such changes have been observed to accompany the operation of bleeding, and yet the result of the case was favourable. The blood is gene- rally found to be less changed in appearance, in those cases of Cholera which have been ushered in with symptoms of excite- ment, than where the collapsed state of the system has occur- red at an early period. The blood has been occasionally found on dissection, to be of as dark colour in the left, as in the right side of the heart — affording reason for believing that in the whole arterial system, it was equally changed. The temporal artery having been freqently opened, the blood was found to be dark and thick like the blood of the veins. In the natives of India, in whom respiration is pretty gene- rally free, until the very last stage, the colour and consistence of the blood in the instances in which venesection was performed, has been very uniformly found to be dark, whether excessive discharges prevailed or not. In the majority of cases, the se- cretion of urine is diminished — and in violent cases it is en- tirely suspended throughout the attack. When medical aid is early administered, and the consti- tution of the patient is otherwise healthy, the recovery from an attack of Cholera is so wonderfully rapid, as perhaps to be de- cisive of the disease being essentially unconnected with any very decided morbid change in the several organs of the body. In the natives of India, in whom there is ordinarily very little tendency to inflammation, the recovery from Cholera is gene- rally so speedy and perfect, that it can only be compared to re- covery from fainting, colic, and diseases of a similar character; but in Europeans, in whom there is a much greater tendency to inflammation, and determination to some of the internal or- gans, the recovery from the disease is by no means so sudden or perfect; on the contrary, it is too often complicated with affec- tions as various, as the diseases of various internal organs are known to be in India. The most frequent of the sequelae of Cholera are affections of the intestines, of the brain, of the liver, and of the stomach. When Cholera, however, is of long con- tinuance, and when the congestions appear to have been tho- roughly established, few, either Europeans or natives, who out- live the attack, are restored to health without considerable dif- ficulty. It has already been remarked, that recovery from an attack of Cholera, is indicated by the return of heat to the sur- face of the body and rising of the pulse; a deceitful calm, how- 67 ever, sometimes attends these favourable appearances, which too often mocks our hopes and expectations, and, on the contrary, patients have been observed to remain for one, two, and even three days, in a state of the greatest collapse, and yet, contrary to all expectation, have recovered. The tendency to death in Cholera consists in a general sus- pension of the natural, and gradual cessation of the vital func- tions, rather than in the establishment of morbid actions. Cases have been remarked, where the vital functions have been more suddenly overcome, and where death took place, before the usual development of the symptoms of the disease. Fatal terminations likewise occur from topical inflammations super- vening, as of the stomach, intestines, or liver. The intestinal canal seems especially obnoxious to the effects of Cholera — numbers of those attacked with it having been subsequently seized with dysentery. Such are the general symptoms of Cholera as it presented it- self in the different districts of India, and they correspond pre- cisely with those observed in the disease during its prevalence in Russia, Poland, the north of Europe, the Canadas, &x. This is proved by the history of the disease which is contained in the circular distributed by the Austrian Government, and the elabo- rate epitome of its symptoms, transmitted by Dr. Keir, of Mos- cow, to the British Government, and in the accounts transmit- ted from Montreal and Quebec. It is needless to dwell on this topic, with the view of establishing the identity of the symp- toms of the Epidemic Cholera which prevailed in Europe, with those remarked by the English practitioners in the Cholera of the East Indies. All the Russian and German reports agree, that in the generality of cases there w r ere the same excessive evacuations upwards and downwards, of a watery turbid fluid, the same collapse of the skin, coldness of the surface, sinking of the pulse, failure of the strength, lividity of the face, shrink- ing of the features, spasms of the muscles, sense of pain, on pressure on the region of the splanchnic plexus of nerves, en- tireness of the mental faculties, and blackness and inspissation of the venous blood; that in Europe, as in India, some instances occurred of rapid, death, with collapse and spasms, and with- out vomiting or purging; that in other instances chronic irri- tation of the bowels continued for a long time after the violence of the disease was broken; and that sometimes, symptoms of cerebral congestion supervened on the violent constitutional disorder which accompanied the intestinal symptoms, and 68 quickly terminated in coma and death, when not counteracted by an appropriate treatment. If any decided difference has been observed between the character of Cholera as it prevailed in India, and after its ex- tension into Europe, it consists merely in the gradual ameliora- tion of the disease; the comparatively diminished violence of its symptoms, its less extensive diffusion among the various populations it has visited, and its lessened mortality in pro- portion to those populations, as the disease has progressed westward into civilized Europe — Poland suffering less than Russia, Austria less than Poland, Prussia less than Austria. That, however, the Eastern and European Cholera are sub- stantially the same disease, every circumstance with which we are acquainted, tends fully to establish. We have also the evi- dence in favour of its identity, of various physicians of emi- nence who have witnessed the Cholera both in India and Eu- rope. In our description of the symptoms characteristic of an in- vasion of Cholera, we have not included those of the stage of reaction or anastasis. — Our account would, however, be incom- plete, were we to omit drawing the attention of our readers to the fact, that Cholera Asphyxia, declared and unmitigated Cho- lera, ought rather to be regarded as a stage of fever— -too often, indeed, a violent and fatal one, than as a separate disease. — The forming stage is marked generally by diarrhoea and some other disturbances of function. The third stage, that of reaction, corresponds with the febrile reaction after the chill of inter- mittent fevers, or still more, after the stupor, coma, &c. of per- nicious or malignant intermittents, as they have been termed. In both cases, the violent or distinct asphyxia of Cholera, and coma of intermittent fever, will kill — in both escape from these may be followed by fever and phlegmasia, which will often de- stroy the patient. Mr. Searle, a judicious writer, who witnessed the disease both in India and Poland, observes that " Cholera was generally based upon, or succeeded by, fever of a bilious inflammatory type — in Europe, of a low remittent or typhoidal character. In Europe, the choleric symptoms were less marked than in India, and the succeeding fever : evinced less of simple re- action. "I have said remittent, though the first few days I have generally found it to be intermittent; coming on daily at about the same hour, preceded by coldness of the extremities, quiver- 69 ing of the lip, and depression of the circulation: but from the excitement of inflammation, which but too frequently becomes developed in the organs previously congested, the intermissions become imperfect, and in consequence, it assumes a remittent, and, from the conjoint debility, a typhoidal form." Almost all the cases in Poland, which were neglected or ill- treated at the beginning, lapsed into this form of fever. This is a strong proof that the choleric symptoms are only a stage or form of fever. The following passage is important. " In reference to the foregoing, and in exhibition of the con- nexion that subsists between Cholera, fever, and dysentery, I would add the notice of a milder species of the disease, which was, in the month of August, exceedingly prevalent at War- saw, and where fever and dysentery are, I was informed, an- nually at the same season extremely common. The following is the best account I could collect from my patients of its insi- dious mode of attack. A sense of fulness at the praecordia, of languor and incapacity to exertion — mental or bodily, occasion- ally with giddiness or headache; the latter, however, was often attended with an obscure form of fever, and only felt at some particular hour of the day; a slimy, coated, white, or furred tongue, and which appeared occasionally to be swollen, being indented along its edges by the teeth; or otherwise, an unu- sually clean, smooth, and red tongue; lips pallid, or of leaden hue; eyes often of a pearly appearance, and surrounded with a brown circle; the countenance sallow; appetite frequently but little impaired, though the digestion was in general imperfect, evinced by flatulence and distention after a meal. Bowels at first constipated, succeeded, however, in general, by relaxation, and this, when attended with inflammation, terminating not unfrequently in bloody muco-purulent evacuations, or, in other words, in dysentery. "The preceding symptoms, fluctuating with the weather and contingent circumstances, may continue two, three, or more weeks; the individual feeling that he is unwell, but not attach- ing any importance to his condition, till the depressing influ- ence of the atmosphere, preceding or accompanying wet wea- ther, or an attack of indigestion, succeeding to the use of some improper article of diet — as potatoes, cabbage, sallad, or the like, or drinking too freely of some cold fluid, or fatigue, or exposure to the sun, or cold — develops the attack of Cholera, coming on by purging, or vomiting, succeeded by cramps in the legs, lividity of countenance, cold skin, and feeble pulse: — a I 70 condition which, if the patient recovers, is almost invaria- bly succeeded by fever, of an intermitting or remitting type, coming- on daily or oftener, and generally unpreceded by any very marked cold stage, further than a sense of shuddering, tre- mor, or quivering of the lip, and depression of the circulation. An attack of this kind, it must be obvious, is nothing more than one of fever, based upon torpor of function, and conges- tion of the liver and chylo-poietic organs: and attributable to the continued respiration of an impure atmosphere of a milder degree than ordinarily gives rise to Cholera, such as results from the imperfect ventilation of the town, and foul state of the drains: or in persons otherwise situated, from some swamp or filth in the neighbourhood of their abodes." The views which we hold of Cholera, as properly a stage of Cholera fever, are further corroborated in the following ex- tracts from two letters published by Dr. Negri, an intelligent Italian physician, residing in London. They go to show the great resemblance, if not identity between the malignant Cho- lera and the pernicious fevers, described by Torti, more than 120 years ago. " Speaking of the character of those fevers, Torti says, ' the pernicious intermittent, more especially that wearing the ter- tian form, kills about the beginning of the paroxysm, when it is accompanied with violent bilious vomiting and purging of bilious humours, equally vicious both in quality and quantity, being sometimes clear, at others coloured, and occasionally of inspissated greenish bile; to which vomiting and purging are added, hiccup, a hoarse sonorous voice, hollowness of the eyes, pain of stomach, small sweat upon the forehead, weak pulse, and cold or livid extremities — in one word, all the symptoms which usually mark cholera morbus; from which, however, this, as it were, choleric affection, is to be distinguished; since it is a mere symptom, of the fever, the period of which it follows, as a shadow does a body..' " Torti describes a u febris perniciosa cholerica" in which the patient becomes nearly exhausted, " universally chilled, lies su- pine, with a pulse almost abolished, sunken eyes, and difficult breathing." Dr. Negri also quotes from Mercatus, physician to the King of Spain, who describes a pernicious tertian, pre- senting the same symptoms as Cholera, and frequently lapsing into a pernicious fever. The following passage from Morton, quoted by Dr. Negri, will be read with interest at the present moment. 71 a Among- the innumerable symptoms attending these fevers, there is none which may not rise to a great height, endan- gering the life of the patient, so that typhus fever (marked in its stages of cold, heat, and sweating) supervenes, rendering it impossible to be distinguished by the urine, temperature, pulse, or indeed any other means; but, concealed under the appearance of cold, vomiting, diarrhoea, cholera morbus, cholic, or other disease, not unfrequently misleading the physician." Torti, as well as Morton, exhibited bark as early as possible, and in large quantities, and this practice is recommended by Dr. Negri, from experience of its good effects in the malarious fevers of Italy. Dr. Negri comes to the conclusion " that the malignant cholera of our days belongs to the same class of dis- eases which was seen by Mercatus in Spain, Torti in Italy, and Morton in England." He suggests the administration of bark in large doses and early in the disease. The following case from Torti presents (says Dr. James Johnson) a complete picture of the Sunderland cholera. " When I reached the patient, he had been several hours labouring under the disease. I found him universally cold as marble, with the pulse altogether, if I may so say, absent, breathing laboriously, and having a leaden-coloured counte- nance. There was some torpor, but no confusion of intellect, (he never mentioned delirium) and his urine was secreted in a small quantity. I prescribed the bark in large doses. A gentle heat soon pervaded his entire frame; the pulse gradually return- ed; the respiration became natural; the face lost its leaden hue; the urine was secreted in its ordinary quantity, and in three days he was quite recovered." 72 CHAPTER IV. Of the Morbid Appearances detected in the Bodies of those who have died of Cholera. For the information of our professional readers, we present the following description of the morbid appearances detected after death, in the bodies of those who have died of Cholera. The appearances ordinarily discovered in India are given with con- siderable minuteness in several of the medical reports. The following description is condensed from the very able Report drawn up by Mr. Scott for the Madras Medical Board. The external appearance, after death, of European subjects, closely resembles that which they exhibited whilst labouring under the Cholera. The surface is livid, the solids shrunk, the skin of the feet and hands corrugated. There exists no uncommon tendency in the body to putrefaction, nor any cha- racteristic fetor from the abdominal cavity. The cavities of the body lined with serous membranes, as well as these mem- branes themselves, presented no particular morbid appearances. The cavities indicated have almost uniformly been found in a natural state, or the deviations from that state which were met with, had manifestly no connexion with Cholera. The surfaces which are lined or covered with mucous membrane, on the contrary, very generally exhibited signs of disease. The lungs have not unfrequently been found in a natural con- dition, even in cases where much oppression of respiration had existed previously to death. Much more generally, however, they were found to be gorged with dark blood, so thick that they have lost their characteristic appearance, assuming more that of liver or spleen^ or they were in an opposite condition, — that is, collapsed into an extremely small bulk, and lying in the hol- low on each side of the spine, leaving the cavity of the thorax nearly empty. This has been supposed to have arisen from the extrication of a gas, but on piercing the thorax of the dead body under water, no gas escaped. The blood found in the lungs has been always black. The heart, and its larger vessels were found to be distended with blood, but not so generally as 73 the apparent feebleness of their propelling power, and the evi- dent retreat of the blood to the centre, would have led us to expect. The engorgement of the right cavities of the heart with blood is not peculiar to Cholera, but in some cases the left ca- vities were found filled even with dark or black blood, which we may consider a morbid appearance more peculiar to this disease. In the abdominal cavity, the peritoneal covering of the visce- ra presented seldom any morbid appearances; the morbid ac- cumulation of blood in the vessels of the viscera, imparting to it, however, an appearance of turgidity and blueness, which was occasionally evident on its exterior surface. Where the patient has lingered long before death, this membrane occa- sionally exhibits traces of inflammation. In other cases, the whole intestinal tube presented a blanched appearance, both ex- ternally and internally. The stomach and intestines generally preserved their ordinary size. The omentum was not sensibly affected. So various were the morbid changes in the stomach, that upon them no pathological conclusions could be founded. This organ was rarely found empty, or much contracted, nor was any appearance of spasmodic stricture of the pylorus often detected. It did, however, sometimes occur. The contents of the stomach appeared to be chiefly the ingestae in an altered state; in some cases a greenish, yellow, or turbid matter was found. Various appearances, either of active inflammation, or a congested state of the vessels, were noticed, sometimes in one part and sometimes in another. The parts seemed as if they were sphacelated, thickened, softened, and friable, — and, in short, exhibited so great a variety of appearances from a per- fectly natural state, to the most morbid condition, that no par- ticular light is shed by them on the nature of the disease. The intestinal tube was sometimes collapsed, but oftener more or less filled with gas; distended in some points, into bags or pouches, containing a whitish, turbid, dark, or green colour- ed fluid; and in others presenting the appearance of spastic constriction. The intestines contained no fcecal or other solid matters, but very commonly large quantities of a. congee looking fluid, or of turbid serous matter. The duodenum and occasional- ly the jejunum, were found loaded with an adherent whitish or greenish mucus, at other times they were found denuded, as it were, of their natural mucus, and often they were perfectly healthy. Traces of bile in the intestines, or of any substances apparently descended from the stomach, were exceedingly rare. Sangui- 74 neous congestion, and even active inflammation, are stated to have been more common in the bowels than in the stomach; but, on the other hand, instances were very numerous where no such indications were detected. The thoracic duct is stated to have been found empty of chyle. The liver was commonly gorged with blood, but not always; the gall bladder was almost universally found to contain bile, and in the great majority of cases, was even completely filled with it. As is usual with this secretion in cases of retention, it was of a dark colour. Very different states of the gall ducts have been described; cases of constriction and impermeability seeming to be equally numerous with those of an opposite character. The urinary bladder was found, we may say universally, without urine, and very much contracted. The mucous membrane of the bladder and uterus, have been found coated with a whitish coloured fluid. In the spleen, nothing unusual was detected. The vessels of the mesentery were very generally found to be loaded with blood. In the head, appearances of congestion, and even of extrava- sation, were frequently observed; but not so uniformly, nor to such an extent, as to require any particular notice. Only one case has been given, Avhere the state of the spinal marrow was examined; and in that, indications of great inflammation were detected in its sheath; the case in which this occurred was, however, in some degree, a mixed one. It will be useful, in many points of view, to compare the foregoing result of the autoptical examinations by the physi- cians of India, with the morbid appearances detected after death by the physicians of the north of Europe. For this pur- pose, we present the following extract from the memoir of Dr. Keir, of Moscow. In the bodies of those who have died of the Cholera, the ex- tremities in general were more or less livid and contracted, and the skin of the hands and feet corrugated : the features sunk and ghastly. On opening the cranium, the blood vessels of the brain, as well as of its membranes, were more or less turgid, especial- ly towards its base. The arachnoidea had sometimes in seve- ral places lost its transparency, and adhered to the pia mater, A fluid in considerable quantity was occasionally found effused between the convolutions of the brain, and more or less of se- rum in the lateral ventricles. The blood-vessels of the verte- bral column and spinal chord were more or less loaded with blood, which was, also, sometimes effused between its arachnoid and pia mater; partial softening of the substance of the chord wa^> 15 sometimes met with, and marks of inflammatory congestion in the larger nerves. The lungs were generally gorged with dark coloured blood; the cavities of the heart were filled with the same, and frequently contained polypous secretions. In all the dissections at which Dr. Keir was present, very dark coloured blood, which, when spread on a white surface, resembled in co- lour, that of the darkest cherry, was found in the arch of the aorta, and in other of the arteries. The state of the abdominal organs va- ried considerably; the stomach and different parts of the intestines were frequently found to be partially, but considerably contracted; the internal surface of the stomach sometimes seemed to be little affected; a whitish or yellow fluid matter, resembling the evacu- tions was frequently found in different parts of the alimentary canal, which now and then contained a good deal of gas; in other cases, both stomach and intestines bore marks of conges- tion, and of a sub-inflamrnatory state, varying from dark co- loured spots, of small extent, to several inches, affecting the whole internal circumference of the intestine; the colour of these parts, also, varied considerably, from dark coloured ve- nous congestion, to light rose coloured inflammation. In one case, the internal surface of the stomach was so strongly and so generally tinged of a very dark colour, that it might easily have been mistaken for gangrene. On exposing the stomach between the eye and the light, it was evident that there was neither gangrene nor solution of continuty, but that the dark colour proceeded from a very general and great congestion of very dark coloured blood, in the vessels of the organ. The subject of this case was understood to have died, with symp- toms of a typhoid character, after suffering from the usual symptoms of Cholera. Excepting in this case, which was evi- dently one of congestion, and not of inflammation, Dr. Keir saw nothing in the morbid appearances from which a conclusion could be drawn that inflammation was a very general phenome- non in the alimentary canal, or a common cause of death, how- ever it might, by its presence in the second period of the dis- ease, add to the general irritation, or even, as a consequence of preceding congestion, be itself occasionally the cause of the fatal event. Both the stomach and bowels were frequently of a paler colour than natural, as well internally as externally; but neither thickening nor condensation from inflammation, nor ul- ceration, destruction of substance, nor abscess, was present in any of the dissections witnessed by Dr. Keir. The liver was generally pretty full of dark coloured blood; the gall bladder 76 frequently much distended with tenacious ropy bile, of a dark yellow or green colour; the gall ducts sometimes contracted, at others not; the appearance of the pancreas, spleen, and kid- neys, was various, frequently differing but little from their na- tural state, in other cases slightly surcharged with blood; the urinary bladder was always collapsed and empty; the uterus was in e;eneral natural. 