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/ 
 
 THE 
 
 CHOLERA SPASMODICA 
 
 AS OBSERVED 
 
 IN PARIS IN 1832: 
 
 COMPRISING 
 
 ITS SYMPTOMS, PATHOLOGY, AND TREATMENT. 
 
 ILLUSTRATED BY CASES. 
 
 I /** 
 
 x 
 
 % 
 
 BY ASHBEL SMITH, M. D. 
 
 OF NORTH CAROLINA, 
 Officially attached to the Necker Hospital, during the prevalence of this Epidemic. 
 
 NEW-YORK: 
 
 PUBLISHED BY PETER HILL, 94 BROADWAY. 
 
 SOLD ALSO EY 
 
 J. GALES AND SON, RALEIGH, N.C., AND AT THE OFFICE OF THE WESTERN 
 CAROLINIAN, SALISBURY, N. C. 
 
 1832. 
 
 "1 
 
Jb eoussigne, m6decin del'hQpital Necker (de Paris) et membredel'Academie Royale 
 deMedecinedela rnemeville, certifiequeM. Smith (Ashbel) docteur en Medecine a 6t6 
 attach6 pendant tout le temps de l'Spideuiie de Paris, au service des choleriques de 
 l'hopital, et qu'il a soigne les malades avec un courage et un zele dignes des plus grands 
 Sloges, qui lui ont merite d'ailleurs une indemnit6 de la part de l'administration des 
 hopitaux, et l'estime de ses confreres mS decins et chirurgiens de l'hopital. 
 
 BRICHETEAU, D. M. P. 
 
 Paris, 1832, Hopital de Me Necker. 
 
 GEORGE P. SCOTT AND CO. 
 
 FlUNTHUS, CORNER Ob' ANN AND NASSAU STREETS. 
 
TO 
 
 MY FATHER. 
 
 ASHBEL SMITH. 
 
PREFACE. 
 
 What I have written on the cholera was com- 
 menced in the form of a letter to a medical friend. 
 As I proceeded, my observations spread over a much 
 greater space than I had anticipated, and I resolved 
 to publish them. To avoid as much as possible 
 any unnecessary increase of bulk, I determined to 
 confine myself to the relation of what I have seen. 
 To this determination I have strictly adhered, ex- 
 cept in one or two instances, where I expressly 
 quote the authority of others. It is to this that 
 my pamphlet owes its merit, if it have any. I have 
 related facts which I have seen, and for the truth 
 of which I therefore pledge myself. I have described 
 no symptom, no post mortem appearance, no treatment, 
 which I have not myself witnessed. The little spe- 
 culation, in which I have once or twice indulged, 
 I shall never take the trouble to defend against the 
 attack of any person. 
 
VI 
 
 That it may appear that I have had abundant 
 opportunities for studying the cholera, I think it 
 proper to mention, that during the prevalence of 
 this epidemic, I was officially attached to Necker 
 Hospital, where I remained the greater part of 
 each day ; that I not only heard the medical pre- 
 scriptions, but was charged with much provisional 
 and active service in their administration; that I 
 watched their effects, and recorded them at the 
 bedside of the patient. 
 
 Notwithstanding the redundancies and repeti- 
 tions contained in what I have written, I should 
 have found it much easier to write a book on the 
 subject than to compress my materials into a 
 pamphlet. To keep this within a proper size, I 
 have omitted some things, and briefly touched on 
 others where I wished to be much more full. Some 
 slight omissions are a consequence of the despatch 
 I was obliged to use in arranging my facts. 
 
 I had also intended to publish many more cases, 
 but I considered it would swell this publication to 
 an inconvenient bulk to add a sufficient number to 
 enable the reader to draw conclusions from them. 
 For this purpose, less than fifty or a hundred would 
 be of little use ; I have therefore concluded to give 
 a few cases as specimens, and to occupy my pages 
 with a digest of the symptoms and treatment, made 
 from the whole number in my possession. 
 
Vll 
 
 My observations on the cholera were written in 
 Paris, and in part sent to America, when I heard 
 of the appearance of this disease in Canada. This 
 accounts for my having spoken in several places 
 of the appearance of this disease in our country, 
 as problematical. My intention, as I have before 
 stated, was simply to embody those facts of which 
 I had been a witness. On my arrival in New-York 
 I found my pamphlet in the course of publication. 
 I concluded to publish it as it was written — an ac- 
 count of the cholera as it appeared in Paris, and 
 of the means employed to combat it, by the cele- 
 brated practitioners of that city. Though my 
 observations have been chiefly made in a single 
 hospital, yet from the frequent intercourse of me- 
 dical gentlemen, and the publicity given to the 
 different methods of treatment, by means of the 
 Royal Academy of Medicine, and the various pub- 
 lications on this disease, I have been enabled to 
 see put in practice the remedies suggested by the 
 combined skill and experience of the Parisian 
 facultv. 
 
 We are assured by those who have observed 
 the cholera in different countries, (and I had oc- 
 casion to remark the fact on seeing it in London,) 
 that though presenting in all places nearly the 
 same leading characteristics, this disease exhibits 
 in different regions, a considerable variety in the 
 
vm 
 
 rapidity of its march, and the severity of its symp- 
 toms. The same epidemic is also much modified 
 at different periods, most noticeably on any great 
 increase in the number of new cases. For this rea- 
 son I have dwelt on several of the minor symptoms 
 with a minuteness that some may think excessive. 
 
 In noticing the remedies unsuccessfully employ- 
 ed, I have not mentioned all that charlatanism has 
 vaunted, because they have notoriously failed in 
 the hands of their patrons, and were clearly unde- 
 serving a trial. 
 
 I have said nothing of atmospheric vicissitudes, 
 as I was unable to perceive that the epidemic was 
 thereby affected. 
 
 The distinction made in Europe of cholera, into 
 a severe form and a mild one under the name of 
 cholerine, I have retained. It is important to bear 
 this in mind in considering comparatively the sta- 
 tistical results of different methods of treatment ; 
 otherwise we commit great errors, for a cholerine 
 is very seldom fatal, if attended to. 
 
 If it be found that I have faithfully executed the 
 
 task which I have imposed on myself, I shall be 
 
 satisfied, though I do not profess to point out any 
 
 method of treating cholera which shall in all cases 
 
 prove successful. 
 