77 CHAPTER V. Treatment of Cholera; when in time, it is not an unmanageable Disease. — Blood- letting. — Sinapisms and Rubefacients. Dry Frictions. Blisters. — -Dry Heat. — Warm Bath. — Calomel. — Opium. — Internal Stimuli. — Emetics. — Pur- gatives. — Enemata. — Sub-nitrate of Bismuth. — Muriate of Soda. — Drinks. — Secondary Stage. — A Sketch of the Several Stages of Cholera, with an Account of the Treatment adapted to each of these Stages. The Cholera has not been found to be less under the control of an appropriate treatment than any other disease equally ra- pid in its course. When remedies of a proper kind have been administered in the early stage of the complaint, and judicious- ly managed, a favourable termination has in the majority of cases been the result. The difficulty is to induce patients to apply sufficiently early for medical aid, — with the loss of a very few hours the chances of recovery are greatly dimi- nished. " If the disease," says Annesley, whose experience in the treatment of the Epidemic Cholera during its preva- lence in India, was considerable, "be taken at its commence- ment, or within an hour after the seizure, it is as manageable as any other acute disease, but the rapidity with which it runs through its course, requires the most active exertions before it can be checked, and the loss of an hour may cause the loss of a life."* The remedy, the good effects of which, in the treatment of Cholera, appears to have been most generally acknowledged, and the early employment of which is most insisted upon, is blood-letting. Bleeding from the arm in the first stage, when the pulse is full, and the temperature not reduced, is often sufficient to cut short the disease. The patient always feels immediate relief, particularly where the head has been much affected. The bleeding should be performed in a horizontal position, and the patient remain quiet for some time afterwards. We are direct- ed by Dr. Dyrsen to increase the flow of the blood from the arm by frictions to the surface of the body, with flannel cloths * Diseases of India, p. 175, K 78 wrung out of hot water, or by bleeding during immersion in the warm bath. According to Mr. Bell, " in no case in which it has been possible to persevere in blood-letting until the blood flows freely from the veins, and its colour is recovered, and the op- pressed chest is relieved, will the patient die from that attack of the disease." He directs, that when the blood has once begun to flow, it be allowed to escape till these changes are observed. The ordinary rule for the use of venesection in acute diseases, namely, to continue till syncope come on, is here inapplicable, as it is extremely difficult to induce fainting in patients affected with Cholera.* It is the opinion of Mr. Ken- nedy, that, in ninety-nine instances out of a hundred, where pa- tients are said to have died " despite of blood-letting," it will be found, upon examination, either that no blood flowed from the incised veins, or that it came away in drops, or in a small broken stream, rarely exceeding a few ounces in quantity. "On the contrary," he adds, " where blood was freely obtained to the extent of twenty or thirty ounces, and where the depletion was followed by proper auxiliaries, the patients have usually recovered."! The testimony of the German, Russian, and Polish physi- cians is equally decisive in favour of the beneficial effects re- sulting from blood-letting, when early resorted to in Cholera. The absence of the pulse is no prohibition to the use of the lancet, unless it be accompanied by other symptoms of great debility, and the system has been exhausted by previous evacu- ations, and the surface is covered with a cold clammy sweat. Even under such circumstances, many attest the advantages of blood-letting, especially when preceded by sinapisms, the application of dry heat and frictions to the surface, and dif- fusible stimulants internally. In some cases of Cholera, Dr. Lefevre remarks, the pulse ceases to beat very early, but upon opening a vein the blood flows slowly at first, gradually the current becomes fuller and stronger, the pulse beats very sen- sibly, and the heart thus relieved is enabled to continue the circulation. The only cases in which bleeding would appear of doubtful propriety, during the first stage, are those occurring in old, debilitated subjects, and in constitutions completely broken down by intemperance. * Treatise on Cholera, p. 105. et seq. i History of Cholera, p. 169. 79 When blood cannot be drawn from the arm, and the spasms continue — when severe pain and burning heat are felt at the epigastrium — when the skin is cold, and deluged with a cold clammy sweat, and when there is oppression at the chest, and difficulty of breathing, excessive pain and confusion of the head, with great intolerance of light, no pulse, or a very indistinct one, and a cadaverous smell from the body, Mr. Annesley ad- vises the immediate application of twenty or thirty leeches to the umbilicus and scrobiculus cordis, in conjunction with fric- tions with turpentine externally, and the calomel pill internally, while at the same time leeches are to be applied to the temples and base of the scull. In the advanced stage of the disease an opportunity is some- times afforded for the abstraction of blood. This, according to Annesley, is marked by a struggle or effort of the circulation to overcome some resisting power, and is a most auspicious symptom, which should never be overlooked: as soon as it oc- curs, bleeding, directed with great judgment, should be resort- ed to.* Dr. Lefevre objects to leeches in Cholera, and, we think, with propriety, from the slowness of their operation; he advises cup- ping as preferable. The patient, after bleeding, should be warmly covered with bed clothes, and allowed to remain perfectly still for a short period. Sinapisms and Rubefacients. — These are among the most effi- cacious means adapted to the cure of Cholera. " It may be said of them, that they are indispensable, and there is hardly any stage of the disease in which they may not be employed with advantage — so long as the disease endures, so long will their use be indicated, and they should be repeated continual- ly." The pain in the bowels, and even the sickness, are often instantaneously relieved by the application of a large sinapism over the abdomen, and much pain is saved the patient, if it be applied early.f In violent cases of the disease the application of sinapisms to the ancles, wrists, calves of the legs, inside of the arms and thighs, and along the spine, is recommended in the strongest terms in various treatises on the Cholera, and we feel persuaded, from the beneficial effects which we have seen result from the practice, that it is one which should never be neglect- " Diseases of India, p. 156. et seq. t Lefevre, Obs. on the Nat. and Treat, of Cholera, p, 58. et seq. 80 cd — it would be as well probably to defer, however, the sina- pisms until the full effects of dry frictions have been tested. When the skin has been excoriated by the use of sinapisms, anodyne fomentations, or even pulverised opium, sprinkled over the tender surface, will often be useful in relieving pain and nausea.* Dry Frictions are recommended as remedies of great efficacy in all cases of Cholera — they are best adapted to, and have been found most beneficial in the early period of the attack. " The object of friction is two-fold. 1st. To restore the circulation in the part, and the heat that is dependent upon it. 2d. To in- troduce remedies into the system by absorption. The first may be effected by mere dry rubbing with the hand, or a warm flannel, or the flesh brush, and, if persisted in, will often restore the circulation to the extremities, which were previously cold and senseless; but it requires great perseverance, and long conti- nuance, for it is necessary to keep up the circulation after it is restored; hence it can only be recommended in those circum- stances where there are plenty of attendants to wait upon the sick. Various liniments have been proposed to aid the effects of friction, but they may be superseded by steady rubbing with the hand, which should be sprinkled occasionally with a little powdered starch, or a little camphorated oil, to prevent abra- sion. Where proper and effectual rubbing cannot be maintain- ed, stimulating liniments should be employed, — because little rubbing will suffice, and the effect will be more permanent. The liniment composed of camphorated spirit and ammonia will answer every purpose. When the spasms are severe, Mr. Annesley prefers the spirits of turpentine as an embrocation. Embrocations with ardent spirits are evidently improper, as their rapid evaporation will have a tendency to increase the coldness of the surface. Medicines may be introduced into the circulation by frictions — and thus certain indications fulfilled, when the stomach is in too irritable a condition to retain the appropriate remedies. Especially may local pain and spasm be alleviated by frictions with opium, hyosciamus, and other narcotics, in the form of liniment or unguent.f Blisters would appear to be less proper than sinapisms, in the first stage of the Cholera, from the slowness of their action. * Lefevre, Obs. on the Nat. and Treat of Cholera, p. 58. et seq, I Lefevre on Cholera, p. 60, et seq. 81 In the second stage, however, they may be demanded, should local congestions or chronic inflammation occur. Dry Heat. — This remedy is strongly recommended by many of the practitioners who have witnessed the Cholera in the north of Europe. Mr. Kennedy, also, recommends it in the first stage of the disease, after bleeding, the warm bath, and the other remedies which are immediately demanded. He re- marks, "as soon as the cramps are subdued, or have received a decided check, the patient, with all possible expedition, should be removed from the bath, and placed between dry heated blankets. Dry warmth should be further afforded by sur- rounding his body and limbs with bags of heated sand. Here dry heat, be it remembered, is the remedy, and not the sand which contains it. On this principle, bottles of hot water roll- ed in flannel, have been employed, and, also, hot ashes, bran, oat meal, Sec. Sec. A more efficient mode of applying dry heat, than any of these, may suggest itself; but occasionally, to pre- vent loss of time, we must take the first that offers."* Warm Bath. — In regard to the good effects of this remedy, there is some discrepancy of opinion among the different writers upon the treatment of Cholera. While it appears to have been viewed by many of the East India surgeons, and most of the Russian and German practitioners, as a remedial agent of great power, rousing the dormant activity of the circulation, and de- termining the blood to the superficies of the body, others have objected to its use entirely. In St. Petersburgh, according to Dr. Lefevre, the use of the warm bath was, at the commence- ment of the epidemic, almost universal; but it soon fell into disuse, and, upon the whole, he believes that its use has been found prejudicial. This, he conceives, arises from the exhaus- tion produced by transporting the patient from his bed to the bath — and by the effects of the latter, and from the pain and uneasiness which the patient experiences by his " sudden tran- sition from cold to heat." These objections appear to us, however, to be due rather to the injudicious manner in which the bath has been administered, than to the bath itself. Dr. Lefevre admits that if employed at the commencement of the attack, " when the excitement is still considerable,' 5 it will often be found serviceable, and prove very comfortable. He considers, however, the vapour bath, dry heat, and frictions, to be preferable. Others recommend the substitution of hot fo- * Kennedy on Cholera, p.. 176 82 mentations, poultices, &c. The evidence, however, in favour of the use of the warm bath, in the treatment of Cholera, is of too strong a character to allow of its being slightly rejected. On this subject there is much good sense in the following re- marks of Mr. Kennedy: — "In the treatment of Cholera, several physicians limit their encomiums to the warm bath; others extol the vapour bath to the exclusion of the former; while lat- terly, a third authority* maintains that a hemp seed poultice is better than either. A grain of reflection might have convinced the three parties that they were divided on the merits of a name alone. The medical virtue is the same in all, and it con- sists simply in the application of heat and moisture to the sur- face of the body. The question to be determined is the effect which these remedies are, individually, capable of producing, in a given time, upon the patient, and where there is a choice at command, we should select the strongest one of the number. Now, the warm bath is by far the most effective and convenient agent of the class to which it belongs; it communicates heat more rapidly to the body than either the vapour bath or the poultice, and the relaxing power of its moisture is commensu- rate. It should, therefore," he adds, " be preferred in those stages of the disease where the use of moist heat is indicated — from its superior power, a greater degree of caution, it should be recollected, is required to prevent its being too long conti- nued or misapplied." Mr. Kennedy considers the proper pe- riod for the use of the warm bath to be the early stage of the disease.f The following are the directions of Dr. Harnett, one of the British Medical Commission at Dantzic, for the use of the warm bath. " It has been found necessary to guard against the indiscri- minate use of the hot water and vapour baths, in hot weather, after perspiration has broken out, and above all, in the clammy stage of the disease, and after marked venous congestion has taken place, when it seems to increase the latter, which is par- ticularly observable in the brain and heart. The bath should be used either in the critical moment at the beginning of the disease, or, at farthest, instantly after, if admissible even then. To obviate the determination of blood to the head, cold appli- cations ought to be occasionally applied to it, while the patient * Warsaw Committee of Health. t Kennedy on Cholera, p. 166. 83 is in the bath. The patient should be most gently, and other- wise judiciously placed in the bath, with respect to the gra- dually inclined position of his body, and the due support of the head, neck, and shoulders; and the immersion or subjection should be short; merely long enough for the positive commu- nication of heat and its effects; when he ought to be as gently and judiciously taken out, well wrapped up in hot blankets, promptly laid in a bed, and gently rubbed with warm, dry, coarse, but soft thread towels, all over; and wiped dry as fast as the clammy sweat oozes out. There is much handy and careful personal management requisite, in this essential part of the treatment."* Calomel. — The exhibition of calomel in Cholera is a prac- tice which has been pursued by a majority of the English surgeons in India, and it is spoken highly of by such of them as have witnessed the disease in the North of Europe. In many instances the use of calomel has been carried to an enormous extent — doses of a scruple to half a drachm being considered the smallest which are adapted to the disease; others, howe- ver, have condemned the use of the remedy, to this extent, and recommend it to be given in smaller doses, frequently repeated, and in general combined with opium. The evidence which is advanced in favour of the beneficial effects of calomel under both modes of administration might at first view appear per- fectly conclusive; but in making up our mind on this subject, we are to recollect that in almost all the cases which are ad- duced where the practice is supposed to have been eminently successful, other important remedies have at the same time been employed — especially bleeding — frictions and stimulating applications to the surface, and very commonly the warm bath also. Upon the early and judicious employment of the last mentioned remedies, nearly all the writers agree that the cure of the disease mainly depends; by many they are supposed to be of themselves fully sufficient, and that the various internal remedies that have been resorted to are either useless or abso- lutely pernicious. Among the physicians of Russia, Poland, and Germany, there are but few who recommend the use of calomel at all, and the majority denounce, in very decided terms, its employment in the early stages of Cholera, or to the extent to which it was carried by the practitioners of India. In Warsaw, the result of experience showed, according to Dr. * Reports to the British Government, by John Harnett, M. D, < 84 Hille, that whether in large closes, or in small ones, frequently repeated, the calomel did more harm than good, and hence its use was either entirely abandoned, or it was given in a single dose of a few grains combined with opium.* Dr. Gibbs, writ- ing from St. Petersburg says, expressly, that scruple and half scruple doses of calomel would not do thereat And Dr. Le- fevre very properly remarks, that small doses combined with opium can be of no use in the first stages. " In slight cases, 5 ' he adds, " where the quantity of opium is sufficient to allay the spasmodic action, whilst time is allowed for the calomel to act gradually, the combination, however, may be of service: but it must share the same fate as all the vaunted nostrums which, when administered indiscriminately, lose even the merit to which they are really entitled.^ In Dunaburg, no calomel was administered, and of 745 cases, many of which were in the last stages of the disease when first seen by the physician, only 75 terminated fatally.§ Opium. — No remedy has been proposed in the treatment of Cholera, which has so great a mass of testimony in its favour as opium. Nearly all physicians, whatever may be their opinions as to the nature of the disease, employ it in some shape, at one period or other of the disease. By some it is recom- mended in the largest possible doses, by others, however, when given in smaller doses, it is considered much more efficacious, and less liable to produce injurious consequences. Mr. Orton considers it " probable that a single dose of opium alone, given at the very commencement of the disease, would be found, in a great majority of instances, to put an effectual check to its progress." He warns us, however, against an excessive use of the remedy. When given in large doses, its secondary, perhaps its immediate effects, he thinks are an increase of that oppression of the vital powers, which so strongly marks the intense degrees of the disease. He prefers giving it in sub- stance to the tincture, as less liable to be rejected. Four grains he recommends for the first dose, to be repeated, if a favoura- ble change is not produced, in diminished doses, at intervals, of from three to six hours.|| The Polish and a few of the Ger- * Ueber die Assiatische Cholera, p. 115. t Observations of Cholera, Ed. M. & S. Jour. p. 396. vol. 36. | Observations, &c. on Cholera, p. 72. et seq. § Ueber die Cholera in Dunaburg von Dr. Ewertz, Jour. f. Chirur. u. Au- genheilhunde, p. 313. vol. 17. || Essay on the Epidemic Cholera, p. 304. et seq 85 man physicians object, however, to the exhibition of opium in Cholera. The brain and spinal marrow tend so rapidly to as- sume in this disease a congestive condition, remarks Dr. Hille, that opium, even in small doses, from its tendency to accelerate and augment this morbid state of those organs, becomes a very doubtful remedy. This was likewise the opinion of most of the physicians at Warsaw* and at Riga.f Internal Stimulants. — The exhibition of ether, brandy, am- monia, and other stimulants, we find to be very generally re- commended, especially in the advanced stage of the disease. They are directed to be continued until reaction is fairly esta- blished, after which they are to be gradually relinquished. In the early stage of the disease we have less evidence of their good effects than during that period in which the clam- my sweat, icy coldness of the surface, scarcely perceptible pulse, and sunken countenance, indicate a state of collapse, which, if not speedily removed, the loss of the patient is inevi- table. Many would appear to have employed the most power- ful stimulants even from the very commencement of the attack, and with no sparing hand. This practice cannot, however, be too severely reprobated. — Stimulants require at all times much judgment and great caution in tjieir employment, or they will most assuredly produce far more harm than good. Mr. Bell very properly warns his readers against the practice so gene- rally adopted in India of prescribing inordinate doses not only of internal stimulants, but likewise of calomel and opium. He maintains that some individuals, in whom the disease appear- ed to be checked by them at first, nevertheless eventually died from their poisonous operation.^ Emetics. — By several physicians emetics are directed in the early stage of Cholera " to remove crudities from the sto- mach." According to Dr. Lefevre, they were found productive of very little benefit. Their efficacy, as we shall hereafter show, must greatly depend upon the stage of the disease, and the constitution and prior habits of the patient. Purgatives. — Though considered by some as indispensable remedies in the treatment of Cholera, they do not appear, with the exception of calomel, to have been very generally employed until after the more pressing and violent symptoms of the dis- ease have been subdued. At this particular juncture it is very * Beobachtungen liber die Cholera, p. 116. t Nachricten Rigaer aertze Uber die herrschende Cholera Epidemic p. 330. \ Treatise on Epidemic Cholera. L 86 generally conceded that they have been productive of the best effects. " They are indicated so long as the bowels do not per- form their functions regularly, and the motions have an unu- sual appearance; nor is there any fear of reproducing the dis- ease by their continuance, so long as we take these marks for our guide. It is much more likely to recur from neglecting to administer them; and the quantity of unhealthy matter which is often evacuated for a long time after the disease has been subdued, warrants the assertion." Such is the experience of Dr. Lefevre in regard to the use of purgatives. — Mr. Orton pronounces them indispensable after the favourable crisis for preventing or removing the train of fatal sequelae which so frequently attend the disease. They are found to produce co- pious discharges of vitiated bile and faeces. By Mr. Annesley nearly the same statement is made. Until the dejections became, under the use of purgatives, of a blackish grey colour, sub- stantial and tenacious, the latter gentleman never considered that he had made much advancement in the cure of his patients. " A full dose of calomel," remarks Dr. Lefevre, " is often use- ful in the beginning of the convalescence, as it acts upon all the secretions — but the simple purging, which is so requisite after this disorder, is best effected by small and repeated doses of castor oil." The virtues of the latter have indeed been extolled in a very positive manner, by the physicians both of India and Europe. " The success under its use was very considerable, and there seems," says Mr. Scott,* " to be sufficient evidence to warrant a more extensive trial." It is admitted on all hands, that purgatives which produce frequent, watery dejections, with griping and' tenesmus, are in the highest degree prejudicial. Enemata. — When the irritability of the stomach, or incessant vomiting, prevents the exhibition of remedies by the mouth, enemata appear in some cases to have been useful. From the great irritability of the intestines, their speedy rejection pre- vents, in the majority of instances, any great advantage from being experienced from their use in the commencement of the attack. In the latter stages of the disease, however, they are of signal service, especially in such cases as have been attended with much spasm, and the bowels continue sore for a long time after, and every motion is productive of pain. Here an enema composed of half a pint of flaxseed tea and ten drops of lauda- num produces immediate relief — administered in this manner, * Madras Report. 87 the opium is less liable to produce injurious consequences than when given by the mouth.* Injections per annm of hot water, above blood heat, have been highly spoken of in cases of great collapse and general coldness of the surfaces. After re- maining in a while, the water may be withdrawn by the syringe and a fresh supply introduced. Tobacco enemata have, also, as we shall soon see, been recommended and used. Mr. Fife speaks favourably of injections of mustard — they have, he says, promptly brought on a discharge of urine, after it had been entirely suppressed. Sub-nitrate of Bismuth. — To read the statements given by some of the Polish and a few of the German physicians, of the beneficial effects of sub-nitrate of bismuth in every case and stage of Cholera, we should conclude certainly that a specific for the malady had at length been happily discovered. More extended experience has shown, however, that the character which the bismuth at first obtained as an infallible remedy for Cholera was unmerited, and by many it was pronounced to be incapable of producing any good effects, and if indiscreetly ad- ministered, was mischievous. Mr. Lefevre, who has evinced not a little judgment in his estimate of the value of the various re- medies proposed in the treatment of the disease, believes that much good is to be derived from the prudent use of this article. No remedy seems to quiet the cramps and vomiting more ef- fectually, and when employed in moderation, it does not produce those unpleasant effects upon the system which follow the use of severer remedies. The doses administered by Dr. Leo, by whom the article has been principally recommended, were from two to four grains every two to four hours. Dr. Lefevre warns us to discontinue its use as soon as the vomiting and spasms have ceased. If this does not take place after six or eight doses, it is useless to continue it longer. It is proper to remark, that ac- cording to the testimony of Dr. Baum, great inflammation was detected in the bowels of those who died after the use of the bismuth.f Muriate of Soda. — Although a solution of common salt is praised by a few of the continental physicians as a powerful re- medy in Cholera, and is recommended by Mr. Searle as an eme- tic in the commencement of the case, we cannot say that the evidence in its favour is very strong. It is true we are told by Dr. Barry, that at St. Petersburgh, two German physicians de- * See Lefevre's Observations, &c. on Cholera Morbus, p. 63, et. seq. I Dr. Harnett's Reports to the British Government from Dantzic. 88 clared in his presence at the medical council," that during the preceding eleven days, they had treated at the custom-house hospital thirty Cholera patients, of whom they lost none. They gave two table-spoonsful of common salt in six ounces of hot water at once, and one spoonful of the same, cold, every hour subsequently."* But let it be recollected, that these gentlemen, as well as the others who have recommended this remedy, al- ways premised bleeding and other remedies, upon the impor- tance and good effects of which in Cholera there is but little discrepancy of opinion. It is thus that many remedies in this and other diseases, acquire a fictitious reputation, from being conjoined with others of acknowledged power- — when had they been omitted, the case would, in all probability, have proceeded as rapidly, or perhaps even more so, to a favourable termina- tion. We might extend this chapter to a much greater length, by a notice of various other remedies which have been proposed and strongly recommended in the treatment of Cholera by different writers, but the means not being afforded us by which any de- cided opinion as to their efficacy can be formed, we conceive it more prudent to confine our remarks to those most generally employed, and in regard to the effects of which we are furnish- ed with the results of a pretty extensive experience. We have merely in addition to the remarks already made, to say a few words upon the drinks proper to be allowed in this disease, and the general treatment demanded in its secondary stage. Drinks. — A strange diversity of opinion exists among the writers upon Cholera, as to the proper drinks to be allowed the patient. By some, diluents of every kind were entirely prohibit- ed, in consequence of a supposition that they increased the vo- miting. The great desire of the patient is for cold water— he appears to labour under the most distressing thirst, the calls of which, it must be evident, cannot be disregarded, without ma- terially increasing his sufferings, and eventually, the disease under which he suffers. Mr. Scott, in common with nearly all the best practitioners, concedes the propriety of allowing some bland diluent, but maintains that it should be given of tepid warmth — he conceives that cold drinks are always danger- ous, and generally fatal. f This was the opinion very generally of the surgeons in India. Mr. Annesley, however, gave cold * Communication from St. Petersburgh, July 20, 1831. Madras Report. 89 water with a slight impregnation of nitric acid. This was the general drink at the hospital under his care, and was found to relieve the most distressing symptom of the disease, the burn- ing sensation at the stomach.* From the experience of the Eu- ropean physicians, it would appear very fully settled, that cold drinks are not more prejudicial than warm, and when desired by the patient, should be freely given. According to Lefevre, iced lemonade has often been taken with advantage,! and even the lower orders of the Russian people drank their quass as usual, and with seeming benefit. The diluted nitric acid, he states, may be added with great benefit to the common drink. I^ifty drops of the diluted acid, added to a pint of water, sweet- ened to the taste, is a grateful beverage.^: Mr. Orton allowed usually only moderate quantities of a weak infusion of ginger, with the addition of a little sugar and milk.§ Dr. Dyrsen, of Riga, says, that when the thirst is great, warm or even hot drinks are the best, and are often retained and even desired by the patient. He directs infusions of the various mild aromatic herbs, or when these are unpleasant to the patient, of common black tea. But when the patient desires earnestly cold drinks, they maybe given in small portions at a time, without fear of any bad con- sequences. Fresh milk, moderately cool, he states, has been found very beneficial, and when the diarrhoea is considerable, a decoction of rice or pearl barley, thin tapioca, and the like, to which, when there is entire absence of pain or tenderness of the abdomen, a little red (Port) wine may be added. A cup of strong coffee he has found very readily to suspend the vomiting in this disease — he advises the patient, in case of the drinks be- ing rejected by the stomach, to be allowed to swallow small por- tions of ice somewhat rounded into the shape of a pill by being rolled between the fingers || — a practice also recommended by Broussais. The strongest testimony in favour of warm water, is that given by Dr. Sturm, a surgeon in the Polish army: writing from the encampment near Kamienka, he says, " The treatment which we now pursue is probably already known to you, as Dr. Hel- big has been ordered to publish an account of it in the newspa- * Annesley on the Diseases of India, p. 174. \ By Mr. Bell also, and some few of the practitioners of India, cold lemon- ade was allowed. Bell on Cholera, p. 108. See also Searle's second publica- tion on Cholera. % Lefevre on Cholera, p. 82 et seq. § Orton on Cholera, p. 309. || Kurzgefaste anweisung die Orientalische Cholera, p. 37. 90 pers. It consists in nothing else than giving to the patient as much warm, nearly hot, water, as he is able to drink, in the quantity of a glassful every fifteen or thirty minutes. By the time he has taken fourteen glasses the cure is complete, with the exception of a slight diarrhoea, which it is not proper sud- denly to suspend. The effects of this plan of treatment are so quick and effectual, that in two hours, or often sooner, the pa- tient is well, particularly when it is commenced with sufficiently early."* Treatment of the Secondary Stage of Cholera. — After the more violent symptoms of the disease have been removed, that is, af- ter the vomiting and purging have been suspended, the regular action of the heart established, and the circulation and heat of the surface permanently restored, the attention of the physician must be directed to guard against or remedy local congestions, to prevent inordinate reaction, and to produce a healthy action of the bowels. Congestion is most liable to take place after the first stage or that of collapse is over, in the liver and lungs, and sometimes in the head also. For this, moderate blood-letting, local or general, according to circumstances, is the most cer- tain remedy. When febrile symptoms with determination to the brain present themselves, topical bleeding will be found very successfully to relieve it. The judicious employment of blis- ters, and of cold applications to the head, will also be of advan- tage. When the healthy condition of the bowels has not been produced by the remedies administered in the first stage, mo- derate doses of calomel, followed by castor oil or other mild purgatives, will be demanded. As soon as the discharges have become feculent, the patient may be considered out of danger, and the purgatives discontinued, but not until then. Tender- ness or fixed pain in the region of the stomach or any part of the abdomen, call for the application of leeches.f The great debility which necessarily continues for a short time after the symptoms of the first period of the disease have been removed, would appear to many to demand stimulants, powerful tonics, and a nourishing diet; but these are dangerous remedies. Simple debility is seldom dangerous in this or in any other malady: it is best removed by a light, unirritating, and very simple diet, in connexion with properly regulated ex- ercise. Change of air has been found to exert a remarkably be- * Beobachtungen uber die Assiatische Cholera, von Dr. Hille, page 92. t Bell on Cholera. — Annesley on the Diseases of India. 91 neficial effect during convalescency from Cholera, provided it can be obtained without much fatigue or exposure.* We need hardly say that much depends upon the careful at- tention of the patient during some time after recovery, to avoid all the exciting causes of the disease, and thus prevent a second and perhaps fatal attack of the disease. Strict cleanliness, tem- perance in the widest signification of the term, appropriate cloth- ing, equanimity of mind, regular exercise and repose, are the sole means to ensure a perfect restoration of health and its con- tinued enjoyment. Having reviewed, in succession, the various therapeutical agents which have been had recourse to for the cure of Chole- ra, and stated the indications which they have been intended to fulfil, we shall now exhibit an analysis of the symptoms of the disease, with reference to the treatment. We propose, in fact, to place before our readers the several circumstances under which the practitioner will be required to act with prompti- tude and effect. Whether we compare the epidemic with our own endemic cholera, in reference to the progress and phenomena of the two diseases, or compare each of the several stages of this epide- mic with some one stage of other familiar diseases, we, in these United States, need not look on it with wonderment, as pe-. culiarly new or anomalous. We have already had occasion, in the chapter in which the symptoms were described, to show that the difference between the epidemic and the endemic, or even sporadic Cholera, is rather in degree than in kind. If the group of symptoms in the latter be thought sufficient to indi- cate a rational treatment, we cannot well refuse to the collec- tion of symptoms in the former, a similar indication. Nothing short of rank empiricism should make us rely in either disease on any one remedy, to the exclusion of others, nor on the same routine or succession of remedies without regard to the stage of the disease, or the age, constitution, and prior habits of the patient. But we are told that the want of success in the treat- ment of the Epidemic Cholera, or Cholera Asphyxia, is dis- couraging, and that the differences of practice among medical men are sufficient to induce scepticism of the value of any at- tempt at cure. It is indeed deeply distressing to see sudden and numerous deaths from Cholera^ but to be able, by human power, to prevent a great number of these, considering the * Orton on Cholera. 92 class of people attacked, their situation, and habits, and their neglect of first symptoms, would imply, not so much a deficiency of skill and weak resources of art, as the possession of nearly miraculous power. As relates to the second objection, need we be surprised that the practice in the disease of India should be different from that in Russia, or that the course found useful in the cases of the European soldier and civil servants of the East India Company, should not be applicable to the miserable, filthy, drunken serfs of Russia, or scum of the people in the cities and towns of Great Britain and Ireland. In comparing the therapeutical agents which have been re- commended and used for the cure of Epidemic Cholera, with those which we either have recourse to or would promptly put in requisition in our own endemic form of the disease, we can discover no addition to our store — no discovery of any moment. We say nothing now of the many pretended specifics which have had their short-lived reputation in Epidemic Cholera, such as camphor, cajeput oil, flowers of bismuth, 8cc. or the nostrums vended with fraudulent intent by avaricious empi- rics. But while thus left free to adopt for ourselves a course of treatment for this disease, it does not follow that we should do so at random. The American physician has good data for a ratio medendi of Epidemic Cholera, obtained from his know- ledge of the endemic disease. He has also annually before his eyes a representative of the malady in question, in the Cholera Infantum, or endemic of our cities, between which and the Cho- lera Asphyxia, there is not only resemblance, but often strict identity. In both, there is for the most part a precursory stage, marked by diarrhcea and other symptoms of intestinal irrita- tion — in both, we have discharges of the same kind and variety, in the second stage, together with symptoms of collapse of the capillaries of the skin, which is cold and sodden, and also shrunk- en and altered features. In both, the first and violent stage of Cholera will often be followed by fever, and various degrees of complication, in phlegmasise of other organs. Commonly, indeed, the second, or strictly Choleric stage, rnns its course with more rapidity in the Epidemic Cholera than in the endemic variety attacking children; and yet we have seen instances of nearly as rapid a course, and violent a termination, of the latter as of the former malady. The Cholera fever is in general, more dis- tinctly marked and of longer duration in Cholera Infantum ian in Cholera Asphyxia, but even here there are no distinctly 93 contrasted features by which to show any specific difference between the two diseases. Strong as are the evidences of gastro-intestinal irritation, and clearly referrible as are the symptoms of Cholera Infantum to this source, dissections have not, any more than in the epidemic variety, with any uniformi- ty, added to the force of our convictions on this head. So that, even in the uncertainties of their pathology, there is a resem- blance between the two diseases. Akin to Cholera, if we have regard more especially to gas- tric distress, and violent spasm of the muscles of the abdo- men and limbs, is Bilious Colic, a common disease in the mid- dle and southern states. The chief causes of this malady are the same as those of Cholera, viz. irritating ingesta, and suppression of the cutaneous functions, by the sudden appli- cation of cold to a body overheated, and enfeebled by much exercise in, and exposure to the sun. It is also often the foun- dation, or first stage of bilious fever. To the parallel between the cold, eg*, on occasions, comatose stage of intermittent fever, and the collapse and asphyxia of Cholera, we have already ad- verted. The same order of parts is affected in both, viz. the abdominal viscera, the lungs, the heart, and the brain, by con- gestion. In both, death has taken place in this stage; in both, reaction may come on to the present relief of the patient; but with the effect of bringing on new and different symptoms, re- quiring for their removal remedies of a different nature from those administered in the first stage. On recapitulation, we find, that our common disease, the En- demic Cholera, both of adults and children, acknowledges com- munity of causes, and of pathological phenomena, with Epide- mic Cholera, and that between the latter and bilious colic, and the cold stage of intermittent fever, there is a close resem- blance. All these familiar endemics, in various sections of our country, have their seat and sustaining cause in the same or- gans, viz. — primarily, in the gastro-intestinal canal — secondarily and sympathetically, in the liver, spleen, and often brain, which are engorged. Impressions on the skin have, it is true, a very important bearing on these diseases — since, but for the conti- nued debility and deterioration of function of this surface, kept up by residence in a damp and unwholesome air, and want of suitable clothing and cleanliness, the digestive canal would not have acquired that susceptibility by which ingesta become ir- ritating, and act as exciting causes of the diseases referred to. Still it is not the less true, that the gastro-intestinal surface is M 94 the prime seat of irritation — whence this morbid state is radi- ated to other parts of the body. Attempts have been made to show, that Cholera Asphyxia, or Epidemic Cholera, has its chief seat in the ganglia of the great sympathetic, and the spinal nerves. Dissections barely give a colour to such a supposition, which, moreover, is not borne out by the phenomena of the disease. That the centre of the nervous system of nutritive life, should suffer in a disease in which are involved all the organs supplied by this system, is natural enough. But this is rather one of the effects, than a cause of the disease — just as turgescence of the brain, and delirium, are effects often of gastro-hepatic inflammation. The convulsive movements of the muscles of the abdomen and extremities, lead us to presume, of course, an active state of the spinal nerves, but by no means an inflammatory lesion of them, or of the spinal cord itself. There is reception of a strong irritation from sentient surfaces by this cord, and its subsequent trans- mission to the muscles; but this series of actions dqes not im- ply inflammation such as might be suspected where' there was fixed tetanic spasm. Treatment of the first or forming stage of Cholera. — If we examine, in succession, the several stages of Epidemic Cholera, we believe that the symptoms will be found sufficiently indica- tive of the order of parts affected, and will, in a measure, guide us to a rational treatment. In the first or forming stage, we meet with diarrhoea. Atony of the skin, and the use of unsuit- able ingestce, are causes adequate always to the production of this disorder — the greater the atony of the skin, the more rea- dily will diarrhoea be induced by the slightest deviation from the customary regimen. Sudden and powerful depressing causes, such as cold and moisture, or mental anxiety and fear, will induce this state of things, even without any change of diet. The colon is the part of the intestinal canal, on the irri- tation of which we know the symptoms of diarrhoea more par- ticularly to depend. The practical question then arises — how are we to manage this forming stage? how contrive that it shall not be followed by the invasion of Cholera in all its horrors and danger? Certainly not by specific remedies, or an uniform treatment. Regard must be had to the constitution of the in- dividual complaining, and to the extent of pain or tenderness of the abdomen, and sympathetic vascular irritation. At this time, says Dr. Kirk, " the skilful practitioner will give pills composed of aloes and calomel, or a pill composed of scam- mony, calomel, and aloes. The bowels, then, in general, act 95 briskly. Continue the course for three days — keep the patient warm in bed — give him mild and gentle nourishment — and after an immense quantity of horribly offensive dejections, the patient is completely recovered, and snatched from the jaws of the dreadful fate which awaited him. Some practitioners pre- scribe the mustard emetic in this state, small doses of calomel and ginger, and bleeding freely; but I prefer decidedly and on experience, the purgative system." In the cases of individuals whose bowels are habitually torpid — who have indulged in the use of irritating ingestse — or in whom there is an absence of much heat or pain of the abdomen, the purgative plan will, doubtless, answer well. But as our object here is to allay in- testinal irritation, we have but to recur to former and long- tested experience, which shows that one of the very best means for this purpose, especially where diarrhoea is present, is to keep quiet in a recumbent posture, restore the warmth of the skin by additional clothing, friction, and the warm bath, and to take warm drinks, either simple diluents, or those of a stimu- lating nature, according to the condition of the stomach, and the prior habits of the patient. It was often sufficient, in this forming or diarrhoeal stage, for the person to go to bed, get himself warm, and take a draught of hot herb tea. Perhaps a dose of castor oil, or of magnesia, may be premised. The great object in this stage, is to restore the lost balance of function — to bring back the skin to its natural action, and in so doing*, to restore the bowels to their healthy secretions.