 ASHBEL SMITH. 
 
THE 
 
 CHOLERA SPASMODICA, 
 
 AS IT APPEARED IN PARIS IN 1832. 
 
 There were rumors, from time to time, which since 
 appear to have been well founded, of sporadic cases of 
 cholera occurring in this city, previously to the 26th of 
 March last, when the disease appeared epidemically. So 
 rapid was its increase, that on the 9th of April, at 12 o'clock, 
 1020 new cases were officially reported for the preceding 
 twenty-four hours. On the same day, according to the offi- 
 cial bulletin, there were 86 1 deaths from the cholera. It is 
 the opinion of very many persons, that the number of new 
 cases and deaths was considerably greater than that offi- 
 cially given, either from the great fatigues and unintermitted 
 employment of the physicians rendering it impossible for 
 them to return complete repoits, or from design on the part 
 of the administration, in order to allay the apprehensions of 
 the people. However this may be, the disease at this time 
 was arrived at its maximum of intensity, which it main- 
 tained with slight variations till the 14th. that is, about five 
 days. The period of decline then commenced decidedly, 
 and continued about a month. Since that time the disease 
 has remained nearly stationary, with some occasional fluc- 
 tuations. 
 
 During the first few days of the epidemic, the victims, 
 with extremely few exceptions, were of the lowest classes. 
 So noticeably was this the fact, so prompt and terrible was 
 
 2 
 
10 
 
 their death, that these classes, incredulous of the existence of 
 cholera, accused the government, and the physicians leagued 
 with it, of an infernal conspiracy to carry them off by poison. 
 To the horrors of the cholera, which in its desolation resem- 
 bled the destroying angel more 'than an ordinary disease of 
 our race, were added those of an infuriated excitement which 
 defies my powers of description. Figure to yourself that 
 Paris commonly contains nearly a million of inhabitants, a 
 very large portion of whom form a class to which happily 
 we have no parallel in our country ; and this class in a state 
 of bloodthirsty frenzy, compared to which the common forms 
 of insanity are mildness, and yo\i will have a faint idea of 
 Paris during two or three days. In their fury the populace 
 killed several persons, severely wounded others, and precipi- 
 tated horses, carriages, and even men, into the Seine. They 
 besieged the doors of the hospitals, which were guarded 
 night and day by armed soldiers. Crowds were collected in 
 the streets, the burden of whose conversation was "poison- 
 ing." Raising the cry of a " poisoner" they pursued indi- 
 viduals with the ferocity of tigers. They even lay in wait, 
 in chambers, for physicians whom they sent for, pretending 
 to be sick. The eloquent description, by Thucydides, of the 
 scenes acted at Athens while the plague ravaged that famous 
 city, hardly conveys an adequate picture of what passed 
 among us. 
 
 My observations on this disease have been chiefly made 
 on patients received in the hospitals — persons, in general, 
 poorly clad, indifferently nourished, much exposed to atmos- 
 pheric vicissitudes, of enfeebled constitutions, in whom con- 
 sequently the disease manifested itself with the greatest 
 intensity. There were, however, among the robust and 
 muscular, many of the severest cases. 
 
 After briefly sketching the progress of a case of cholera 
 during the first days of the epidemic, I will resume the con- 
 sideration of symptoms, for the purpose of describing them 
 
11 
 
 more in detail, with some modifications they underwent in 
 the course of the epidemic, and of dividing the disease into 
 stages with reference to its treatment. 
 
 A diarrhoBa, of a few days' or hours' duration, so slight 
 perhaps as to be disregarded ; slight general indisposition ; 
 impaired appetite ; a slight headache, were pretty common 
 precursory symptoms. Oftentimes the patients were in good 
 health, and engaged in their usual occupations on the day 
 of attack. To denote the suddenness of the invasion in 
 some cases, the patients compare it to a blow of a club, — 
 u coup de baton? Frequently the patient awakes in the 
 night with an earnest desire to go to the water-closet ; or 
 he experiences this sensation, or is struck indescribably on 
 rising in the morning, or soon after. A sudden and great 
 increase of a previous diarrhoea, or a violent inclination to 
 have a passage, without pain, is in most cases the first symp- 
 tom described by the patient. Yomiting occurs simultane- 
 ously, or soon follows. Cramps occupying the soles of the feet, 
 the calves of the legs, the thighs, and in a much less degree 
 the superior extremities, supervene instantly, or in the course 
 of two or three hours. The patient becomes cold and livid. 
 On his arrival at the hospital, an hour or two after the inva- 
 sion, he presents that frightful choleric decomposition of the 
 features, of which language can convey no adequate idea : 
 his eyes are sunk and surrounded with a livid circle — the 
 pupils sometimes dilated ; face shrunk, triangular, cold and 
 livid, particularly the lips ; nose cold and pinched up ; tongue 
 cold, moist, livid, and a little furred with white ; air respired 
 from the lungs perfectly cold ; voice profoundly altered, 
 nearly extinct, or heard only in a feeble whisper, on great 
 exertions, of a peculiar disagreeable harshness, in a few cases 
 quite extinct ; ears livid ; extremities cold, shrunk, livid or 
 marbled ; the skin of the hands, forearms and feet is without 
 contractility, and when pinched up in folds slowly subsides — 
 it is wrinkled like a washerwoman's ; cold and lividity some- 
 