* Failing or ne- glecting to do this, the remote cause of disease still acting, and acquiring additional power by the irritation caused by exciting ones, the patient is thrown into the second or distinctly marked choleric stage of the disease. * In a case, the symptoms of which were evidently of choleric diarrhoea, and which came under the care of Dr. Bell, in the month of May last, he had the pa- tientbled, prescribed calomel and rhubarb pills, and afterwards a grain of opium, with some magnesia. — The patient was soon restored to health. In directing venesection, Dr. B. was not so much induced by the choleric form of the dis- ease, as by his knowledge and former attendance on this person, of hisprone- ness to enteritis. We have said that the symptoms were evidently of choleric diarrhoea. The patient went to bed, feeling as well as usual — he was awoke in the night with urgent desire to go to stool, which was often renewed, and barely allowed of his getting out of bed for the purpose — the discharges were profuse, resembling, as he expressed it, gruel, and at another time he compared them to rice water. They were very exhausting, and accompanied with some nausea and heat of the stomach. The tongue was white and loaded — pulse small, and rather frequent. He complained also of severe cramps in his legs. 96 Treatment of the second stage, or that of distinctly marked Cho* lera. — The transition, says Dr. Craigie, from the diarrhceal stage to that of collapse, though rapid, is never made per saltum, as it were, but in all cases, in however short a time, by gradual and successive changes. In most of the cases in which I had an opportunity of remarking this transition, the countenance became first slightly blanched, and the skin began to assume a colliquative humidity. When the pulse was felt at this period, it was not gone; but greatly weakened in force, and small in its size. The patient, at the same time, complained of a sense of sinking at the breast, with an uncomfortable sense of thrill- ing heat and unsteadiness, as if unable to support himself; and though there were instances in which the patient fell down at this period, from weakness, yet afterwards, when the stage of collapse was thoroughly established, this extreme enfeeblement of the voluntary muscles was not recognized. Bearing in mind the remark of Dr. Craigie, that by far the most powerful, both as predisposing and exciting causes, are to be found in the diet of the persons attacked; and remember- ing the habits of those who are the most ready victims to the disease, as well as its great frequency and mortality in coun- tries, the rural population of which has been compelled to use damaged or imperfectly matured grain, or vegetable produc- tions of an indigestible nature, we cannot doubt of the gastro- duodenal seat of Cholera. The first symptom — an uneasy constriction or cramp deeply seated in the epigastric region, speedily followed by profuse vomiting and purging of watery fluids, would seem to show the duodenum to be the part more immediately affected. Farther corroboration of this view is furnished in the effects of poisonous substances and putrescent animal matter taken into the stomach. After a time, their in- gestion is followed not only by vomiting, but by great prostration of strength, cold and clammy sweats, shrunken features, small and frequent pulse, and often violent spasms of the voluntary muscles. The treatment under the circumstances just mention- ed, which is generally deemed most serviceable, is to encourage the expulsion of the offending matters by a mild emetic, and free dilution, by draughts of warm water, or some other bland fluid. A similar practice has been adopted in Cholera, and, in many cases, on good grounds, especially when the attack is re- cent, and the discharges are either mixed with the food, or are white and inodorous. Inflammation cannot be presumed to exist at this time. The stomach had, up to the date of the at- 97 tack, exhibited often its customary craving for food, and was not oppressed by its reception — the tongue and skin, and ab- sence of thirst, did not betoken gastritis or gastro-enteritis; and hence we are left free to substitute one irritant, or medi- nal and controllable one, for another of a more poisonous kind, which is acting on the mucous expansion of the small in- testine, especially of the duodenum. Some practitioners prefer ipecacuanha, others sulphate of zinc, and some again, mustard, in order to produce full vomit- ing in Cholera. Mr. Hall, in his account of" Epidemic English Cholera," prevailing on the river Medway, tells us, that "having practically discovered the efficacy of exciting full vomiting by emetics of ipecacuanha, he employed this in future, in every case, without exception. Several of the cases were infants at the breast^ some were pregnant women, and one was a female above eighty years of age. In every case an ash-coloured, slimy, consistent fluid, of a peculiar smell, as well as sourish taste, was discharged by full and efficacious vomiting." "If," says Mr. Greenhow, (on Cholera) "the stage of col- lapse have not yet established itself, and if, with bilious diar- rhoea, the patient complains much of nausea and occasional retching, the matter rejected consisting principally of undigested food, we shall probably find a dose of ipecacuanha, with or without antimony, answer the purpose, or even copious draughts of warm water will suffice to wash out thoroughly the contents of the stomach." At this time, should the patient be of sanguineous habit, or complain of pain in the abdomen, head-ache, or vertigo, with accelerated pulse, we may have recourse advantageously to ve- nesection. A favourite, and, as it would seem, successful practice, in Russia and Poland, was to give a solution of common salt, so as to procure vomiting. After this, bleeding was often had re- course to, and with marked advantage. After the operation of these remedies, calomel, or calomel with opium, has been given with a view to restore the biliary and natural intestinal secretions. For such an object, calomel alone is best adapted, followed by castor oil, or rhubarb and magnesia. In cases in which the stage of collapse is impending, or has actually supervened, with violent spasms and excessive cold- ness of the surface, our remedial course must be prompt and energetic. Guided by what we know to be good and success- 98 ful practice in bilious colic, in which there is great pain of the abdomen, and cramp of the voluntary muscles, viz. — to bleed freely, give large doses of laudanum, and immersion in the warm bath, we should have some confidence in a similar course in the critical stage of collapse of Cholera. Here, however, we are required to be still more prodigal than in the former disease, of every variety of external stimulus — frictions with warm cloths, or with mustard flour and spirits of turpentine, dry heat by the introduction of hot air under the bed-clothes, by the application of heated bricks or irons, bags of hot sand, salt, or oats, flannels, &c. — sinapisms to the epigastrium — along the spine, and to the inside of the calves of the legs, and on the inside of the arms. The warm, or, rather, the hot bath, for to be of service, it ought to be upwards of 100° F. — is a remedy of undoubted power, and if found serviceable in India and Europe, cannot be without value among us. The warm bath has doubt- less disappointed many practitioners, owing to their not using it of a sufficiently elevated temperature, nor insisting on a long enough immersion of the patient in -it. "I know a gentleman," says Mr. Greenhow, " who suffered from Cholera in Archan- gel, during the last summer, and who was restored from a state of complete asphyxia by being kept in a warm bath of high 'temperature, for an hour and a half." In reply to the objec- tions made against the remedy, from the circumstance of the danger of the patient's using any voluntary exertion, and of the necessity of his strictly preserving the horizontal position dur- ing arrested circulation, this author very properly remarks, — " The patient might merely be placed in, and removed from it, with such quickness and so little disturbance, as to obviate the objections that have been made to it." Experience teaches that few means are better calculated to rouse the sensibility and excite the action of the cutaneous ca- pillaries, than the vapour bath. Accordingly, it has been used largely in different parts of Europe in the asphyxia, or col- lapsed stage of Choleraj and, as we learn from Dr. Ucelli, of the Crimea, and others, with marked benefit. Some have ob- jected to the application of moist vapour to the skin, already sodden and wet with cold sweat — and allege that it is of the utmost importance to keep the skin dry, by constant rubbing with dry and warm cloths. — The objection is hypothetical, and based upon erroneous data.— A leading object is to rouse the capillaries of the skin to action; and heat combined with water in the form of vapour, will be found one of the most efficacious means of accomplishing this end. It has also been said that 99 the use of the vapour bath is apt to cause undue fulness and turgescence of the vessels of the head, and determination to the brain. This effect may be obviated, however, and is at the moment comparatively of minor importance to the collapse and asphyxia from which it is so desirable to rouse the patient. When we recommend the vapour bath, we of course mean our remarks to apply to that variety in which the head is external to the bath, and the patient does not breathe the va- pour. Dr. Kirk has applied the actual cautery in the stage of col- lapse in three different cases — they were all fatal ones.— -The cautery he uses is a tube of porcelain, of a foot long, and an inch and a half diameter. It is inclosed in a copper tube, to which it is luted at the upper and under ends. A rod of an inch and a quarter diameter is made, of the length of this tube, and one half inch longer exactly. The rod has a little wooden handle at top. It is made red hot, and introduced into the tube in another room, and delivered to the Surgeon in that state, who, by pushing it down its extreme length, and applying it to the skin, can apply the actual cautery, without the patient knowing that a red hot iron has been used. The best place to apply the cautery seems to be the lower part of the back of the head where it joins the spine, and along the spine itself. Dr. Barry says that Dr Lange, at Cronstadt, by the cautery, cured 12 cases out of 14. This is rather too strong a claim upon our belief. " The next effectual and most efficacious mode of applying a violent irritant, is by placing on the skin a cloth newly wrung out of boiling water. This mode I am in the habit," says Dr. Kirk, "of regularly practising, and often with benefit. The blister is raised instantaneously, and in the pains of the hypo- gastric regions, so common in this disease, it in general gives relief in a few minutes. The next speediest mode is the infu- sion of cantharides in strongest acetic acid, which will raise an effectual blister on the scalp, or other part of the skin, in a few minutes." Among the internal means of rousing the patient in the stage of collapse, and bringing on reaction, are the administration of a mustard emetic, followed by laudanum and ether, each twenty-five drops, in an ounce and a half of strong peppermint water — or pills of opium in grain doses — warm brandy and wa- ter, or hot water itself. Of the great efficacy of this last simple remedy, in kindred states of the animal economy, We can speak with great confidence, We are surprised not to have seen 100 mention made of the camphorated draught with nitrous acid and opium, as recommended so strongly by Mr. Hope, and since largely used by other practitioners in dysentery. It is a remedy entitled to confidence and early use, after the exhibition of an emetic, or action on the bowels by calomel. In reference to the free use of brandy and such like diffu- sible stimuli, we cannot do better than give the opinions of Dr. Kirk, to which we entirely subscribe: — " Is brandy, then, a remedy in any stage of this disease? In the report, I have permitted its use in small quantities, not venturing to make an innovation on the established practice by avoiding it altogether; but it is now my duty to say decidedly, that the cup of brandy you perpetually see at the head of the Cholera patient, cannot be given to him innocuously. His bow- els are in general in a state of positive high action and inflam- mation: so are his brain and spinal marrow, and so are even the vascular systems of the greater nerves. What do we gain by brandy? We obtain a temporary diffused excitement from its stimulant powers, and a kind of soothing of the sensations from its narcotic influence; and can these effects produce any change in that morbid condition of the system, which, we have seen, is the cause of Cholera? I will be told that brandy, by the mouth and by enemata, have often and evidently done good. — Let, then, this be its restricted use. Never give it, either in the one mode or the other, but in those extreme cases of dis- ease where even the temporary fillip to nature, which it can give, may be courted; and though it is to come into contact with and irritate diseased tissues, still perhaps, in these extreme circumstances, its use may be indicated. But in the premoni- tory stages, while action, sometimes high action, still exists,' — and when we know many vital parts are highly irritated, and that our business is to subdue that action, — I never see the glass of brandy at the patient's head without a shudder. It is a fact that intelligent practitioners are every day becoming more and more cautious of the use of this stimulant. I feel that I have ventured far in this wholesale condemnation of it; but I confidently anticipate the decision, in my favour, of those who are to come after me, inasmuch as my views are certainly founded in the ascertained pathology of the disease. When I think a cordial strongly indicated, I am in the habit of prefer- ring the pure wines, the irritation to the inflamed tissues, from their use, being less to be dreaded than the sharp and naked points of alcohol." Enemata of various compositions have been much used in 101 the different stages of Cholera.—- In the stage of collapse, large injections of warm water have been much used in the north of England, and with a very encouraging result. Mr. Lizars di- rects the water to be as hot as the hand can bear — in quantity three or four pints, with a teaspoonful of laudanum. In cases where it was retained in the intestines for the period of an hour, it has come off quite cold. If reaction does not take place, the injection should be renewed in less time than an hour, — the former one having been sucked off by the enema pump. The chief agent here is heat applied to a large intes- tinal surface, and the plain hot water thus repeated, has been found more efficacious in relieving the spasms and collapse than the laudanum. By keeping the fingers on the anus for five minutes, the sphincter would generally resume its tone, and the injection will be retained for hours together: but should an occasional cure of relaxed sphincter occur, the plan of Dr. Clanny, of Sunderland, will answer very well; it is to merely plug the rectum with a thick greased wax candle. The more stimulating injections of spirits of turpentine, camphor, Sec. are retained but a short time — they cause much local irritation, and at times bloody discharges, without favour- ing general reaction — and on good grounds are objected to. Swayed by an hypothesis that there is a spasmodic stricture of some of the important organs, as of the ventricles of the heart, the intestines, and of the duct of the gall-bladder, and of the urinary bladder, as well as of the secreting organs; some of the British practitioners have prescribed tobacco ene- mata. It is used in infusion, made with half a drachm to a drachm of the tobacco, in a pint of water. Mr. Baird, of New- castle (England), the originator, we believe, of this practice, tells us, that if his pathological " opinion had been at variance with the fact, the powerful remedy he had adopted, must of ne- cessity have hurled the patient into the -grave;" but the cases which Dr. Kirk appends to his essay on Cholera, would seem to entitle it to some confidence — yet we cannot forget that the symptoms produced by an over dose of tobacco on a healthy man, are nearly the same as those met with in the collapse of Cholera. That we may not, however, prejudge the doctrine and practice, we shall give the details of a case in which it was used with apparent advantage.* Dr. Kirk says, I have seen ten cases of the exhibition of tobacco myself, and though in two life was not saved, yet in all distinct reaction took place; and all the symptoms were improved. * See Appendix. N 102 Among* the means of alleviating and arresting the violence of the spasms, and enabling us at least to gain time for the ad- ministration of other remedies, the application of the tourni- quet to one of the limbs merits a trial. We have heard the late Dr. B. R. Reese, of this city, speak in high terms of the beneficial effects of the tourniquet, in cases of the Cholera coming under his charge in Canton, China. It would seem from the best evidence furnished us in the treatment of Cholera, that, whilst we may be justifiably prodi- gal of external remedies to rouse the collapsed capillaries to action, and the transmission of blood, we cannot by any means exercise the same freedom in the employment of internal sti- muli. In the collapse of Cholera, we have, not a case simply of debility, but of debility and congestion — it is desirable to rouse, it is true, and to equalize the action of the system, and to re- lieve the oppressed viscera. But we well know that this is not to be accomplished readily or safely, by much internal stimula- tion. In apoplexy, and even in asphyxia, we are not free to use these without limitation and wise discretion. In that stage of disease which bears the closest analogy to the collapse of Cho- lera — we mean the chill of intermittent fever-— the prodigal use of internal stimuli would seem to be called for by all the symptoms in the case. Yet, aware of the subsequent reac- tion, we well know that no small reserve is requisite, in the administration of such remedies. During the chill, they have very little effect — they are, as it were, in almost insensible cavi- ties, in the stomach and bowels; but the hot stage supervening, and the susceptibility of the parts restored, they powerfully sti- mulate, and even irritate — increasing the fever, causing deli- rium, and phlogosed stomach, and leaving a more imperfect re- mission than would have followed, had their use been entirely- withheld. But not only are we wary of using internal stimuli in the cold stage of intermittent fever — we even on occasions have recourse to sanguineous depletion at this time.* We have * The following case is so confirmatory of the above views, that we are persuaded it will interest our readers — we give it as related by one of the au- thors of this Essay, Dr. Bell, in the North American Medical and Surgical Journal, Vol. VIII. The patient had had an attack of bilious fever, for which he had been repeatedly bled from the arm, and cupped over the abdomen. Convalescence seemed about to be established. " The patient gained very little strength, although he was allowed light animal broth and farinaceous food. Visited in the afternoon of September 17th of last year [1828], I found him in a state of great apathy, with an inclination to dose. The pulse was not ma- terially altered, nor was there any other new symptom. A blister was di- 103 ourselvesjdone so, and we have reason to believe, with good ef- fect. This practice has been adopted, and is strongly recom- mended by Annesley. — (See Appendix.) The remarks of this writer on the stage of reaction in the true Cholera fever are exceedingly important, and are corroborated by nearly every physician who has witnessed the disease. It would be well if we could almost forget the existence of the previous stage of prostration and collapse, if it so far occupy our minds as to induce a dominant idea and fear of debility, and lead to the exhibition of stimuli in this reaction or third stage. It is in the complications of symptoms, by phlegma- sia of the gastric intestinal surface and oppression of the brain at this period, that the injurious effects of the unrestricted use of brandy and laudanum in the early stages, including the period of collapse, become evident. It is at this juncture that we must draw upon the resources of rational pathology, and be guided in our practice by the symptoms of lesion and inflam- rected to the back of the neck, and a laxative of rhubarb and magnesia at bed-time. At 11 o'clock, P. M., I was sent for in great haste, and on my ar- rival found the patient in a state of complete coma, utterly insensible to all objects of sight, sound, and touch; hfs limbs, at first extended, remained in whatever position they were placed ; the pulse was barely perceptible, and the breathing very slow. It was impossible to make him swallow any thing, or to elicit from him the slightest evidence of consciousness. On applying my hand to the epigastrium, I could feel the abdominal aorta beat with con- siderable force ; so also did the carotids. The contractions of the heart were frequent, and laborious. The blister had been put on, but no medicine taken. Sixty leeches were now applied over the epigastrium, and sinapisms to the extremities. After the leeches had begun to fill, the pulse lost somewhat of its extreme tenuity, and by the time they were detached, it had regained its natural volume, was soft and easily compressible. The patient at this time began to move his eyes and the muscles of his mouth and face ; he turned a little towards one side, yawned and stretched himself. The extremities were still cold and unaffected by the sinapisms. Before all the leeches were re- moved, the skin became moist in places ; and finally a sweat covered the face, trunk, and limbs, with the exception of the hands and feet. Enemata of tepid water were administered at different times throughout the night. In the morning, though languid, he was partially sitting up in bed, by leaning on his elbow, helping himself to some light nutriment. In the afternoon of this day he experienced some rigours, which disappeared in the evening in mois- ture on the skin. " On the evening of the following day, 19th, by eight o'clock, he was in nearly the same state as on the 17th, being completely comatose. Cups in large numbers were now applied to the temples, and over the abdomen, so as to detract about ten ounces of blood. The effect was most salutary, and the recovery even more prompt than from the first attack, Enemata of cold water were given on the present occasion." 104 malion of the organs. Patience and firmness are now virtues to be put in requisition — the former to prevent undue haste in forcing up the system to an imaginary standard of strength by stimuli, the latter to induce perseverance in judicious local deple- tion and cooling practice, to moderate the excitement of parti- cular organs, and prevent disorganizing inflammation in them — ■ the stomach, intestines, or brain. Children, we are told, recover sooner than adults from the cataleptic or collapsed state. The first mark of rallying in them, was a slight injection of the conjunctiva, with marks of general restlessness and tossing of the head. After these, fol- low often all the symptoms of cerebro — meningeal, or hydroce- phalic inflammation, which, unless rapidly controlled, cut off the patient. In one case of this kind, Mr. Fife, of Newcastle, had leeches applied to the head twelve times. In the Appendix, we have subjoined a sketch of the practice, in Cholera, of some of the most eminent medical men of New- castle. When compared with that of Annesley, and others in India, and of some of the chief physicians on the continent of Europe, the reader will discover that, except in the article of calomel, there is not such a discrepancy in the employment of remedial means generally, where the disease has prevailed, as many, from superficial observation and reading, have ima- gined. In the " Observations on the Cholera of Paris," by two in- telligent young physicians of this city, Drs. Pennock and Ger- hard, we are pleased to find a general confirmation of the views expressed in the preceding pages, respecting the pathology and treatment of the disease. These writers lay great and deserved stress on the danger from inflammation after re- action. For a summary of the treatment recommended by Drs. Pennock and Gerhard, our readers are referred to the Appendix. We have not mentioned the inhalation of oxygen gas, nor the use of galvanism, among the remedial agents in Cholera, be- cause the few trials made of them, have not been so encou- raging as to attempt their repetition, even could this be done with less difficulty than necessarily obstructs their employment. APPENDIX. (A.) — Referred to page 46. EARLY NOTICES OF EPIDEMIC CHOLERA. (From the Report of the Madras Medical Board.) [Noticed by Bontius in 1629.] The Dutch Physician, Bontius, who wrot* in the year 1629, at Batavia, thus describes Cholera Morbus. " Besides the diseases above treated of as endemic in this country, the Cholera Morbus is extremely frequent; in the Cholera, hot bilious matter, irritating the sto- mach and intestines, is incessantly, and copiously discharged by the mouth and anus. It is a disorder of the most acute kind, and therefore requires im- mediate application. The principal cause of it, next to a hot and moist dispo- sition of the air, is an intemperate indulgence of eating fruits ; which, as they are generally green, and obnoxious to putrefaction, irritate and oppress the stomach by their superfluous humidity, and produce an OBruginous bile. The Cholera might, with some degree of reason, be reckoned a salutary excretion ; since such humours are discharged in it, as, if retained, would prove prejudi- cial. However, as by such excessive purgations the animal spirits are ex- hausted, and the heart, the fountain of heat and life, is overwhelmed with pu- trid effluvia, those who are seized with this disorder generally die, and that so quickly, as in the space of four-and-twenty hours at most. Such, among others, was the fate of Cornelius Van Royen, steward of the Hospital of the sick, who being in perfect health, at six in the evening, was suddenly seized with the Cholera, and expired in terrible agony and convul- sions before twelve o'clock at night; the violence and rapidity of the disorder surmounting the force of every remedy. But if the patient should survive the period abovementioned, there is great hope of performing a cure. This disease is attended with such a weak pulse, difficult respiration, and coldness of the extreme parts ; to which are joined great internal heat, insa- tiable thirst, perpetual watching, and restless and incessant tossing of the body. If, together with these symptoms, a cold and fetid sioeat should break forth, it is certain that death is at hand." In treating of the " Spasm," this author gives the following account. <: The disorder of the Spasm, almost unknown with us in Holland, is so common in the Indies, that it may be reckoned among the popular and endemic diseases of the country. The attack of it is sometimes so sudden, that people become in an instant as rigid as statues; while the muscles, either of the anterior or pos- terior part of the body, are involuntarily and violently contracted. A terri- ble disorder ! which, without any primary defect of the vital or natural func- tions, quickly precipitates the wretched sufferer in excruciating torments to the grave; totally deprived of the capacity of swallowing either food or drink. There are, likewise, other partial Spasms of the limbs ; but these being more gentle and temporary, I shall not treat of them. People affected with this disease look horribly into the face of the by- standers (truculente admodum astantes intuentur) especially, as often hap- pens, when the cynic spasm comes on, and both the cheeks are drawn in convulsion towards the ears ; a red and green colour is reflected from the eyes and face; (ruber et viridis color ex oculis et facie oritur), the teeth gnash; and instead of the human voice, a rude sound issues forth of the throat, as if heard from a subterraneous vault ; so that to those unacquainted with ths* dis- order, the person appears to be daernoniac." 106 In speaking of Cholera, Bontius no where mentions the colour of the mat- ters evacuated. He talks indeed of seruginous bile: but that would appear, from the context, to refer to its assumed acrimonious quality, rather than to any sensible property ; and we shall presently see that practitioners of much later times dwell greatly on the supposed bilious and irritative nature of the evacuations, when it is pretty evident, that they were merely speaking hy- pothetically. His descriptions indeed are not at all full: for, though he does not mention spasm as a symptom of Cholera Morbus, he states that Corne- lius Van Royen expired in convulsions, within six hours from an attack of it. Still, in his description of Cholera, where " the heart is overwhelmed," where " those who are seized with the disease generally die," and that within twenty-four hours at most ; and in his enumeration of symptoms as marked in italics, every one, familiar with the epidemic Cholera as it has prevailed in this country, will probably admit, that he has truly pourtrayed that disease, and no other. Although Bontius has treated of " the Spasm," and of " the Cholera Mor- bus," under separate chapters, it is highly probable that these disorders were one and the same. It would seem that he has considered the tonic spasm as idiopathic, and the clonic spasm as symptomatic, yet it is evident by the expression, " there are likewise other partial spasms of the limbs," that both these forms of spasm existed in the same patient, a fact which is amply confirmed by innumerable observations in the present epidemic. . If it be objected that he does not men- tion the usual symptoms of Cholera as occurring in " the Spasm,", it may be answered, that neither does he mention the state of the skin, of the pulse, nor of respiration, which functions it is impossible to suppose remained unaffected in such a commotion of the system. The edition of Bontius, which has been quoted from, is an English transla- tion, published in London, 1769; but, from the passages in the original, as in- serted in parenthesis, it is evident that the translation is not quite correct. The expressions, especially, of the eyes and face " reflecting'" a red and green colour can only be intelligible by supposing, that the former was suffused with blood, and the latter changed to that ghastly and cadaverous hue, so familiar to us all in the collapse stage of Cholera. [By Dr. Paisley in 1774.] The next notice, in point of time, which we find of Cholera, is in the copy of a letter written by Dr. Paisley at Madras, dated l'2th Feb. 1774, as given by Curtis, in his publication on the diseases of India. Dr. Paisley says, " I am favoured with yours, and am very happy to hear you have caused the army to change its ground ; for there can be no doubt, from the circumstances you have mentioned, that their situation contributes to the frequency and violence of the attacks of this dangerous disease, which is, as you have observed, a true Cholera Morbus, the same they had at Trincomalee. It is often epidemic among the Blacks, (natives) whom it destroys quickly, as their relaxed habits cannot support the effects of sudden evacuations, nor the more powerful operation of diseased bile. The first campaign made in this country, the same disease was horridly fa- tal to the Blacks; and fifty Europeans of the line were seized with it. I have met with many single cases since, and many of them fatal or dangerous, of different kinds, arising from putrid bile being disturbed by accidental causes, or by emetics or purgatives exhibited before it had been blunted or corrected." Dr. Paisley does not give any particular description of the disease: and though he dwells much on the putridity and acrimony of the bile, he does not allude to the colour or appearance of the evacuations. He observes that " when it (the Cholera) is epidemic here, it is totally a disease of highly pu- trid bile, which operates on the system as poison, and brings on sudden pros- tration of strength, and spasms over the whole surface of the body." In re- laxed habits, when the pulse sinks suddenly, and brings on immediate dan- ger, the same method must be pursued, but with more caution." The letter is quoted by Curtis as referring to the Cholera Morbus, or Mort de Chien: and these extracts will probably be deemed sufficient evidence of the correct- ness of the reference. 107 It is highly important to remark, that Dr. Paisley here speaks of the dis- ease as being "often epidemic;" that it prevailed in that form in the " first campaign," and affected both Europeans and natives. The particular periods here alluded to are not known, but we have seen, by the extract from the records of the Medical Board, that Cholera raged as an epidemic, in 1769, or 70. [By Sonnerat from 1774 to 1781.] Sonnerat, whose travels in India em- brace the period between 1774 and 1781, speaks of a disease on the Coro- mandel Coast, in all respects resembling Cholera, and he notices it as "an epidemical disorder which reigns.'''' His account of it is this. " There is also another epidemical disorder, which reigns, and in twenty- four hours, or sometimes less, carries off those who are attacked. It never appears but in cold weather." " Debauchees, and those who have indigestions, are attacked with a loose- ness, or rather with an involuntary flux of the excrementary matter become liquid, but without any mixture of blood. They have no remedy from this current of the bowels,* which they call a sharp flux, but leave the cure to the care of nature." " The flux of this kind which reigned some years ago, spread itself in all parts, making great ravages: above sixty thousand people, from Cherigam to Pondicherry, perished. Many causes produced it. Some were attacked for having passed the night and slept in the open air j others for having eat cold rice with curds; but the greater part for having eat after they had bathed and washed in cold water, which caused an indigestion, an universal spasm of the nervous kind, followed by violent pains and death, if the patient was not speedily relieved. This epidemical disorder happened during the northerly winds in December, January, and February; when they ceased, the malady disappeared. The symptoms of this disorder were a watery flux, accompa- nied with vomiting and extreme faintness, a burning thirst, an oppression of the breast, and a suppression of urine. Sometimes the deceased felt violent cholicky pains; often lost his speech and recollection, or became deaf, the pulse was small and concentered, and the only specific which Choisel, a for- eign missionary, found, was treacle and Drogue amere. The Indian physi- cians could not save a single person." " There is great reason to imagine that the perspiration being stopped, and reflowing into the mass of blood, by finding its way to the stomach and bow- els, occasioned the vomiting, which terminated by this flux." " That which followed, two years after, was the most dreadful. It did not proceed from the same cause as the first, as it began in July and August: it first showed itself by a watery flux, which came in an instant, and sometimes cut the deceased off, in less than four-and-twenty hours. Those who were attacked had thirty evacuations in five or six hours; which reduced them to such a state of weakness that they could neither speak or move. They were , often without pulse; the hands and ears were cold; the face lengthened ; the sinking of the cavity of the socket of the eye was the sign of death ; they felt neither pains in the stomach, cholics, nor gripings. The greatest pain was a burning thirst. Some brought forth worms by stool; others by vomiting. This cruel pestilence affected all the castes in general, but particularly those who eat meat, as the Parais. The native physicians succeeded no better in their treatment of this disorder, which was again renewed during the north winds." It is by no means easy to determine the precise dates of the epidemic visi- tations of Cholera alluded to in these extracts, as prevailing, in the first in- stance, " some years ago" and in the second, " txoo years after." It is, how- ever, reasonable to suppose, that a disease, which " spread itself in all parts," and carried off " above 60,000 people from Cherigam to Pondicherry," would not have been passed over without some special notice by Dr. Paisley, in his letter dated 1774, already quoted, had it occurred prior to that date. The presumption seems to be, that Mons. Sonnerat described invasions of Epide- * Probably " cours de ventre," in the original. The edition here quoted is a translation by Francis Nagnus, Calcutta, printed 1733. 108 mic Cholera which took place subsequently to the year 1774. That they were certainly considerably prior to that epidemic which is stated in the re- cords of the medical board to have prevailed " over the whole coast in 1783/ is evident, from the date of the work : and consequently, when viewed in re- ference to other authorities, it is obvious, that Cholera maintained its influ- ence, ivith little apparent interruption, from a very remote period, down to a date comparatively modern. Sonnerat notices the term " mort de chien," as being used in India, but applies it to " indigestions," which " are very fre- quent," and from which " many have died suddenly." [Cholera observed at Mauritius in 1775, and in 1819.] It appears from the report of a committee of British medical officers at the Mauritius, which was assembled in the month of November, 1819, under the authority of the government, in order to examine into the nature of the epidemic disease which then prevailed at that Island, that the Epidemic Cholera was not un- known there. The following is an extract from the report. " The commit- tee request to say, that they have not, either in this island or elsewhere, met with a disease possessing the characters of that which now prevails: but that, from the reports of several individuals, some of whom belong to the medical profession, it does appear, that a disease, most strongly resembling in its symptoms, progress, and termination, that now under consideration, did for some time prevail in this colony in the year 1775." The symptoms which are detailed by the committee, as characterising the epidemic of 1819, sufficiently indicate the identity of that disease, with the form of Cholera, which prevailed at the same period, and still continues, on the continent of India. " The symptoms, in the two cases alluded to, per- fectly corresponded with those of the numerous instances of the disease, which have since occurred. Those more particularly characteristic of the disease are sudden and excessive prostration of strength, with sinking of the pulse; extreme coldness of the surface of the body, which is covered with cold viscid perspiration; and a distressing uneasy sensation in the abdomen, the progress of which has generally carried off the patient in the space of a few hours." Dr. Burke, the chief medical officer in the island, makes the following ob- servation in his letter transmitting the report of the committee. " A similar disease prevailed in this island in 1775, after a long dry season, fyc. the symp torns, fatal and sudden effects, and duration, of the disease, would seem to be exactly the same. A hurricane put a stop to its ravages, which continued for probably two months, and caused a great mortality, particularly among the Blacks and people of colour." But it is necessary to state, that a committee of French medical gentle- men, who were assembled under similar circumstances with the British Committee, make no mention of the epidemic visitation of 1775. Assuming, however, the circumstance to be true, it is highly worthy of remark, that while, as we have shown in the preceding pages, the Indian continent suf- fered under Cholera, about that period, viz. 1775, the disease had then also extended to that remote island. [At Ganjam, in 1781.] Cholera appears to have manifested itself pretty extensively as an epidemic in 1781; its appearance on this occasion is thus noticed in the report on Cholera by Mr. Jameson, secretary to the Calcutta Medical Board. " A Division of Bengal troops, consisting of about 5,000 men, was proceeding, under the command of Colonel Pearse of the Artillery, in the spring of 1781, to join Sir Eyre Coote's army on the coast. It would appear, that a disease resembling Cholera had been prevalent in that part of the country, (the Northern Circars,), some time before their arrival; and that they got it at Ganjam on the 22d March. It assailed them with almost inconceivable fury. Men, previously in perfect health, dropt down by dozens ; and -those even less severely affected were generally dead or past recovery within less than an hour. The spasms of the extremities and trunk were dreadful; and distressing vomiting and purging were present in all. Besides those who died, above five hundred were admitted into hospital on that day. On the two following days, the disease continued unabated, and more than 109 one half of the army was now ill." In a note it is added, " The occurrence of the disease on this occasion is noticed in a letter dated 27th April, 1781, from the supreme government to the court of directors; and the destruction which it caused in this detachment mentioned in terms of becoming regret." After adverting to its progress in the Circars, the letter thus proceeds: " The disease to which we allude, has not been confined to the country near Ganjam. It afterwards found its way to this place (Calcutta); and after chiefly affecting the native inhabitants, so as to occasion a great mortality during the period of a fortnight, it is now generally abated, and pursuing its course to the northward." It would have been interesting to have traced this disease, as it seemed to have put on the epidemical form, but every at- tempt to discover its further progress has proved fruitless. [Noticed by Curtis, in 1782.] From this period, up to the year 1787, and perhaps even to 1790, the Cholera would appear to have existed epidemically, in various parts of India. Curtis states, that the fleet, in which he served, joined Sir Edward Hughes's squadron at Madras, in the beginning of 1782; in May of that year, his ship, the Seahorse, arrived at Trincomalee, and he says, " The mort de chien, or cramp, I was also informed by the attending surgeon, had been very frequent and fatal among the seamen, both at the hospital and in some of the ships, particularly in the Hero and Superb." The Seahorse had no case of the disease till the 21st of June, when between that day and the 25th they had eight cases. " In every one of the eight cases the symptoms were so much alike, both in order and in degree, that a description of any one would answer almost equally well for every other. Any difference that took place was in the sud- denness of the attack, or the rapidity with which the symptoms succeeded each other. In all of them the disease began with a watery purging, at- tended with some tenesmus, but with little or no griping. This always came on some time in the night, or early towards morning, and continued some hours, before any spasms were felt; and slight affections of this kind being very common in the country, the patients seldom mentioned them till they began to be more severe, and extended to the legs or thighs. This -purging soon brought on great weakness, coldness of the extremities, and a remarka- ble paleness, sinking and lividity of the whole countenance. Some at this pe- riod had some nausea, and retching to vomit, but brought up nothing bilious. In a short time the spasms began to affect the muscles of the thighs, abdomen, and thorax, and lastly they passed to those of the arms, hands and fingers ; but I never saw, then or afterwards, those of the neck, face, or back, at all af- fected. The rapidity with which these spasms succeed the first attack, and their severity, especially as affecting the muscles of the thorax and abdo- men, denoted in general the degree of danger in the case. The affection is not, as in tetanus, confined to a single muscle, or to a certain class of mus- cles OHly. Neither does it, as in the spasmus clonicus, move and agitate the members. It is a fixed cramp in the belly of the muscles, which is gathered up into a hard knot, with excruciating pain. In a minute or two this relax- es, is again renewed, or the affection passes to others, leaving the miserable sufferer hardly an interval of ease: and, lastly, it passes from one set to an- other; from those of the inferior extremity to those on the upper parts, leav- ing the former free. The patients complain much of the pain of these cramps; think they obtain some relief from friction of the parts, and cry to their companions to rub them hard. As the disease proceeded, the counte- nance became more and more pale, wan, and dejected; the eyes became sunk, hollow, and surrounded with a livid circle. The pulse became more feeble, and sometimes sank so much as not to be felt at the wrist, in two or three hours after the spasms came on. But so long as it could be felt, it was but little altered in frequency. If the spasms happened to intermit, it would sometimes rise a little, and the countenance assume a better look. The tongue was generally white, and more or less furred towards the root; the patients had all great thirst, or rather a strong desire for cold drinks; but there was no head-ache or affection of the sensorium commune throughout. ," " The coldness of the extremities, which was perceptible from the very o 110 first, continued to increase, and spread over the whole body, but with no moisture in the skin till the severity of the pain and spasms forced out a clammy sweat, which soon became profuse. The hands now began to put on a striking and peculiar appearance. The nails of the fingers became livid, and bent inicards : the skin of the palms became ichitc, bleached, and wrinkled up into folds, as if long soaked in cold water ; the effect, no doubt, of the profuse cold sweat, which is one of the most pernicious and fatal symptoms of the disease, both from the effect it has in such a climate, of exhausting the strength, and in abstracting heat from the system. In some of the pre- sent cases, and in many others after this, we had recoveries from the severest degrees of spasmodic affection; even where the pulse had been for hours completely lost at the wrist, and the body perfectly cold ; but never of any who had these profuse cold clammy sweats, and where the hands had put on this appearance." " All this while the purging continued frequent, and exhibited nothing but a thin toatery matter or mucus. In many, the stomach became at last so ir- ritable, that nothing could be got to rest upon it; but every thing that was drank was spouted out immediately; without straining or retching. The countenance and extremities became livid, the pulsations of the heart more quick, frequent and feeble; the breathing began to become laborious and panting ; and, in fine, the whole powers of life fell under such a great and speedy collapse, as to be soon beyond the power of recovery. In this pro- gression, the patient remained from three to five or six hours from the ac- cession of the spasms ; seldom longer. These began at last to abate, but with more internal oppression, great jactitation, panting and gasping for breath, from the diminished action of the respiratory organs; for there were no marks of oppression or effusion on the lungs; and the motion of the heart, so long as it could be felt, became more and more quick and irregular, till death came at last to the relief of the miserable sufferer. Sometime be- fore that event took place, the spasms gradually abating, left the sufferers entirely, and so much possession of their faculties did they retain, that they would continue to talk sensibly to their messmates, to the last moment of their life, even when the %chole body had become perfectly cold, and all pulsation of the heart had ceased for a long time to be distinguishable." " About the middle of July, 1782, I entered on duty at Madras hospital. Here, again, I had occasion to see many more cases of the mort de chien. It was frequent in the fleet in the month of August, and beginning of Sep- tember, the season at which the land wind prevails on this part of the coast. We had some cases in the hospital in the end of October, and in November after the monsoon, but few in comparison." [Mso by Birdleston.] Although Cholera would thus appear to have been of limited prevalence in the naval hospital at Madras, in October, 1782, its in- fluence was most severely felt at that period by the newly-arrived troops from England, as stated by Girdleston in his essay on spasmodic affections of India. — He observes, " spasms were the first disease which appeared amongst the troops who arrived at