12 
 
 times invade the trunk, particularly the sides of the chest ; 
 scrotum livid and contracted ; radial pulsation extremely 
 feeble or imperceptible ; thirst torturing ; urine no longer 
 secreted ; though the intellectual faculties are -unharmed in 
 almost all cases, the patient lies regardless — except to make 
 frequent demands for drink, or when his cramps tear from 
 him distressing cries — mostly on his back, his eyes half closed 
 and turned upwards, his mouth open ; he vomits a wa- 
 tery inodorous liquid ; his discharges, occurring every few 
 minutes, and made in bed, without pain, and oftentimes 
 even without his knowledge, resemble dirty rice water, and 
 have the odor of stale fish or stale oysters ; his cramps 
 are atrocious, and renewed at short intervals ; from a vein 
 opened the blood flows not all, or with great difficulty, is of 
 a deep dark color, and at the end of some hours resembles 
 a dark, feebly coagulated, vegetable jelly, and is without 
 serum ; respiration slow, and accompanied with more or less 
 precordial anxiety. In a very few cases hickup and deli- 
 rium supervene near the fatal termination. At the end of 
 four, eight, ten, twelve, or sixteen hours, the patient dies 
 without a groan. In most cases the purging, vomiting and 
 cramps, cease some time before death ; and the patient, say- 
 ing that he is better, sinks so quietly that it is impossible for 
 the looker on to determine when the spirit quits its tenement. 
 If he survives longer, or rather if he is to last a little longer, 
 after some hours an imperfect reaction takes place, he is par- 
 tially warmed, a feeble pulsation is perceived at the wrist, 
 the vomiting and cramps are less urgent, an abundant viscid 
 perspiration covers him, the decomposition of his features is 
 less frightful ; but the eye is injected in a peculiar manner, 
 chiefly that portion of it exposed to the light, in a less degree 
 the part covered by the lower lid, and slightly, or not at all, 
 the portion covered by the upper lid ; or an ecchymosis forms 
 in the coats of the eye ; or, finally, a thin pus is secreted. 
 The patient at length falls into a stupor, and dies without 
 
13 
 
 the slightest struggle, twenty-four, thirty-six, or forty-eight 
 hours after the attack. Sometimes the reaction is more per- 
 fect, the purging, vomiting and cramps, disappear entirely, or 
 nearly so, and hopes of recovery are entertained for two, three, 
 or four days, when the patient manifests inclination to sleep, 
 his face becomes flushed, his eyes injected, and in despite of 
 revulsives or excitants, depletion local or general, stupor and 
 coma succeed, sometimes accompanied with delirium, and 
 he dies with the usual cerebral symptoms. Sometimes per- 
 sons are brought into the hospital in a state of the pro- 
 foundest stupor, resembling dead-drunkenness, if I may use 
 such a word in describing so awful a disease, from which 
 they cannot be roused ; and often the only account we can 
 obtain from their friends, is that the patients were found 
 in this state, perhaps in their chamber. Death succeeds as 
 quietly, in a few hours, as we sometimes see sleep follow 
 intoxication. This disease is sometimes still more rapid in 
 its progress. A woman, walking on the Boulevard, in the 
 neighborhood of Neckar Hospital, was seized with cramps ; 
 she fell, and before she could be placed on a litter, was dead. 
 Such was the progress of the disease, with slight varia- 
 tions, and such too its terminations, with individual excep- 
 tions, during the first days of the epidemic. The course of 
 the disease, when followed by recovery, will be described 
 farther on. Indeed, it would not be a very great exaggera- 
 tion to say, that the recoveries during this period were too 
 few to furnish the materials for a general description : for of 
 the one hundred first cases received at Hotel Dieu,it was never 
 pretended that more than four were cured ; and it has been 
 shown that three of these four never had the cholera ; that 
 is, one cure in ninety seven ! I am, however, clearly of 
 opinion, that those who after the development of a more 
 perfect reaction, sunk beneath cerebral symptoms, were in 
 general recoverable by means hereafter to be mentioned, 
 though experience clearly proved to me, that they could not 
 
14 
 
 sustain local depletion sufficient to overcome the determina- 
 tion of blood to the brain. 
 
 From its first appearance, the epidemic was gradually 
 undergoing considerable modifications, which were quite 
 noticeable at its stadium, and more especially about the 
 commencement of the period of decline. By these modifica- 
 tions of the cholera, I mean that when meliorated and less 
 rapid, it permits the development of symptoms lost under 
 the violent ataxic form assumed by almost all cases that fell 
 under my observation during the rise and part of the stadium 
 of the epidemic. As it has since preserved this ameliorated 
 character in most cases, as it is against these alone that the 
 efforts of the healing art are directed with any reasonable 
 prospect of success, I shall have this less rapid and modified 
 form chiefly in view hereafter, occasionally glancing at any 
 variety of symptoms as appertaining to the different epidemi- 
 cal periods. In the mean time the epidemic influence had 
 shown itself in an immense number of the inhabitants of this 
 city, with every possible degree of intensity, from the slightest 
 perceptible indisposition to the most violent form of cholera. 
 However mild the indisposition, the experienced eye rarely 
 failed to recognize the choleric impress. When the derange- 
 ment of the health was so considerable as to require medical 
 aid, some of the essential symptoms of declared cholera 
 being absent, it was denominated a cholerine. In many 
 cases the cholerine, if carefully examined, was found to be 
 the first or forming stage of cholera ; in others, the cho- 
 lerine constituted all the disease likely to be produced by 
 the epidemic influence, rendering the patient, nevertheless, 
 very liable to an attack of confirmed cholera. I will take 
 up the consideration of this subject more at large in another 
 place. 
 
15 
 
 FIRST PERIOD, OR STAGE OF FORMATION. 
 
 In many cases, particularly during the rise and stadium 
 of the epidemic, this stage has been wanting, it being impos- 
 sible to detect any precursory affection. In these cases the 
 cholera was ushered in without any premonitory symptom, 
 by a sudden, indescribable, momentary sensation of being 
 " seized with the cholera," with extreme weakness, so great 
 sometimes as to produce the fall of the patient. The patient 
 tries to convey this idea by representing himself as struck as 
 it were with a blow — "frappe comme oVun coup de baton" 
 
 Most commonly, however, as a precursory symptom of 
 cholera, there is a diarrhoea of some hours', generally of some 
 days' duration. This diarrhoea, consisting of fecal and bilious 
 matter at first, becomes more liquid, watery, whitish and ur- 
 gent, up to the time of invasion. The matters are rendered 
 with briskness, but without local pain or tenesmus. In some 
 few cases I have known the diarrhoea, after having existed 
 for a few days, to be checked without the use of any reme- 
 dy, and complete constipation, for several days, precede the 
 declaration of cholera. In a few other cases, I have seen, 
 as a precursor of the disease, a confined state of the bowels, 
 without previous diarrhoea. Accompanying the diarrhoea, or 
 existing without it, we find as prodromes one or more of the 
 following symptoms, viz : — a feeling of general indisposition ; 
 impaired appetite, with viscid salivary secretions ; borboryg- 
 mies, with slight colics; slight vertiginous headaches; hearing 
 impaired in such a way as imperfectly to guide the intona- 
 tions of the voice ; coldness of the extremities ; dull, numb, 
 nervous pains or sensations, amounting almost to cramps in 
 the calves of the legs ; a general nervousness, occasioning 
 fitful slumbers instead of refreshing sleep. 
 