Madras in October, 1782, under the command of Major General Sir John Burgoyne. More than fifty of these fresh men were killed by* them within the first three days after they were landed in that coun- try, and in less than a month from that time, upwards of a thousand had suf- fered from attacks of this complaint." " The symptoms which commonly first presented themselves were coldness of the surface of the body, especially of the hands, feebleness of the pulse, and spasmodic contractions of the lower extremities, soon extending to the mus- clesof the abdomen, diaphragm, and ribs. As the spasms advanced, the muscles might be seen to assume the rigidity of cartilages; sometimes causing the body to remain immoveably extended, sometimes bending the trunk through its whole length, anteriorly ; and sometimes, though seldomer, backwards. The parts in which the spasms began generally remained rigid ; but those which were subsequently seized with them, had momentary intermissions of the contractions ; the only intervals of relief experienced by the patient from the most tormenting pains. The hands and feet then generally became sodden, Ill with cold sweat, the nails livid, the pulse more feeble and frequent, and the breath so condensed as to be both seen and felt, issuing in a cold stream, at a considerable distance. The thirst was insatiable, the tongue whitish, but never dry; vomitings became almost incessant; the spasms, cold sweats, and thirst, increased with the vomitings; which last, if not checked, soon termi- nated the existence of the patient." " In this manner, most commonly, was the succession of phenomena; but often they were so rapid in their attack, that they seemed to seize the patient all in conjunction instantaneously." " In some few, the extremities remained warm ; in others, also, the spasms were only clonic or convulsive. Some died in the first hour of the attack ; others lived a day or two with remissions ; when they died, either of univer- sal spasms or an apoplexy. On dissection of the bodies after death, it appear- ed that no injury hail been sustained by the brain, liver, gall-bladder, stomach, or heart. The prognosis of this disease is formed with greater certainty from the-warmth or coldness of the extremities, than from either the universality of the spasms, or the frequency or steadiness of the pulse. Thus, if the spasms were ever so general, with warmth of the extremities, there was no immediate danger : on the contrary, if the spasms were ever so trifling, with coldness, there was every danger to be feared." Girdleston, like Bontius, treats of the "spasms" as an idiopathic disease; yet it is obvious from his observations on the prognosis, that spasm was merely a symptom, and one of secondary importance. He has not noticed purging, and from the casual way in which vomiting is mentioned, it seems doubtful whether we are to consider purging to have been inadvertently omitted, or that it really was not present, as has often been observed to be the case on late occasions. It is accordingly assumed that the " spasm," described by Girdleston was, in fact, the Spasmodic Cholera, or Mort de Chien of Curtis. It is also noticed in the Bengal Report, that in the month of April, 1783, Cholera destroyed above 20,000 people, assembled on occasion of a festival at Hurdwar; but it is said not to have extended to the neighbouring country. All these authorities would seem accordingly to establish the fact of the pre- valence of Cholera in India; and especially of its existence during the period extending from 1769-70 to 1787, when we find the first notice of the disease in the records of this office as given in the extracts, page 239, and which we now come to consider. [Dr. Baffin's account of it at Vcliore, in 1787.] Dr. Duffin, in a letter dated the 28th October, 1787, says, " I returned yesterday from Arcot, where I had an opportunity of seeing the situation of the sick. The Cholera Morbus rages with great violence, with every symptom of putrescency, and so rapid in its progress, that many of the men are carried off in twelve hours' ill- ness." Dr. Duffin considered the disease to depend on putrid bile: he re- commended castor oilj external heat, frictions, and the internal exhibition of warm cordial drinks, as the plan of treatment he had always found successful. In a subsequent letter, dated the 3d of November, he enters more fully on the nature of the disease. " The symptoms were generally pretty much the same in all I have seen, only the violence of the spasms was greater according to the stamina of the patient, and the quantity of putrid matter in the primae viae. They are generally seized with a nausea, frequent heats and chills, a dryness of the skin, and numbness and uncommon sensation, as they ex- press it, in different parts of their body. Then came on cold sweats, severe gripings, and mostly a purging of bilious colluvies, appearing often in fer- ment like yeast, and not unlike it in colour, with a putrid offensive smell, retchings to vomit, often bilious, and at other times scarce any thing is brought up but the liquor that is drank ; an intense thirst, oppression on the praecordia, with difficulty of breathing ; frequently the spasms begin with the first attack, though sometimes they only appear as the disease advances, and then generally affect the lower extremities, afterwards the abdominal muscles ; and the whole system becomes convulsed. The pulse from the first sinks, and at times is scarcely to be felt; profuse clammy cold sweats, and a pallid hue overspread the body ; the countenance ghastly, the eyes sunk, and the voice scarcely to be heard, with great dejection. The tongue in general 112 moist till near the close of the disease, when it becomes dry and foul, and the breath offensive; the urine generally pale and in small quantity." It is to be observed, that Dr. Duffin, at the period in question, was stationed at Vellore, about 14 miles from Arcot; and that his description of the Chole- ra could not be founded on any lengthened observation of the cases at the latter station, since he only made a very short visit to to it. There seems some reason to doubt, therefore, whether he was not describing partly what he saw at Arcot, and partly what he had more experience of at Vellore, where the Cholera was then also raging, but not in a very dangerous degree. His confident allusion to the bilious nature of the contents of the primoe viae, and the success of castor oil in curing the disease, may lead us to suppose that at Vellore he had in fact to contend chiefly with the Cholera Morbus, as it is commonly termed, not with the Epidemic or Spasmodic Cholera. This conclusion is supported by a reference to the sick returns, which happen in this instance to be somewhat less meagre and imperfect than they generally are found to be at that distant period. It appears that, during the month of October, 1787, twenty-two Europeans were admitted into hospital with " Cholera Morbus" at Vellore, and two natives ; of whom it cannot be ascertained that any died, for the returns of that period do not show the disease from which the casualties arose ; how- ever, only two Europeans died during that month at Vellore from any dis- ease, and not one native. At Arcot, on the contrary, 35 Europeans are en- tered in the sick returns, under the head of" Cholera Morbus," in October, 1787, but no natives ; and 25 Europeans died that month, a number which falls short of what Dr. Davis distinctly attributes to Cholera alone. In No- vember, 45 Europeans are returned^at Vellore under the head of " Cholera Morbus," and one native ; only one European died that month at Vellore. At Arcot, 17 Europeans are returned in November as ill with " Cholera Mor- bus;" only one death took place in all, but during this month, it seems to have slightly affected the natives, 12 being returned, of whom none died; there were at this time four regiments of native cavalry quartered there. It seems reasonable, therefore, to infer that the disease prevalent at Arcot, and described by Mr. Davis as " spasmodic affection of the nervous system," was not the same, in general, with that which existed at Vellore, unless we im- pute a degree of efficacy to castor oil which can hardly be admitted. [Dr. Davis's Account of it at Arcot, in 1787.] Mr. Davis, a member of the then Hospital Board, appears to have been deputed from Madras to investi- gate the nature of the sickness which prevailed at Arcot. In his report to the Board, which is dated the 29th of November, 1787, he states as follows: " I found, in what was called the epidemic hospital, three different diseases, viz. patients labouring under the Cholera Morbus, an inflammatory fever, with universal cramps; and a spasmodic affection of the nervoas system dis- tinct from the Cholera Morbus. I understood from the regimental surgeon, that the last disease had proved fatal to all icho had been attached with it ; and that he had already lost seven-and-twenty men of the regiment in a few days. Five patients were then shown me with scarce any circulation whatever, to be discovered ; their eyes much sunk within their orbits; their jaws appa- rently set, their bodies universally cold, except at the praecordia, and their extremities livid. Mr. Pringle observed that these five men were attacked on the 26th October, that Mr. Duffin had seen them, and had recommended castor oil to be administered, &c. &c." He then goes on to say, " finding on the day of their attack, the rectum had discharged its contents in the action of straining to vomit without being able to bring any thing up, I directed a stimulant injection to each of these patients which produced a copious discharge of feeCes, without any bilious in- duration (indication ?) whatever." Having prescribed some antispasmodic medicines, he. says, " from all which I had the pleasure to observe, that in four-and-twenty hours after my first visit, the spasms had totally subsided, the patient's voice, which all along had been so low as scarce to be heard, was returned almost to its natural state; the pulse that was imperceptible, full and even." After ordering some carminating purgatives, he observes, 113 " I attended to the operation of these respective medicines, and could disco- ver no bilious indication in the whole system." Two of the five patients having died in a few minutes after being taken out of a hot medicated bath, " upon dissection the duodenum was found dis- tended with putrid air; the other intestines empty, except the colon and rectum, in which latter there were indurated faeces; the whole viscera sound, the gall-bladder turgid, but not diseased !" Mr. Davis does not state the symptoms of the "inflammatory fever with violent cramps," farther than that the patient complained of a " tightness of the abdomen with a costive habit." The " cholera morbus" was distinguished by "spasms of the praecordia, and cramps of the extremities, with bilious li- entery, and a copious discharge from the stomach of a green, yellow, and dark-coloured bile. During his residence at Arcot, upwards of sixty pa- tients labouring under these three forms of disease were admitted, and only two or three deaths ensued. The dissection of a case is given, where, it is stated, " the bladder was most singularly contracted, and did not exceed in size a large nutmeg, yet without inflammation, or any apparent disease, ex- cept its contracted state." [Mr. Thompson's account of it, at Arcot and Trincomalee.] Mr. Thomp- son, surgeon, who was also sent to Arcot at the same time with Mr. Davis, observes, " This disease is exactly the same as prevailed at Trincomalee in the months of April and May, 1782, when the season was very hot and chill, the winds blowing from the land, and reaching some leagues to sea. The weather here at present is the same as I experienced at Trincomalee." Mr. Thompson also gives an account of a dissection where " the gall-blad- der was exceedingly distended with bile, so much so as to appear protruded some inches below the liver, and to contain near six ounces of-bile. No marks of putrescence in any of the abdominal viscera. The urinary bladder quite empty and contracted to the size of a walnut; the stomach and duode- num both empty of bile, and no appearance of inflammation in any part of the intestinal canal or peritoneum." To persons familiar with the progress of Cholera during late years, there can be little difficulty in understanding and reconciling the apparent discor- dances in the accounts just quoted. Many instances of the common Cholera would seem to have occurred at Arcot, as well as at Vellore, where, it has been conjectured, this form of the disease chiefly prevailed. Some cases seem to have commenced with a degree of febrile excitement, an occurrence which has been occasionally observed in the present epidemic ; or perhaps, these cases might be properly referred to a species of febrile affection with cramps, of which we have a very distinct history by Mr. Anderson, who ob- served the disease at Ellore in 1794, and styled it a " Causus ;" lastly, that which Mr. Davis characterises as a " spasmodic affection of the nervous sytem distinct from Cholera Morbus," was no doubt the same low and dan- gerous form of the disease with which we have become too well acquainted in recent times. The disease would seem to have lost its force at the period when Mr. Da- vis arrived at Arcot; for we find that the five cases, of the low form, which he first saw, had lingered from the 26th to the 29th ; and few of the subse- quent seizures proved fatal, which is quite analogous with our present expe- rience. — Whether the bowels were less generally affected in that epidemic, or whether the means employed, and the prolongation of life for three days, had given rise, in the cases in question, to faecal formations, and to their accumulation in the large intestines, it is not easy, from the scantiness of our information, to decide. But, if any doubt could be entertained of the cases described being Cholera, such as we have lately witnessed, the testimony of Mr. Thompson to their identity is conclusive, if we admit that the mort de chien of Curtis, which he states to have prevailed at Trincomalee at the time mentioned by Mr. Thompson, was really Cholera. \_Cholera noticed in 1790 in the Northern Circars.] It is stated in the Cal- cutta report, that " Cholera was again very prevalent and destructive in a detachment of Bengal troops marching through the Northern Circars, in the 114 months of March, April, May and June, of 1790. " The disorder was cha* racterised by precisely the same symptoms which marked the late epidemic. It began with violent pain and spasm in the stomach and bowels ; which were followed by purging, vomiting, and all the signs of extreme debility." [Noticed by Dr. James Johnson.'] The next account we have of Cholera is to be found in Dr. Johnson's work on the diseases of the tropical climates. It does not appear in that work, that Cholera was then epidemical, but it would seem to have occurred pretty frequently, both on shore, and on ship board, chiefly in the vicinity of Trincomalee. The precise date is not mentioned; it is concluded," however, to have been about 1804. Dr. Johnson does not detail the symptoms with much minuteness, contenting himself with those occurring in one or two cases, and referring generally to Curtis's description of the disease, a pretty satisfactory proof that they were the same. A sea- man on awaking after a debauch, repaired to the deck, and there again fell asleep, during the chilly part of the night. " About 4 o'clock in the morn- ing, he awoke with a shiver and left the deck, but was soon seized with fre- quent purging and griping, his stools consisting of mucus and slime. Nausea and retching succeeded; nothing being ejected but phlegm, and the contents of the stomach. His pulse was now small, quick, and contracted; his skin dry, but not hot. About eight o'clock in the morning he began to feel spasms in different parts of his body, which soon attacked the abdominal muscles, and threw him into great pain. During these paroxysms, a cold clammy sweat would be occasionally forced out, especially in the face and breast. The extremities now became cold; his features shrunk; the sto- mach rejecting every thing which was offered, either as medicine or drink. The abdomen and epigastrium all this time were distended and tense, with incessant watery purging and painful tenesmus. By ten o'clock his pulse could scarcely be felt: his breathing was oppressed and laborious, his eyes sunk, and the whole countenance singularly expressive of internal agony and distress. The extremities were cold, shrivelled, and covered with clammy sweats. The violence of the spasms now began to relax; and by eleven o'clock, or seven hours from the attack, death released him from his sufferings." " This may serve as a specimen of the worst form of that dreadful disease, which has obtained the appellation of " mort de chien," or the " death of a dog." [Cholera supposed to have been met with at various times since 1787.] Since Cholera has become familiar to the older practitioners here, many, perhaps all of them, recollect having met with insulated cases of that dis- ease, as well as of sudden, and often fatal illness, which they, at the moment, could not well understand, and which consequently, proved extremely em- barrassing. Such cases would no doubt be attributed by different practition- ers to different causes, and be referred to different heads of disease, accord- ing to the various states in which the patients were seen; and, perhaps some of them were considered to be merely anomalous instances of common Cholera ; but late experience has now very generally led to the opinion, that they were, in fact, cases of Spasmodic Cholera. The records of the medical board throw no light on this subject. The number of cases of the description alluded to, which may have entered the military hospitals, could not how- ever, in all probability, have been great, without attracting observation. It might perhaps be thought that the necessity of classing the cases in the offi- cial returns would have led to their being detected by a bare inspection of these documents ; but in the absence of any nosological arrangement, which then distinguished the returns, no difficulty would be experienced in dis- posing of them. Sporadic cases of Spasmodic Cholera might naturally produce the impres- sion that some poisonous matter had been swallowed, which other circum- stances would contribute to render sufficiently plausible; for, it is notorious, that intoxicating liquors are prepared by the natives, and clandestinely sold to the European soldiery, which contain the most deleterious matters, and which often produce fatal consequences to those who drink them. The symp- toms attending such cases are frequently very anomalous and perplexing. 115 Although the natives are less prone to debauch in spirituous liquors, they are yet not altogether to be exempted from the reproach ; and the notion of a poison having been swallowed, would, in their case, be rendered still more pro- bable, from such occurrences being not unknown amongst them, and from our ignorance of the nature of the poisons which are used. It must be admitted, however, that very few cases either of sudden death, or poisoning, or Cholera, are to be found in the returns; but it will be pre- sently shown, that no positive conclusion can thence be drawn against the existence of Spasmodic Cholera prior to the year 1818, when it appeared epi- demically in these territories; and that some at least of the cases designated as Cholera in former times, were clearly of the spasmodic species. [Described by Mr. J. Wyllie in 1814.] Mr. John Wyllie, in his report, dated 20th July, 1818, (page 68) makes the following remarks: " Before concluding, I think it proper to add, that although I have never, before the late occasion, seen this peculiar disease prevailing as an epidemic, yet I have at various times met with single cases of it in the most aggravated form, and I am much mistaken, if I have not recorded two particular instances of it in my journal of the 1st battalion 24th regiment, for the month of June, 1814, under the names of Paramuttee, and Madaramooto, sepoys." On referring to these cases which have been preserved, Mr. Wyllie's conjecture seems to be fully confirmed. The first case is thus described : " Jaulnah, 19th June, 1814, P. M. 2 past 2. He is in a state of the most extreme exhaustion, unable to move or speak, features contracted ; eyes sunk, half open, and of a dull lustre ; countenance bedewed with a cold sweat; pulse low, skin cold. Has been vomiting and purging very frequently since 7, A. M. and had all yester- day been affected by a watery diarrhoea ;" at 3, P. M. he " is greatly distress- ed by excruciating crampy pains of the thighs and legs;" at 9, P. M. " com- plains of thirst, tongue moist ;" on the 20th he " continues very low ; coun- tenance still of a ghastly appearance ;" " alvine discharges copious, alone of ash-coloured slime." The patient recovered. The next case is on the 24th June, 7, A. M. " Is in great distress from violent crampy pains of the mus- cles of the upper and lower extremities, but more particularly of the fingers ; there is great prostration of strength ; countenance ghastly ; surface cold ; pulse gone ; much thirst. He had a very copious watery purging on him since one o'clock this morning. He attributes his complaints to having slept last night on the damp ground, and in the open air, while on guard ; at 9, A. M. " pulse just perceptible ;" at 2, P. M. "slight giddiness, eyes red, says he has much appetite;" at 6, P. M. " one copious pale watery evacuation." This man also recovered, and both were treated with opium, and diffusible stimuli. [Also by Mr. Cruickshanks in 1814.] Another incidental notice of Cholera has led to the discovery of that disease having prevailed to a remarkable ex- tent, at the same time, and much in the same neighbourhood, as in the pre- ceding instance. The late Mr. J. J. Duncan, in a report dated 1st Septem- ber, 1819, after making some observations on the comparative advantages of dry and moist heat, externally applied, goes on to say, " in the month of June, 1814, when the Cholera appeared with great severity, in the 1st bat. 9th regt. N. I. on its march from Jaulnah to Trichinopoly, I employed exactly the same plan of exciting heat, (heated sand,) and found the greatest benefit re- sulting from it." " The disease in the 9th regiment in 1814, resembled in every particular, (with the exception of the heat at the praecordia,) the Cho- lera at present so common, although it could not be called epidemic. The best behaved, the most robust, and the most active, were attacked, and suffer- ed equally as much as any patient I have seen with the Epidemic Cholera; out of a very considerable number of patients I only lost one man; the num- ber I could not specify, as I was ordered back to Jaulnah on duty about ten days after the appearance of the disease, and before the monthly returns were dispatched." On referring to the returns of that corps, it appeared, that in the month of June, 1814, ninety-nine cases of " bowel complaint" were entered, of which fourteen proved fatal ; and about sixty cases of the same disease were ad- 116 mitted in the succeeding two months, of which, however, very few died. As these returns made no allusion to Cholera, and as they were signed by Mr. Cruickshanks, a reference was made to him for information, respecting the preceding observations of Mr. Duncan, which has drawn forth the very va- luable report inserted at page 234, and bearing date the 17th June, 1823. It now appears, that a brigade of two battalions of N. I. marched from Jaulnah on the 29th May, 1814, and that about the 10th or 11th of June a disease broke out in one of the corps which there can be no doubt was the Spasmo- dic Cholera. " When taken into the hospital," Mr. Cruickshanks observes of the first cases he saw, " they exhibited ait those symptoms now so well known, of per sons labouring under the advanced and fatal stage of Epidemic Cholera; the skin cold, and covered with cold perspirations ; the extremities shrivelled, cold, and damp ; the eyes sunk, fixed, and glassy, and the pulse not to be felt. These persons all died, and I find, on referring to such notes as I have pre- served, that, influenced by consideration of the vascular collapse, and total absence of arterial pulsation, I had denominated the disease Asphyxia. Many sepoys were brought into hospital in circumstances approaching to those above detailed. Of th-em, in a considerable proportion, the disease terminated fatally. Thus the cases which I first saw of this malady, in the aged, among the camp followers, differed in no respect from the worst cases of that affection since so well known under the name of Spasmodic Cholera. That name, how- ever, I did not adopt, neither in my public reports, nor in the private notes which I took at the time. In this I was chiefly influenced from considering the nature of the matter ejected by vomiting and by stool, which in Cholera is said to consist of bile, but which in these cases was aqueous or mucilagi- nous. Besides, it is evident that the diiulent treatment, recommended in Cholera, could never be applicable to such a disease as that with which I had to contend. I continued therefore to employ in my reports the term " bowel- complaint," both because I found it in the hospital books on joining the corps, and because, if it conveyed no very precise idea of the malady which it was meant to designate, it was at least an appellatiou whence no erroneous im- pressions could be derived." This paper by Mr. Cruickshanks is of great importance, inasmuch as it evinces that Cholera did exist to an extent not hitherto suspected to have oc- curred at so recent a date ; and also that even under these circumstances, no trace of it is found in the public records, for, unless we had been guided by the ■incidental remark of Mr. Duncan, made five years after the occurrence, and had most fortunately been able to refer to Mr. Cruickshanks, the medical re- turns of the corps never could have led to a knowledge of it. Hence, as al- ready observed, though Cholera very rarely appears in the sick returns of former times, it is by no means from thence to be inferred that it did not then exist . But this paper is also peculiarly valuable, as showing that the Cholera as- sumed, on that occasion, one of those singular and unaccountable features which it has frequently manifested in the present times ; for, after enumerating various striking atmospherical vicissitudes, change of food, and many other pre- disposing, remote, and exciting causes of disease, to which the brigade had been exposed, Mr. Cruickshanks goes on to observe, " To none of these causes of disease which I have enumerated, did the natives themselves attribute the sickness and mortality which prevailed; and on considering that of two bat- talions composing the brigade, alike exposed to all those causes, one only suf- fered from the epidemic, the hospital of the bth K.I. exhibiting not a single case of analogous disease, those adduced can only be regarded in the light of re- mote or predisposing causes ; while, something or other, acting exclusively on one battalion, must be sought for as instrumental in exciting the malady." We shall have occasion hereafter to revert to this particular subject; at pre- sent it is mentioned as showing that Cholera did, even then, manifest one of the most curious of its features, namely, that of two bodies of men, apparently under similar circumstances, one shall be attacked by it, and the other shall escape. 