16 
 
 A usual prodrome of the cholera is a cholerine, that is, 
 some of the symptoms of cholera in a decided form, with 
 the absence of others, which are essential characteristics of a 
 fully developed case. 
 
 I have mentioned a little in detail these prodromes, an 
 assemblage of any of which I have denominated the stage 
 of formation ; not for their importance by themselves con- 
 sidered, but as the precursors of a very fatal disease. They 
 occur in a vast majority of cases, and by obviating them the 
 disease in forma is apparently prevented. During the pre- 
 valence of cholera they should by no means be neglected ; 
 for if they do not always precede a formal attack, we are 
 quite sure that they render a person very liable to one. This 
 stage, then is characterized, by derangement of either the 
 digestive apparatus, or of the innervation, or of both. 
 
 SECOND PERIOD, OR COLD STAGE. 
 
 We might here, perhaps, in strictness, introduce a stage 
 of invasion ; but as this would be in all cases extremely 
 short, and in a vast majority only another name for the com- 
 mencement of the cold stage, neither requiring nor admitting 
 any variation in treatment, I forbear to introduce it. I prefer, 
 too, to distinguish the present as the cold stage, in preference 
 to any other name, since in all cases there is a noticeable 
 diminution of the temperature. Objections might be urged 
 against most other names, such as the blue period. &c. 
 
 This stage is the commencement of the disease in form. 
 The time of invasion is usually between nine at night and 
 nine or ten o'clock in the morning. Attacks, however, 
 
17 
 
 occur at all periods of the twenty-four hours, more com- 
 monly in the morning or late in the afternoon than near 
 mid-day. Whatever may have been the severity of the pre- 
 cursory symptoms, tne patient can tell, to a minute almost, 
 when the disease commenced. " He was struck" — " he was 
 ascending or descending a flight of stairs" — "feeling a lit- 
 tle indisposed, he took a cup of coffee, which he vomited 
 in a few moments, and an instant afterwards had a liquid 
 stool" — " he awoke in the night with an inclination to go 
 to the water-closet ; while there he vomited, or was seized 
 with cramps:" or, " he experienced this last train of symptoms 
 soon after rising in the morning." This sensation of being 
 seized with the cholera, which was more dramatically 
 marked, if I may so speak, during the first period of the epi- 
 demic than subsequently, but which exists in a greater or 
 less degree in all cases, is resolvable, as near as I can judge, 
 into a sense of sudden extreme weakness. 
 
 Of the previous diarrhoea, a sudden and great increase, 
 or the supervention of it upon the other prodromes, with a 
 sense of great debility, are in a very large proportion of cases 
 the first symptoms described by patients. The diarrhoea is 
 not unfrequently preceded by the vomiting, more rarely by 
 the cramps. A few minutes after, the attention of the pa- 
 tients and the standers by is directed to other symptoms. 
 The extremities, particularly the feet and point of the nose, 
 are cold : and in a small proportion of cases there are chills. 
 On examining the hands and feet, it is perceived that they 
 are slightly discolored, of a deep crimson approaching purple. 
 The coldness and discoloration having occupied the parts 
 remotest from the heart, increase and approach the centre of 
 the system. The choleric decomposition of features appears 
 at the same time, and soon becomes frightfully cadaverous. 
 The pulse, slow and feeble, rapidly declines in force and 
 frequency, till it is extremely tenuous or entirely disappears. 
 From this time forth urine is no longer secreted. The 
 
 3 
 
18 
 
 purging, vomiting and cramps continue, and the patient at 
 length presents the following appearance and assemblage of 
 symptoms: — The extremities are cold, shrunk and livid, or 
 marbled. The skin of the hands and forearms, and in a 
 less degree of the feet, is wrinkled like a washerwoman's, 
 has a peculiar moist feel, and when pinched up in folds very 
 slowly regains its former state. In proceeding towards the 
 body, the lividity of the limbs degenerates into purple patches, 
 and at length assumes a marbled appearance. The extent 
 of the lividity varies, of course, according to the seventy of 
 the case. It approaches higher proportionally on the infe- 
 rior than on the superior extremities. The point of the 
 elbow and the kneepan are often livid, while surrounded by 
 a zone of nearly the natural flesh color. The scrotum is 
 livid and contracted. Coldness and livid patches sometimes 
 invade the trunk, particularly the sides of the chest. The 
 face is shrunk, triangular, cold and livid, particularly the 
 prolabia. The nose is pinched up and cold ; its mucous 
 membrane covered with a pulverulence, extending deep into 
 the ethmoid cells : this pulverulence was most abundant 
 when the patients were vacillating between the cold stage 
 and ill sustained efforts at reaction. The eyes are sunk, in 
 appearance atrophied, surrounded with a deep livid circle, 
 and when the patient reposes a moment, the globes, turned 
 upwards, exhibit the white portion between the unclosed 
 lids. The ears are livid and cold. The mouth is moist, with 
 a pretty abundant clammy, or even pasty secretion. The 
 tongue is cold, moist and livid, or pale, having on its upper 
 surface a slight whitish fur. The air respired from the 
 lungs is cold, and has a peculiar sourish odor. The per- 
 fectly cold respiration is, however, rather rare to be met 
 with since the stadium of the epidemic. Respiration is per- 
 formed chiefly by the muscles of the chest, unassisted by the 
 diaphragm and abdominal muscles. It is slow, at times 
 somewhat anhelating, with precordial anxiety. This has 
 
19 
 
 seemed to me to depend in part on the general prostration 
 of the animal forces. Whether decarbonization of the blood 
 is well performed, I have made no experiments to determine. 
 The voice is profoundly altered, heard in a shrill whisper, 
 and on being exerted, it breaks with a peculiar raucous 
 harshness. Sometimes it is entirely extinct. Speaking fa- 
 tigues the patient. In one severe case of cholera, where the 
 voice was for a long time extinct, it was not till the patient 
 was advanced many days in convalescence, that she was 
 able to utter any sound whatever. And so rigid were the 
 vocal organs, that it was some days after the complete 
 recovery of the power to utter loud sounds, before she could 
 articulate intelligibly the simplest sentence, or even single 
 words. 
 
 Notwithstanding the refrigeration of the surface, which is 
 always present in a greater or less degree, some patients 
 complain of a burning heat ; in others, the sensation of the 
 cold is natural. The thirst is always torturing ; some swal- 
 low ice with the greatest avidity ; a large number prefer 
 warm beverages, and others are indifferent on this point, 
 demanding only some liquid. 
 
 The abdomen is very sunk, and has a doughy feel under 
 the fingers : in a small proportion of cases it is of its natural 
 suppleness. In very many cases, neither the abdomen nor 
 epigastrium is painful on pressure ; in others, the pain is con- 
 siderable, and accompanied with precordial anxiety. Pain, 
 and a sense of oppression at the epigastrium, bear no rela- 
 tion to the severity of the disease. Not unfrequently there 
 is a dull vertiginous headache, rarely severe, occupying 
 generally the supra-orbitary region. The headache some- 
 times exists without, at others it is accompanied by slight 
 tinnitus aurium. The patient sometimes describes the sen- 
 sation in the ear, as the blowing of a current of air ; more 
 commonly he likens it to that confusion of sounds we hear 
 when rolling in a chariot over a pavement. We also find, 
 
20 
 
 in some cases, a little deafness ; and patients complain that 
 their ear does not assist them in regulating the intonation 
 of their voice. When not tortured by his cramps or thirst, 
 the patient is more or less somnolent, but not comatose, 
 except a short time before the fatal termination of this stage. 
 When questioned, he answers slowly, but correctly. The 
 intellectual faculties are preserved in their integrity, except 
 in a very small number of patients. ' The mental derange- 
 ment of a patient, who otherwise appeared to be in a state 
 of asphyxia, strongly simulated delirium tremens. Some 
 are fearful of the termination of their disease ; others are per- 
 fectly indifferent, and the latter are considerably more nu- 
 merous than the former. I have seen a mother, apparently 
 in the full possession of her intellect, request her two daugh- 
 ters to leave her, and not to trouble her. It was the last 
 time they ever saw her alive ; she died a few hours after. 
 
 The suppression of urine causes no uneasiness whatever; 
 so far from it, that it is sometimes asserted by the patient 
 that urine is rendered as usual, w T hen a careful examination 
 shows the contrary to be the fact. If an attack of the 
 cholera occurs during the menstrual period, this secretion is 
 arrested. After having been thus suppressed for some days, 
 I have known it re-established during convalescence. All 
 the pregnant women received in our hospital, attacked with 
 cholera have aborted and borne dead children. This number, 
 however, was small, only four. The secretion of milk is not 
 suppressed in suckling women. In one very interesting case, 
 of a woman with a sucking infant, who recovered, the milk 
 was drawn off with avidity by a puppy. 
 
 From a vein opened in this stage, the blood flows out 
 mechanically, as if from a dead body in which the blood 
 has not coagulated. It is of a very dark color, coagulates 
 very feebly, and furnishes very little or no serum. J. Jack- 
 son, jr. of Boston, and myself, saw a dead man, who had 
 been some hours in the Salle de Morts, at Neckar Hos- 
 
21 
 
 pital, move his arms and legs, his eyelids, and open and 
 shut his mouth several times. From one of the venae comites 
 of his arm, we obtained, as well as I can estimate, nearly a 
 quart of blood. The flow of blood was assisted by agitating 
 the body generally, and by pumping it out, as it were, from 
 the central parts of the system, on elevating and depressing 
 the parietes of the chest. I repeated the experiment on other 
 dead bodies, and could perceive no difference in the flow of 
 blood from one of their veins and from the vein of a living 
 cholerique opened in the cold stage. From the vein, of a 
 person in this stage, left to itself, a few drops of blood slowly 
 exude. 
 
 In this stage, if there has been no precursory diarrhoea, 
 the alvine discharges consist at first of alimentary matter, 
 colored as usual by bile ; but they soon become characteristic, 
 and contain no traces of bile. When a diarrhoea has preceded 
 for a few days the explosion, the evacuations are from this 
 moment such as are peculiar to cholera. They are very fre- 
 quent, liquid, of a grayish white color, resembling dirty rice 
 water ; frequently of an odor which, to me, resembles that of 
 stale oysters. A kind of passage which I frequently met with 
 in the first periods of the epidemic, but which I have rarely 
 seen of late, is somewhat turbid, of a darkish brick color, 
 which, on being exposed to the air, is soon changed to a 
 dirty brown. The odor I cannot easily describe, though it 
 is familiar to me : may I be permitted to call it a sourish 
 stink ? It is this variety of alvine discharges which, I sus- 
 pect, has been mistaken by some for sanguinolent. I have 
 never seen a bloody discharge from a choleric. Stools of a 
 greenish hue are not unusual ; they occur more commonly 
 when the system is vacillating between refrigeration and 
 feeble efforts at reaction. There are other slight varieties 
 in the color of these discharges, which it would be useless 
 and tedious to describe. 
 
 These evacuations are invariably very liquid, rendered 
 
22 
 
 with briskness, made without pain, without tenesmus, and 
 oftentimes without the knowledge of the patient. In some 
 mild cases, however, they are preceded by a dull colic. The 
 patient describes them from the sensation as clear, and con- 
 sisting of water. Of their number, I have found it impos- 
 sible to form any tolerable estimate : I have hazarded the 
 conjecture, in some cases, that they were at the rate of one 
 hundred in twenty-four hours ; and from this number a 
 regular gradation to a very few, or none. 
 
 Vomiting. It is not unfrequent to see the vomiting pre- 
 cede the diarrhoea. After the matters usually found in the 
 stomach are voided, the discharges are liquid as water, of a 
 dirty whitish color, semi-transparent, or of a copperas green ; 
 sometimes frothy, with little flocculent masses ; or, very com- 
 monly, modified in color and odor by the beverage of the pa- 
 tient. The green color appears mostly in the same state of 
 the system as where we find green-colored alvine discharges. 
 I have not, among my notes, any case of cramps of the 
 stomach. Vomiting occurs at very various intervals ; in 
 some cases every five, ten, or twenty minutes, and so on to 
 intervals indefinitely remote. It is frequently excited by the 
 liquids taken to allay the thirst. It has appeared to me 
 that the vomiting, in this disease, is not more painful than 
 the operation of a mild emetic. 
 