117 [Mr. Hay considers it to he endemic in Travancore.} It would also seem, by the subjoined extracts of reports from Mr. Staff Surgeon Hay, that Cholera, in a form nowise different from the spasmodic or epidemic, is endemical in the Travancore country, and that he regarded the disease which appeared there in October, 1818, to be this endemic, rather than the epidemic, whose approach from the northward he still contemplated. On the 19th of Novem- ber, 1818, Mr. Hay writes; "the Spasmodic Cholera, I am happy to say, abates; the last seven days not having afforded more than thirty-six cases at Quilon, and there has been no casualty here in that time; but the Vy- thians, who arrive from the country for instruction and medicines, report the deaths of almost all attacked." After acknowledging the receipt of some medical supplies, he continues, " I trust to be able to make a noble stand against the epidemic when it arrives; what I have had to encounter recently I hold to be the endemic Veshoo-ugeka, or Neer-comben, if not of the Mala- bars, certainly of the Travancorians, which is perfectly familiar to all here; committing frequently great mischief, and sometimes (25 years since) deso- lating the country. Ten thousands are said to have died of it; the Vythians fled from it as a plague, and no one who has not early succour from suitable medicines, is ever known to recover;" " the description of the Veshoo-ugeka tallies in every particular with that of the Spasmodic Cholera; and whether the epidemic reaches us or not, the country will have reason to be thankful for instruction and remedies they never might have had, unless the danger- ous inroad of the epidemic had been apprehended. In May last, at Trevan- deran, the capital, one hundred lives were sacrificed to this Veshoo-ugeka (poisonous air) : some of the servants of the palace were seen by Mr. Pro- van's assistants, and saved, but the villagers around, having no assistance, died to a man." Again, on the 24th December, 1818, Mr. Hay writes: " The Neer-comben, which signifies gush of water by stool, the effect of the disease, and its synonyme Veshoo-ugeka, or poisonous air, its imputed cause, which are the vulgar and scientific designations of our present Spasmodic Cholera, has been very prevalent amongst the troops, their families and followers. In Quilon I have treated upwards of 120 under the Spasmodic Cholera, and of the inhabitants a considerably greater number, with complete success in every case where application was made within six hours; and hundreds have been saved by the use of the remedies I have distributed throughout the coun- try. This shows unusally, for be it remembered, that to the central parts of the Travancore coast, and parts quite adjacent, so far as my reports inform me, the endemic has been principally confined, and it is of this I speak; but the epidemic also now rapidly progresses southward, having already at Co- chin yielded Mr. Mather some hundreds of patients, and at Aleppy about 30 per diem are taken ill; as it nears us, I become more apprehensive that the mortality will be great, for, although medicines, with ample instructions, have been distributed to 140 Vythians and others in the country, yet, from the experience 1 daily have of their general inattention, I much fear that when the day of visitation and trial arrives, the sick will be found too often left to their fate, altogether unassisted." Mr. Hay goes on to state, that in some villages where there was no medical aid, from three or four to ten peo- ple were dying daily of the endemic, and, talking of the zeal of the Vythians, he observes, " but when the same malady (Spasmodic Cholera) was epidemic here 34 years since, they ran from their charge, under the persuasion that the disease was contagious, for many died, and numbers in one family." There can be no doubt, however, that the disease described here as an ende- mic, was, in fact, the Epidemic Cholera of other parts ; and no particular mani- festation of it took place afterwards at Quilon in regular course from Cochin and Aleppy, as seemed to have been expected by thestaffsurgeon, nor, indeed, until July and August following. The progress of Cholera as an epidemic along the western coast, however, was much less regular than in other tracks, which may perhaps be attributed partly to the geographical peculiarities of that coast, and partly to the disease being in some degree endemic, which would not only accelerate the invasion and march of an epidemic of the same nature, but also render it difficult to fix the precise dates of its appearance. P 118 [Epidemic Attack of Cholera in Travancore, about 1790, and in the Ceded Districts about the same Time.'] Mr. Hay mentions, in the first letter, that Cholera committed great ravages in the Travancore country " 25 years since," and in the second letter, that " it was epidemic 34 years since;" either of these dates, supposing that there was only one visitation meant, would prove the existence of Cholera, epidemically, at a period considerably ulterior to 1787, and of course anterior to the instance in the 1st battalion, 9th regiment; and the whole communication shows that the disease is at no time of rare oc- currence in that country. There is a very fatal form of disease also known in Travancore, called " the red eye sickness" by the natives, which is evident- ly a modification of Cholera. Mr. Superintending Surgeon Duncan (page 110) also observes, " I find the old inhabitants of Bellary are acquainted with this disease, and inform me that it raged here about 30 years ago, with great vio- lence. This was succeeded by a famine for want of inhabitants to cultivate the country." (B.) — Referred to page 47. Deaths from Cholera for the last ten years in Philadelphia. Years. Under 10 years o fage. Over 10 years of age. Total. 1822 . 199 . "13 - 212 1823 . 252 . . 13 . 265 1824 . 155 ■ . .9 - 164 1825 • 197 - - 12 . 209 1826 . 233 . - 11 - 244 1827 - 229 -- - 10 . 239 1828 . . 284 . - 7 - 291 1829 - 239 - . 18 . 257 1830 - 232 - . 4 - 236 1831 - 303 - - 17 - 320 2,323 114 2,437 In the Reports of the Board of Health, from which the above statement is made, the disease in infants is usually designated by the term Cholera Infan- tum, that in adults as Cholera Morbus. (C .) — Referred to page 101. THE USE OF TOBACCO ENEMATA IN CHOLERA. Case of very malignant Cholera, in which all the symptoms were well marked, cured by the administration of the tobacco enema. — Ralph Crow, eetat. 65, was taken ill about 6 o'clock in the morning of the 28th December, 1831. A medical friend invited me to see him about twelve o'clock at noon, when I happened to be in Gateshead, where the patient resided. He was at that time very ill indeed, and his condition appeared certainly hopeless. His eyes were sunk, the palpebral black and drawn within the orbits. His nose and lips livid. Tongue white and cold ; and his voice quite gone. Indeed the whisper could with difficulty be understood. The skin of the hands and fingers was much sodden, and the nails very blue. Pulsation was not to be felt at the wrist, and the surface of the whole body was completely cold. The secretion of urine was entirely suspended. He was suffering from cramps in most of the muscles. There were incessant vomiting and frequent dejection from the bowels, of pellucid fluid, mixed with flakes resembling boiled rice. I had felt desirous for a day or two to observe the effects of a moderate dose of the tobacco infusion in the form of enema, in this intracta- ble complaint. I availed myself of this opportunity, although a formidable instance to begin with. Half a drachm of tobacco, prepared with half a pint of boiling water, was administered. This was retained in the intestines. In 119 a few minutes the skin became warm, and a clammy moisture was observed upon it. He vomited after it very copiously two or three times. About a quarter of an hour after giving the enema the pulsation at the wrist was evi- dent. I cannot refrain from expressing my obligations to my medical friend in Gateshead, who was so obliging as to repeat the injection in the evening, because he observed the advantage of the practice in the morning. This he did of his own accord, as nothing passed between us respecting any repeti- tion; the unfavourable state of the patient rendering it probable that it would not be required. It was observed at both times that as reaction took place, the colour of the integuments, and partciularly the lips, became changed to a more healthy hue. Dec. 29, 12 o'clock. — Revisited the patient, whom I found much better. The warmth and natural hue of the skin had in a great measure returned. The countenance was improved ; pulsation at the wrist distinct and regular; vomiting and purging had ceased; tongue warm and less white; muscular spasms relieved, and he had enjoyed some quiet sleep. Other remedies were now exhibited to act upon the secretions, which all went on progressively improving. This man, during many days, retained the appearance of having recovered from a dreadful state of disease, but was completely restored to his strength in a few weeks. Case of malignant Cholera, wherein Tobacco enema was administered with effect at the time, but the patient sunk afterwards. — Helen Douglas, eetat. 55, a very fat woman, whose occupation was to sit at a stall for the sale of vegetables, &c, in a confined filthy street in Newcastle, was at- tacked with symptoms of Cholera on the 2d January, 1832. The early symptoms were extreme, and sudden discharges from the bowels and sto- mach, of a fluid resembling rice-water. A medical gentleman was applied to in the night, but did not visit her. She was visited by me about ten o'clock of the following day. She was complaining of violent pain in the hypogastric, and epigastric regions, and in the back. Her countenance was very much sunk and livid. The hands and fingers sodden. The cellular substance of the arms was condensed and inelastic, resembling dead integu- ment. The pulse was imperceptible at the wrist, but might be felt beating feebly in the carotids. She had passed no urine for some time ; the body was very cold ; and she suffered much from cramps and spasms in the abdo- minal muscles, and in thoee of the extremities. Her tongue was white, and nearly resembled white leather; and the breath was cold. An injection, containing half a drachm of tobacco in infusion, was immediately adminis- tered. About fifteen minutes after the injection was thrown up, pulsation became very perceptible at the wrist. Slight perspiration was observed about the central parts of the body, and the countenance became improved in appearance. She still was ejecting large quantities of fluid from the sto- mach. An hour and a half afterwards, she had vomited some yellow fluid mixed with white sediment. The pulsation and perspiration still continued. She was ordered to take five grains of calomel every hour. Four o'clock, P. M. — The spasms have returned : pulse more feeble : still complains of constant pain in the abdomen. I attempted to bleed her from the arm, to unload if possible the venous circulation. By constant friction up the course of the vein, I succeeded in getting away about four ounces of very black thick blood, guttatim. Three scarifications were applied to the abdomen, but the blood stood in the incisions like tar. A common fomenta- t ion was directed to be applied over the abdomen. The tobacco enema was again exhibited, which produced a little faintness at the time, from which she soon recovered. Nine o'clock, P. M. — Her countenance is better, but the pulse not quite so good: still suffers from cramps, although not so severe. Pain of hypogastric region and back, but it has abated in the praecordia. She has vomited very little; has felt frequent desire to empty the bowels. A small quantity of thin dark fluid was evacuated. As she had experienced much desire to pass urine, I placed my hand over the hypogastric region to ascertain the state of the bladder, and was astonished to find every thing about her wet and cold. Upon inquiry I found it was from the flannels used for fomentation, which 120 were absurdly left to cool since four o'clock, until I discovered them. Take castor oil. Jan. 4. — She has had no vomiting all night. Towards morning passed two small fluid bilious stools. Continued to complain of pain in the hypogastric region. I was prevented seeing her until eleven o'clock, when I found her sinking rapidly, and she soon after expired. I had taken a catheter with me to introduce, as I understood from my assistant, who brought me the report in the morning, that she expressed a very anxious desire to pass urine. Finding her so near death I did not attempt it. The blood drawn yesterday was coagulated, very dark and devoid of serum. Other cases are given ;by Dr. Kirk, of the successful effects of this remedy. (D.) — Referred to page 104. [Sketch of the Practice of three eminent and excellent Practitioners &t New- castle] — I shall now (says Dr. Kirk) lay before the public a short summary of what I understood to be the treatment of this disease, by a very eminent and excellent practical surgeon, Mr. John Fyfe, of Newcastle. At the time I was in Newcastle, he had attended 579 cases of Cholera; and in all these, he says that collapse never came on till after profuse serous discharge from the bowels. Mr. Fyfe relies very much on stimulating enemata ; and he says that they seldom fail to produce reaction in its most salutary form, attended by less congestion than that which followed collapse of longer duration, in which stimuli had been withheld, or when the most diffusible stimuli had been given by the mouth. When watery diarrhoea exists, tinged with healthy secre- tions, he has arrested it often at once by opium ; and in nineteen cases out of twenty, convalescence has followed. But if the disease has advanced, he then gave repeated doses of calomel : moderated the discharges by opium, and softened the pulse by bleeding, if necessary. If the disease proceeds to vomiting, purging, and cramp, Mr. Fyfe prescribes a mustard emetic, follow- ed by copious draughts of warm water, friction, and the proper regulation of heat. If the pulse is firm, blood is taken to the extent the pulse can bear. Calomel and opium are then used, and diluents allowed. In collapse, Mr. Fyfe objects to large opiates, and also to general bleeding; but, in general, he gives relief by throwing into the intestines three pounds very hot water, six ounces of brandy, and occasionally, two drachms of laudanum. It will be frequently necessary to withdraw these injections by a tube — they come off cold — and to repeat them either with hot water alone, or with laudanum, if the irritability of the stomach continues. In this stage Mr. Fyfe uses brandy liberally. He treats the reactive fever in the same way Mr. Frost does, as stated below, and I have already alluded to some of his ingenious adaptations in my report. Mr. Fyfe thinks the period of the incubation of the morbific germ of Cholera seems to vary from four hours to eight days. Mr. Fyfe is also of opinion that the effluvia, from the excretions of an individual having diarrhoea cholica, may communicate to another predisposed, the most deve- loped form of the disease. Mr. Frost, of Newcastle, treated 500 cases of Cholera, and is a person of high qualifications, a calm thinker, and an excellent practitioner. I think the profession will be glad to hear his opinion and practice in the disease, which I will give as accurately as I can recollect a conversation held with that gen- tleman at Newburn. He said that he conceived it a malignant congestive fever, — and if English physicians had seen this disease without reading Barry, Bell, Orton, and Lefevre, they would have treated it on scientific principles, and according to the rules of British art. They would have given no astrin- gents. The catch-word of 'stop the diarrhoea' would never have existed. He stopped it, but in a far different method, viz., by calomel, castor oil, and very minute doses of opium ; say five grains calomel, one opium, and two antimo- nial powder to begin with, several times repeated. If there is head-ache, and giddiness, and the pulse is of sufficient tone at the commencement, — if the pulse is from eighty to a hundred, bleed moderately. But the bleeding must 121 be cautious; for in this, as in all cases of intestinal irritation, bleeding cannot be largely practised with safety. If the stomach is much loaded, or there is nausea, give a draught of warm water to excite vomiting. If that does not effect it, you may give salt and water, or ipecacuan, or a dose of castor oil, which may be succeeded by a diaphoretic. This will open the skin. Next day calomel and castor oil again. If the castor oil will not stay on the sto- mach, the best substitute is magnesia and rhubarb. If the patient gets colder, then fill the large intestines with warm water from the forcing pump; and if you have any idea that the bowels are not discharged, then put salt in the water. After this invariable stage of diarrhoea comes that of collapse. In every case where correct information could be obtained, diarrhoea has pre- ceded it. He gives warm water to induce vomiting; injections of hot water; careful regulation of heat; twenty drops of laudanum to allay irritation; two grains of calomel, and one-sixth of a grain of opium, every three hours, for three times, and then castor oil. In one case, for instance, under this treat- ment, the pulse rose to eighty, and the patient became warm. Eight ounces of blood were taken from the arm. He passed no urine for forty-eight hours. Mr. Frost went on with the calomel, and next day the urine returned, and he recovered after a mild consecutive fever. He has never practised stimulation. The consecutive fever of children is almost always attended with the same symptoms as hydrocephalus acutus. The dydrargyrus cum creta is the best remedy for them. He has seldom been able to induce ptyalism. Worms are very frequently vomited. They are always dead. The injesta of Cholera seem poisonous to them. At Newburn, a village where Mr. Frost conducted a great part of the practice, two hundred and seventy-three cases of the dis- ease occurred up till the day on which I visited Newbern with Mr. Frost. Fifty of these cases were fatal. The whole inhabitants of the village were five hundred and fifty, one hundred and forty-one families, and one hundred and thirty-four houses. This is truly appalling. In general, even when the cold stage is incomplete, consecutive fever sets in — there is much giddiness, pain of the head, and stupor. He has always treated this stage with laxatives. Mustard sinapisms applied to the neck, relieve the head ; to the epigastrium, the stomach. They have often been costive, but it has not been difficult to manage the bowels. Leeching to the head was frequently resorted to. Now, I ask the reader to compare the success of this treatment with that in the village of Hartly, where brandy and opium were used, and where, out of thirty-four cases thirty-two died. I beg now to give the experience in this disease of an excellent friend, Mr. D. M'Allum. His acuteness and talents are only equalled by the excellence of his heart and the soundness of his principles. " Dear Sir — Imperfect as naturally must be, from my limited opportunities, my capability of replying to your queries respecting Cholera; yet so far as my information can contribute, in the slightest degree, towards the further- ance of your laudable object, 1 am happy to afford it. " In looking over the list of queries proposed, I do not see that my indivi- dual experience can afford any information worth recording, but upon the last, viz., the treatment found most successful. In reference to treatment, I would divide this disease into three stages. 