 The principal seat of the cramps is the calves of the legs, 
 and in a majority of cases they are first felt here. In others, 
 they commence in the soles of the feet, and attack successively 
 the calves of the legs, and the thighs at the same time with 
 the hands and forearms. In two cases they affected all 
 the voluntary muscles, even those of the head and features, 
 producing a strange and horrible expression of the counte- 
 nance. Since the first epidemic period they are confined, in 
 most cases, to the lower extremities, with a numbness of the 
 arms in some cases. I have not seen the involuntary mus- 
 cles the seat of cramps. 
 
23 
 
 The pulse, which usually could not be felt at the wrist, in 
 this stage, during the rise of the epidemic, was perceptible in 
 most cases that occurred during the subsequent periods. It 
 was extremely feeble and small, and in frequency a little 
 below the healthy standard. I have, however, seen it full 
 and strong a.t the commencement of this stage, especially 
 when the disease is ushered in with slight premonitory 
 symptoms. I have remarked, in two cases, that it was per- 
 ceptible only in one arm. I regret not having examined 
 both arms, more frequently, with this view. 
 
 The patient retains the natural sensibility of the surface 
 to external impressions. Blisters and sinapisms generally 
 take effect, and are as painful as usual, though the limb is 
 ice-cold. From this last remark we must except the feet, in 
 very severe cases, and patients in that state of quiet border- 
 ing on stupor, which immediately precedes their sinking into 
 the arms of death. 
 
 This stage terminated in death or reaction. The fatal 
 terminations assumed two forms. First, where the patient 
 died quietly, as if falling asleep, like those who perish from 
 cold. Secondly, where there is an effort at reaction, not 
 sufficient, however, to carry the patient from the confines of 
 this stage into those of reaction. But these terminations 
 have been sufficiently described in the sketch which I gave 
 at the commencement. 
 
 The characteristic symptoms of this stage are, purging, 
 vomiting, cramps of the lower extremities, choleric decom- 
 position of features, profound alteration of the voice, absence 
 or extreme feebleness of the pulse, great thirst, non-secretion 
 of urine, general prostration, coldness and discoloration to a 
 greater or less extent of the surface, integrity of the intel- 
 lectual faculties. 
 
 The sensibility of the epigastrium on pressure, the head- 
 ache and tinnitus aurium, the sensation of cold or heat, the 
 preference of warm or cold beverages, anxiety or indifference 
 
24 
 
 about the termination of the disease, are absent or reversed 
 in the severest cases, and bear no relation whatever to the 
 mildness or severity of the disease in any case. 
 
 THIRD PERIOD, OR STAGE OF REACTION. 
 
 When the second period or cold stage terminates in reac- 
 tion, we find that some hours after the invasion, the pulse, 
 before imperceptible, or extremely small and feeble, is felt, or 
 becomes a little fuller, the surface is gradually warmed, the 
 cadaverous decomposition of the features in part or wholly 
 disappears, the countenance is a little flushed, and the purg- 
 ing, vomiting, and cramps most generally are less urgent, or 
 entirely cease. These changes take place very gradually. 
 In many cases before reaction is firmly established, there are 
 short efforts at this state with temporary development of 
 heat, succeeded by a return of cold. These vacillations be- 
 tween heat and cold seldom continue longer than a few 
 hours. I have, however, known patients remain in this 
 state for days, and eventually recover. Reaction puts on 
 different forms, and is of various degrees of severity, not 
 always proportionate to the violence of the previous symp- 
 toms. 
 
 Sometimes the reaction seems gradually to augment, the 
 functions to resume their play and increase in vigor, until 
 they have arrived at the standard of health — or perhaps 
 I should say to a healthy balance. The augmentation 
 of reaction is then arrested, convalescence commences, there 
 then remains no adverse symptom so considerable as to 
 require being obviated, except general debility and a state of 
 
25 
 
 the system very liable to relapse, both which demand the 
 strictest attention to external warmth, and the most careful 
 observance of diet. 
 
 Imperfect Reaction, In other cases, reaction, though de- 
 clared, is imperfect. The efforts of the system at reaction are 
 sometimes so feeble that the patient vacillates, as I have be- 
 fore mentioned, between a state of heat and cold. At other 
 times, these efforts are more powerful, but yet insufficient to 
 produce a complete reaction. These states or degrees of reac- 
 tion I have embraced under the name of Imperfect Reaction. 
 It is characterized by prostration, more or less, considerable 
 coldness, slight lividity, occasional cramps, with persistence 
 of the vomiting and purging much abated in frequency and 
 violence, and a continued suppression of the urinary secre- 
 tion. The nasal fossse are lined with a dirty grayish pul- 
 verulent matter. The liquid vomited is usually of a bright 
 green hue ; when it contains bile the omen is favorable, and 
 indicates the near approach of a more complete reaction. 
 
 It is in this state of imperfect reaction that we see, very 
 frequently, ecchymoses formed beneath the conjunctiva at 
 the inner angle of the eye near the transparent cornea, and 
 on a portion of the sclerotica exposed to the light. As this 
 state proceeds towards a fatal termination, ecchymoses form 
 in the same manner near the external angle. 
 
 This state is of very uncertain duration. It terminates in 
 death preceded by coma, in convalescence, or in complete 
 reaction. 
 
 Complete Reaction comes on in the gradual manner de- 
 scribed at the commencement of this period, or it succeeds 
 the state of imperfect reaction. In complete reaction most of 
 the leading symptoms which characterized the second period, 
 or cold stage of cholera, have given place to a new set of phe- 
 nomena. The prostration is still considerable, but the purg- 
 ing, vomiting and cramps exist no longer. The pulse is full, 
 and in general neither frequent nor hard ; the surface is quite 
 
 4 
 
26 
 
 warm ; the face flushed ; the eye slightly injected ; mouth 
 dry ; thirst considerable, but much less urgent than in the cold 
 stage ; the tongue is red, dry, and rather harsh ; the abdo- 
 men, instead of being sunk in as during the previous period, 
 is of its natural suppleness, most commonly a little distended 
 and slightly painful on pressure. The patient is a little 
 drowsy, and harassed with flighty dreams by night. The 
 suppression of urine continues for some time, generally for 
 several days after the complete development of reaction ; and 
 the reappearance of this secretion, though of very favorable 
 omen, is marked by no crisis. 
 