1st, That of excitement, or irri- tation, wherein the patient throws or purges freely, generally accompanied by severe spasmodic action of the muscles of the legs and bowels: the pulse distinctly perceptible, quick, sharp, and in some subjects, full. This stage does not last beyond a few hours, passing on to, ?dly, The stage of collapse; wherein the pulse becomes imperceptible, the extremities cold, the breathing more laborious, the countenance more sunk, especially the eye, which as- sumes a leaden hue ; and 3dly, the stage of reaction. He who is happy enough to be called in during the first stage, willrfiot hesitate, if the patient have any vigour of constitution, to bleed freely, premising, or using simulta- neously, a gentle emetic of ipecacuanha, or salt and water, following this by an anodyne injection. I then administer a pill of two grains of calomel, and one-sixth of a grain of opium, every half hour, with chalk mixture, or saline julap, in a state of effervessence for a few hours, until we have dejections evidently combined with bile. To assist this operation, and especially if the 122 vomiting be still severe, I administer warm emollient injections, and after- wards treat as in ordinary continued fever. In this stage of collapse, or ap- proaching to it, I give a tea-spoonful of mustard in a little warm water, every five minutes, till I produce vomiting; at the same moment I order enemata of very warm water and soap, without reference to quantity, endeavouring to throw up as much as ever 1 can. These means I find more successful in restoring heat than any external means; but which I do not, nevertheless, neglect, ordering hot applications to the feet, hands, and arm-pits, and that the patient be well rubbed with a stimulating liniment of spirits of turpen- tine, tincture of capsicum, mixed with camphorated oil; I then apply the hot air, both which I continue at a temperature about 84, for two hours or more. In the mean time, as soon as the emetic has operated, I give six grains of calomel, one-fourth of a grain of opium, every quarter of an hour, with two table-spoonfuls of a mixture containing compound spirits of ammonia three drachms, spirits of mindererus three drachms, mixed with hot coffee, giving warm liquids very freely and frequently. In this stage I have tried bleeding repeatedly, but wtthout benefit; indeed, it seemed to me to precipitate the fate of the patient. The enemata ought to be repeated frequently until re- action takes place. The third stage, viz., of reaction requires no difference of treatment from that of our usual typhus mitior, excepting that bleeding should be had recourse to with very great caution, as I believe, by its too free use in improper cases, the stage of collapse has returned, and the patient sunk. There is generally a tendency to congestion, either of the brain or liver, which requires the application of leeches and blisters. The mortality in my own practice was during the first three weeks — exactly two to one re- covered, — but since January commenced [ have had seven cases, most of them applying early — six of them are convalescing, and one dead. In Walls- end township, amid a population of 3000, there have hitherto occurred 15 cases and 4 deaths. " In the above observations I have merely referred to my own individual practice, and its results. Although I have had three patients in one house, I have met with no fact that could confirm the doctrine of contagion. " Yours, respectfully, " D. M'Allum. " Blackett Square, Saturday, Jan. 14, 1832." (E.) — Referred to page 103. ON THE TREATMENT OF CHOLERA IN INDIA. Mr. Annesley gives the following account of the way in which Epidemic Spasmodic Cholera has usually been treated under his direction*: — " A patient is admitted into the hospital, I shall say at noon, with all the symptoms of Cholera: a vein is immediately opened, and one scruple of calo- mel and two grains of opium are given in the form of a pill, and washed down with the camphor draught. The body and extremities are well rubbed with dry flannels made warm, and bottles filled with hot water are applied to the feet and hands; but if the spasms are severe, spirits of turpentine are used as an embrocation. In an hour we generally perceive the effects of these remedies, and whether the disease be in any degree arrested, or be pro- ceeding in its progress. If the former, nothing more is to be done till even- ing, when the calomel pill may be repeated, and an enema exhibited. The following morning the bowels should be again fully evacuated, and then the patient may be considered safe. " When blood, however, cannot be drawn from the arm, and the spasms continue; when severe pain and burning heat are felt at the umbilicus and scorbiculis cordis, and are distressing: when the skin is cold and deluged with cold, clammy dew, and when there are oppression of the chest and diffi- culty of breathing, excessive pain and confusion about the head, with great intolerance of light, no pulse, or a pulse scarcely to be felt, and a cadaverous * Diseases of India, second edition, p. 156. 123 smell from the body; twenty or thirty leeches should be applied immediately to the umbilicus and scorbiculis cordis, the calomel pill should be repeated, and the turpentine embrocations continued. Leeches ought likewise to be applied to the temples and base of the skull. " When the leeches bleed freely, the application of them is always attend- ed with decided advantage, and they should be allowed to remain till they have fulfilled their duty; after which a large blister or sinapism should be applied over the whole abdomen. Sometimes the leeches fasten but do not draw blood. In this case they should be removed immediately, and the sinapism or blister applied in their place. When the bowels are very irrita- ble, and constantly discharging a watery fluid, small anodyne enemas, with camphor, may be given, and the drogue amere, a nostrum used by the Je- suits, will be then found very useful in assisting the operation of calomel, which latter should always be repeated every two hours, till three or four scruples have been taken. " Whenever we fail in checking the disease at first, we have no resource but to treat urgent symptoms, and they must always be met with decision as they occur. The patient ought never to be left a moment without an at- tendant who is capable of acting according to circumstances, and who may take advantage of every change. " An opportunity sometimes offers in the advanced stage of the disease to abstract blood : this is indicated by a struggle or effort of the circulating sys- tem to overcome some resisting power, and is a most auspicious symptom, which should never be overlooked. This reaction indicates that the consti- tution is making an effort to restore the circulation, but is unable to do so till assisted by the abstraction of blood, which abstraction aids in removing that oppression which it has not power of itself to overcome. This is a point in the treatment of Epidemic Cholera of the greatest importance, requiring both tact and judgment; but the change in the circulation indicating the proprie- ty of adopting and the time of performing it should always be expected and taken advantage of as soon as it occurs. "In this manner the treatment proceeds, sometimes with evident signs of success, at others without the least impression being made upon the disease. A very few hours, however, will frequently develope what we ought always to hope for, and even to expect, viz., a favourable change. This is always accompanied by relief from the bowels in the form of a blackish, grey, fecu- lent, and tenacious discharge. Whenever this takes place there is hope, and the exhibition of calomel should be followed up by a smart purgative, if the stomach will receive it; if it will not, the enema should be administered and repeated till motions are procured. The purgative I have generally found to answer best at this stage of the disease, and to sit most lightly on the sto- mach, is the following draught : — " R pulv. jalap, comp. g ss - " Aq. menth. pip. 5ij. « M. ft. haust. ° " And, as it is a matter of the very first consequence to act upon the bowels freely as soon as possible, if this draught have no effect in two or three hours, it should always be repeated. " Urine is neither secreted nor passed during the continuance of the dis- ease; whenever it appears, which it frequently does, with a full and free discharge from the bowels, the occurrence is always favourable. " Twelve or eighteen hours generally terminate this disorder either one way or the other; but when we succeed in subduing the violence of the at- tack, the greatest attention and care are required to preserve the patient against the effects of that general disturbance which the constitution has suffered. " The subsequent treatment is now to be considered; and the indication in this stage is to guard against congestion in the abdominal and thoracic vis- cera, and in the brain, some one of wbich suffers in a greater or less degree, and occasionally the whole are attacked at the same time. " The eyes are sometimes peculiarly bright, with contracted pupils, and 124 there is an evident intolerance of light; yet these patients insist that they have no uneasiness in the head, and that they can look at the light with per- fect ease. " The pulse is often oppressed and labouring, notwithstanding a very large quantity of blood may have been taken during the first stage of the disease. " These are symptoms that require immediate attention, and, when urgent, blood should be taken from the arm, but, in general, leeches will answer every purpose, and I consider them a safer remedy in this stage of the disease than general bleeding, because they appear to me to empty the capillary vessels, and aid in regulating the circulation without destroying power — a point of great importance where the constitution has already suffered so severely. " When the patient shrinks from pressure on the abdomen, leeches should be placed over it in considerable numbers, and particularly in the neighbour- hood of the liver ; and when the head is affected, they should be applied at the temples and base of the skull. " Whilst these symptoms of oppression and congestion require the most minute attention, we must not lose sight of the state of the alimentary canal, of the secretions of the small intestines, and of the alvine discharges. " Though the irritability of the stomach sometimes continues till a very late period, yet in general it is subdued early, and that organ retains all that is taken, both as medicine aud nourishment; but as the small intestines ex- hibit, on dissection of fatal cases, a most peculiar appearance, from the duo- denum to the ccecum; as they are very much contracted in their diameter, thickened and pulpy in appearance; and as they are, when laid open, found filled with a cream-coloured, thick, viscid, and tenacious matter, exactly like old cream-cheese, which obstructs their canals; and, moreover, as this mat- ter is to be found in every fatal case of Cholera, so it may be inferred to exist in some degree even in all that recover; and therefore the removal of it must be a primary consideration. " Purgatives do not seem, however, to act upon this matter at first, for they merely produce watery dejections; so long, therefore, as these continue, we may be sure that all is not right, even although they be reported copious and free. The dejections should always be examined with great care; for, until the above described matter is brought away, I never consider that I have made much advancement in the cure. " Calomel, in scruple doses, I have always found most useful in removing this peculiar secretion. Sometimes I have combined the calomel with aloes, and continued it every night and morning, till the dejections became of a blackish grey colour, substantial and tenacious. The purging draught and the enema were then had recourse to, with the best effects. " This practice was followed up regularly every day with leeches, blisters, &c. &c, according to circumstances. In a day or two the motions were usually observed to become dark green, which colour always indicated an ap- proach to healthy action. The calomel and purging draughts were still con- tinued, however, five or six days longer, till the dejections became more natural, and a visible improvement was observed in the appearance of the patient. He was then put upon an alterative course of medicine for a month or more, according to circumstances. This latter measure is absolutely ne- cessary to prevent a relapse, which is very common, and always dangerous. " This plan of treating the Epidemic Cholera, which was adopted in the general hospital at Madras, under my charge, during the prevalence of that disease from 1819 to 1823, was attended with a success that certainly far exceeded my expectations." (F.) — Referred to page 104. TREATMENT OF THE CHOLERA IN PARIS. The subject which we approach with the greatest reluctance, (say Drs. Pen- nock and Gerhard, in their " Observations on the Cholera of Paris,") from the extreme difficulty which it offers, is that of the treatment; this difficulty de- 125 pends upon the little power which our remedial agents possess of opposing this disease, and still more the necessity of constantly varying the means employed, and the degree of activity in their use, according to the diversified stages which Cholera presents, In the diarrhoea, which may either be a pre- cursor of Cholera, or merely a slighter action of the morbid cause, the treat- ment should only differ in energy from that employed in ordinary seasons against a similar affection. In the mildest form th^re is no nausea or ex- citement of the pulse, or pain in the abdomen; the only inconvenience expe- rienced in the borborygmi and the liquid discharges; here the abstinence from food should be immediate, or the diet limited to light broths; this diet alone, or with a moderate dose of opium, will generally arrest the symptoms. The same diarrhoea assuming a severe form, has received the appellation of cholerine at Paris; the dejections are more frequent, and often attended with pain ; the pulse usually a little excited, with general feeling of uneasiness or vertigo. The diet should be as rigid as in the last mentioned instance, but the febrile excitement should be reduced by bleeding, and leeches if any local pain exist ; to these depletory means a warm bath may be added, pro- vided a bath can be placed close to the bedside of the patient, and be given without the slightest , the bath is usually followed by profuse perspi- ration, and with salutary effects, as the authors can attest from their person- al experience. Should the discharges be still abundant, they should be checked with opium, and if the mercurials possess any efficacy in changing the course of Cholera, theoretically we should advise their administration at this point, practically we know nothing of their action in this epidemic. Ex- ternal stimulants, as sinapisms, must be used at the discretion of the practi- tioner, the ordinary rules for their application directing his prescriptions. The symptoms combated by these means do not yet constitute the Cholera, they are but the prodromus, but the most useful and interesting moment for the practitioner is that of anticipation and prevention rather than cure, After the diarrhoea has continued for some time, the commencement of the formal Cholera is announced by the vomiting and cramps, which are not at first attended by the alteration of the voice, or the blueness and coldness of surface. The symptoms are now the most urgent, and require the most vigorous treatment, blood-letting is advisable if the pulse be not much de- pressed, and should be carried as far as the strength of the patient permit it, the effects of it in the cases with which we are familiar was happy ; unfortu- nately our number is necessarily limited, for the patient in hospitals are rare- ly seen at the most favourable moment for treatment. Use should be made of the hot, (not the warm,) bath, at 104° Fahr. as practised by M. Rostan, and external stimulants ; should no pain at the epigastrium exist, other than the colics, which are diminished by pressure, an emetic of ipecacuanha may be administered with great advantage. M. Andral was much pleased with its administration at La Pitie, and we know that during the existence of the Cholera at Vienna, the treatment by ipecacuanha was regarded as the most effectual. It may generally be given without fear for the most careful ex aminations have proved that the inflammatory appearance of the stomach was more frequently found at the termination than during the most violent period of the disease, and at the beginning, our object is to change by a sud den impression the derangement not of one but of the whole systems of or- gans. The cramps are most readily relieved by smart frictions, which are more effectual than compression by tourniquets as tried at one of the hospi- tals: the frietions should be kept up with perseverance until the patient is relieved. Should the blue cold stage come on in spite of the most vigorous treatment, we must not think of pursuing further the depletion; it was imagined that the profound prostration was due to the congestion of the inter- nal organs which impeded the action of the whole machine, but the attempts at blood-letting, which could only be performed by the aid of hot applications to the arms, caused a temporary flutter of the pulse, followed by a more rapid extinction of life. The treatment is the most simple possible, for it is not with the intention of curing the disease itself, but of preserving life, that we must stimulate; frictions with warm liniments should be almost incessant, and made from the extremities towards the central organs ; sinapisms to the Q 126 extremities; and particularly a liniment of ammonia and turpentine, which is applied along the spine by flannels impregnated with it, a hot smoothing-iron is then to be passed rapidly along its whole length. This application was employed by M. Petit, of the Hotel-Dieu, and with great advantage. Dry heat is preferable to moist, hence resort is had to sand-bags, hot cloths, or still better, to the introduction of heated air beneath the bed-clothes by a tube communicating with a small furnace. The question of internal stimulants has been much discussed, we regard them as improper in themselves, but sometimes their employment becomes necessary, but only for the immediate necessity of preserving life, and as soon as a moderate degree of reaction is produced, they should be disconti- nued. The diarrhoea in the cold stage, and that immediately preceding it, should be combated by opiate injections alone, or with a preparation of rha- tania; but if these injections succeed in their effect and are not discharged, their influence if continued is injurious, and tends to aid in producing the in- ternal congestions to which the patient is exposed by his extreme feebleness. The vomiting is best allayed by Seltzer water given simply, or with a mucila- ginous syrup, or if not extremely disagreeable to the patient, ice in substance, or iced water in very small portions. The following notice of the Cholera, at Montreal, already published in the newspapers, merits a place here, to complete our history of the Cholera. " The medical commission appointed by the sanitary committee to visit Ca- nada, for the purpose of making investigations concerning the epidemic dis- ease prevailing there, in anticipation of a more detailed report, which will be laid before the committee in a few days, present the following general conclusions they have formed as the result of their observations, which they flatter themselves will tend to allay the public anxiety. " 1st. The disease so lately an epidemic in Montreal and Quebec, and which now prevails in the city of New Tork, and is extending throughout the country, is Malignant Cholera, the same that has ravaged and spread its devastations over Europe, under the name of Asiatic and Spasmodic Cholera. "2d. That they have not been able to ascertain any positive unequivocal fact to justify a belief that it is a disease communicated by those affected with it, or is one of importation. "3d. That during the prevalence of the epidemic constitution or influence, a general predisposition exists in the whole community, from which very few individuals are exempt, productive of a liability to the disease. " 4th. That this predisposition is manifested by embarrassed and difficult digestion, sense of heat, fulness, uneasiness or pain in the abdomen, irregu- larity of bowels, a furred and pasty tongue, with frequency of cramps or constrictions in the muscles of the extremities, especially at night. " 5th. That this state of predisposition will not give rise to an attack of the disease, without the application of an exciting cause. " 6th. That the exciting causes of the disease are moral excitants, espe- cially fear and anger ; intemperance in the use of fermented and spirituous liquours, or in eating, overloading the stomach; acid drinks, or large draughts of cold water; the use of crude indigestible food, whether animal or vegeta- ble, particularly the latter ; excessive exertion or fatigue in the heat of the day ; exposure to the night air, sitting in currents of air, and particularly sleeping with too light covering, and with the windows raised, except the rooms are very small and confined, Most of the attacks occur in the night, from 11 or 12 o'clock to 3 or four in the morning. " 7th. That prudence in living during the epidemic period, which conti- nues from six weeks to three months, the wearing of flannel, particularly on the body, keeping the feet warm and dry, the avoidance of improper food and drinks, tranquillity of mind and body, are almost certain guaranties against the assaults of the disease, and disarm the pestilence of its malignity. "8th. That the disease, when abandoned to its course, passes through dif- 121 ferent stages, in all of which it is easily controlled, except one — the cold stage-., or period of collapse, and which is in almost every instance, preceded by the symptoms of the forming stage, when the disease, if timely treated, is arrested with facility. "9th. That the symptoms of this forming stage should be generally pro- mulgated, and persons instructed of the necessity of an immediate attention to them. It is ignorance in this respect, amongst the labouring and lower classes of society, and their habits of life, leading to indifference and inat- tention, that plunges so many, belonging to those conditions, in the despe- rate situation so frequently met with, when medical aid and human skill are utterly unavailing. Those symptoms are, a sudden looseness of the bowels, the discharges becoming thin, watery, and colourless, or whitish, with little odour — vertigo or dizziness — nausea, oppression, pain and cramps of the sto- mach, with retching and vomiting of a fluid, generally resembling dirty river water, attended or soon followed by cramps of the extremities, particularly of the legs and thighs. " 10th. When the foregoing symptoms appear, application for remedial as- sistance must be made immediately. The delay of an hour may usher in the cold stage, or period of exanimated prostration and collapse, from which it is almost impossible to resuscitate the expiring energies of the economy. " 11th. That every preparation should be made by the public authorities, in anticipation of the appearance of the disease, providing the means of treatment for those who cannot command them, so that aid may be promptly administered to all, the moment of attack. These means are a number of small hospitals, or houses of receptions, in various parts of the city; stations where nuises, physicians, and students, with suitable medicines and appa- ratus, can be procured in the night without delay, the evacuation of certain localities, where the occurrence of numerous cases indicates a pestiferous in- fluence, and the furnishing to the poor, as far as practicable, wholesome and nourishing food. By the adoption and observance of the foregoing means of precaution and prevention, in addition to the sanitive measures already adopted, the com- mission are convinced that the prevalence of the disease will be greatly cir- cumscribed, its mortality diminished, and the public guarded against panic and alarm, the great sources of danger — and under the blessing of Divine Providence, the pestilence will be shorn of its terrors, and mitigated in its destructive fury. SAMUEL JACKSON, CHAS. D. MEIGS, RICHARD HARLAN. V -A/inA - AA : Aftfy* UySSSSi hfiSnl fcBnSvWn ifc L .A A; 1 '/V ','■' > lii^ii H ft A A I , ^ , fy A A. ; A . fl a L ■' »> a r- ' ' a A *\ 4 A 4 * ' * ',3 5 f\ A f\ w l» flflftWAW, ..Af ^ RfW **\V V ^;^ - ' ^A A WHrW A *. « A A, WNj. rtj^te pftigfei A^A:a mfi-Hhkn^^. Jfei '■ ■■ - /: Jil ; ».. . 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