 Not an inconsiderable proportion of cases 7 however, pre- 
 sents, in this state, symptoms of greater severity than those 
 just described. It is in this state that we meet with typhoid 
 symptoms. The brain is more or less affected, from somno- 
 lence to complete coma. The face is greatly flushed, and 
 the eyes highly injected, with intolerance of the light ; the 
 tongue is very dry, and coated with a harsh black fur ; sordes 
 appears on the teeth and lips. Occasionally slight deafness 
 attends, with confusion of the ideas, and, in some rare cases ? 
 delirium. 
 
 The typhoid symptoms are sometimes so strongly marked 
 as to deceive the superficial observer ; yet have I not seen a 
 case of cholera, which, in any stage of its progress, I con- 
 sidered identical with typhus fever. Carphology ; a pecu- 
 liar way of looking and answering when spoken to ; a pecu- 
 liar feel of the skin, different as it is exposed to the air or 
 covered by the bed-clothes ; lying on the back, with a dispo- 
 sition to slide down in the bed ; and typhomania, I have 
 not seen in cholera. The pulse, too, in this stage of cholera, 
 is generally large, and very soft and slow. Cholera, in this 
 stage, sometimes resembles less typhus fever than those 
 typhoid and nervous symptoms which occur in the sequel 
 of protracted cases of bilious fevers in the southern United 
 States, when, having lost their remittent, they assume a 
 
27 
 
 continued type. I do not deny that genuine typhus may 
 succeed cholera ; so far from it, that I am clearly of opinion, 
 that this latter disease may be, and sometimes is, converted 
 into the former. I only wish to say, that I have not seen in 
 cholera some of the symptoms which I consider essential 
 characteristics of an exquisitely marked typhus. 
 
 The epidemic, as I have before remarked, has presented 
 some slightly modified appearances at different epochs. Ty- 
 phus symptoms were of very frequent occurrence about the 
 middle of April, when the epidemic was at its maximum of 
 intensity. The disease then often simulated that form of 
 typhus described by Hildenbrand. For some time after- 
 wards typhus symptoms were rare. As the epidemic became 
 greatly aggravated, about the middle of July, it often pre- 
 sented another form of typhus, almost identical, in many 
 of its leading symptoms, with the very rapid disease known 
 on Connecticut river under the name of spotted fever. 
 
 The most constant, unmanageable, and fatal symptom, 
 one, indeed, which I am, at times, disposed to think charac- 
 teristic of this state of reaction, is the cerebral congestion. 
 Most of the other symptoms seem to depend directly from 
 this, and they increase or diminish in intensity in proportion 
 to its severity or mildness. While the case is apparently 
 proceeding very favorably, this symptom creeps on very 
 insidiously, first showing itself in a degree of drowsiness, 
 which, if not obviated soon, augments to stupor ; and it 
 occurs with great pertinacity, after having been repeatedly 
 subdued. We find, accompanying the cerebral congestion, 
 or in some rather rare cases existing alone, other local affec- 
 tions ; sometimes of the lungs, indicated by a slight cough ; 
 more frequently there is some inflammation of the stomach, 
 producing tenderness of the epigastrium. These latter affec- 
 tions are generally slight, often absent in the severest cases, 
 and bear no relation to the intensity of the previous symp- 
 toms. 
 
28 
 
 There is sometimes in this period a slight cough, the 
 sequel of previous pulmonic congestion. 
 
 If the termination of this state of reaction is fatal, the 
 drowsiness increases, other symptoms are aggravated, and 
 the patient dies comatose. If the patient recovers, the un- 
 favorable symptoms disappear very generally without a 
 marked crisis. The eye loses its injection, the countenance 
 its flushed appearance, the stupor or drowsiness vanishes, the 
 mouth and tongue become moist, the skin less harsh and of 
 its natural temperature, the patient urinates and has re- 
 freshing sleeps. These changes take place gradually, and 
 some of them successively, and convalescence is declared. 
 
 CONVALESCENCE 
 
 From cholera presents little that is peculiar in contra- 
 distinction from that of any other very severe disease. It is 
 sometimes very rapid, at others very protracted, and is not 
 regulated in this respect by the severity of the preceding 
 disease. Some few patients who have suffered very violent 
 attacks of cholera, have been able to return to their usual 
 occupations in four or five days. I have known other compa- 
 ratively mild cases, in which the patients have been confined 
 to their beds for three months. 
 
 During convalescence there is great liability to relapse, 
 from fatigue either of body or mind, from exposure to the 
 air, or from slight errors of diet. And this liability exists, 
 after the patient is apparently perfectly restored. Diarrhoea 
 recurs during this period, frequently without any assignable 
 cause. During the first few days, there is also considerable 
 liability to a return of the cerebral congestion, with the 
 accompanying symptoms already described. 
 
29 
 
 In a few rare cases, I have seen very moderate epistaxis 
 followed by the removal of some slight remains of cerebral 
 congestion. 
 
 One case of swelled parotid with suppuration, occurred in 
 this period without promoting or hindering the march of the 
 patient towards complete recovery. 
 
 In one case an abscess formed in the left ear, discharging 
 a whitish, turbid matter. The discharge gradually di- 
 minished and disappeared at the end of several days, with- 
 out seeming to affect the progress of convalescence. This 
 case, as well as that of the swelled parotid, were the only ex- 
 amples of the two affections that occurred among upwards of 
 two hundred patients. 
 
 Among the same patients there occurred a single case of 
 intermittent fever. The patient had several paroxysms of a 
 double quotidian. 
 
 Among five hundred choleriques I have not seen or known 
 a hemorrhage to occur from any part, except the moderate 
 epistaxis, of a few drops, in a very small number of patients 
 during convalescence. 
 
 APPEARANCES ON EXAMINATION AFTER DEATH. 
 
 I have been present at sixty-five autopsies, most of which 
 I made myself. But on this head I shall be brief. The post 
 mortem examinations of M. Louis, collected by my friends 
 doctors Gerhard and Pennock, of Philadelphia, are perhaps 
 already in possession of the American medical public, as 
 I hope will also be those of M. Andral, collected by my 
 friend J. Jackson, jun. of Boston. The minuteness and ac- 
 curacy of the examinations made by MM. Andral and 
 
30 
 
 Louis, probably the first pathologists of the age, and re- 
 corded on the spot by Messrs. Jackson, Gerhard and Pen- 
 nock, who have devoted themselves particularly to the study 
 of morbid anatomy, though they may leave much to be de- 
 sired, will leave little or nothing more to be revealed by the 
 scalpel. I shall therefore content myself with describing 
 these appearances in a general manner. 
 
 In the body which was cold as marble while animated by 
 the immortal spirit, there is after death a disengagement of 
 heat that diffuses a genial warmth for twelve or fifteen hours 
 after the extinction of life. 
 
 The body presents externally the blue choleric discolora- 
 tion. Cadaveric rigidity is very great ; the muscles moving 
 the feet, are in an especial manner powerfully contracted. 
 The muscular system in general is very dry, as of an 
 animal bled to death, and is unusually dark colored. 
 
 Brain. Dura mater sound. Arachnoid membrane some- 
 what injected and discolored, with serous infiltration beneath 
 it, in some few cases. The substance of the brain is nearly 
 natural, rather firm, and presenting a very smooth, moist, 
 and I might almost denominate it, oily section when cut. It 
 appeared in some cases rather more pointed with blood than 
 is usual. A little fluid was sometimes found in the ven- 
 tricles, particularly in protracted cases, wherein death had 
 been preceded by cerebral congestion. 
 
 Thorax. Lungs healthy, often a little emphysematous 
 from the dying efforts at respiration. Their posterior por- 
 tions were quite dark colored, which I take to arise from the 
 body being laid on the back after death. Heart and first 
 portion of aorta contain a large quantity of very dark and 
 very slightly coagulated blood. The left ventricle frequently 
 presents the appearance of hypertrophy. Polypous concre- 
 tions at times exist, but less generally than in persons dying 
 from other diseases. 
 
 The serous membrane of the thoracic cavity, as well as 
 
31 
 
 the peritoneum and peritoneal coats of the abdominal viscera 
 are sound and dry. 
 
 Abdominal cavity. The alimentary canal is more or 
 less discolored externally. The duodenum and first portion 
 of the jejunum present this discoloration in the greatest de- 
 gree. This in different cases varies from a rose color to that 
 of brick or Spanish brown. The stomach and large in- 
 testines are much less discolored, or quite natural. This 
 color of the alimentary canal arises from the injection of the 
 cellular tissue, existing between the peritoneal and mucous 
 coats, and embracing the muscular coat. 
 
 The stomach contains from a gill to a pint and a half of 
 a fluid differing in different subjects. It resembles most 
 commonly a slightly turbid whey ; at other times it is a 
 greenish liquor, or of a dirty brown hue and turbid. It is 
 often modified by the beverage of the patient, and has small 
 frothy or flocculent masses swimming in it. Its mucous 
 membrane is in general of the usual thickness and con- 
 sistence, and often presenting red patches, especially where 
 the disease has been violent and of short duration. When 
 the case has been protracted, and accompanied with much 
 tenderness of the epigastrium, we find the mucous membrane 
 red and pointed * in patches. 
 
 The small intestines contain a fluid varying in color and 
 consistence in different individuals, and in different parts of 
 the same alimentary tract, usually more consistent than that 
 found in the stomach. It resembles commonly dirty rice 
 water, or a thin starchy fluid; sometimes it is glairy or 
 creamy. During the first few days of the epidemic I often 
 found in these intestines a turbid brick-colored liquor. This 
 latter was subsequently only rarely met with. Their mucous 
 membrane is somewhat injected, and covered with an ad- 
 
 * Pointille. 
 
32 
 
 herent creamy mucus. Some consider this layer of mucus 
 as peculiar to cholera. M. Majendie says he finds it in per- 
 sons guillotined. The color of the mucous membrane cor- 
 responds very nearly with that of the intestine when viewed 
 externally; and on raising this membrane its color is per- 
 ceived to be owing chiefly to the same cause, viz. to the in- 
 jection of the subjacent cellular tissue. Occasionally there 
 are introsusceptions, and more rarely there are lumbrici. 
 
 The glands of Bruner and Peyer, situated in the coats of 
 the intestine, are somewhat enlarged. I have not, however, 
 examined these glands in persons dead of other diseases 
 sufficiently often to advance an opinion as to the importance 
 we are to assign them among the morbid appearances of 
 cholera. From their size, number, and situation in the 
 lower part of the small intestines, I am not disposed to con- 
 sider it very great. 
 
 The large intestines generally present in some part of 
 their tract, appearances similar to those just described, but 
 limited in extent, and much slighter in degree. In other 
 cases, the mucous membrane is of unusual whiteness. 
 We sometimes meet with patches near their termination 
 which are apparently cadaveric ecchymoses. Indeed, it 
 is only in some few cases that I have considered the large 
 intestines as having suffered any considerable pathological 
 changes. They are frequently contracted, and contain 
 small quantities of a liquid similar to some one of those 
 found in the small intestines. Occasionally they con- 
 tain a dark brown liquid which is destitute of fetor. 
 
 I have never seen, even in its incipient state, gangrene of 
 the intestines. Nor have I perceived any remarkable ten- 
 dency to putrefaction, either of the solids or fluids of the 
 system. 
 
 The liver is in appearance perfectly healthy, though the 
 secretion of bile has ceased from the invasion of the disease. 
 It is generally very dry and free from blood. In a few cases 
 
33 
 
 the large vessels of the liver have contained uncoagulated 
 blood ; but this I take to be in most cases an effect produced 
 after death by mechanical causes. The gall bladder is in 
 a few cases much distended. It is generally moderately full 
 of a dark colored bile. In two instances I have found in it 
 a nearly transparent liquid, resembling a solution of gum 
 arabic. 
 
 The spleen, pancreas, and kidneys, are found in a healthy 
 state. The kidneys, from the position of the body, often 
 contain blood in their large v essels. 
 
 The bladder of urine is empty and contracted. The 
 small quantity of mucus found in it, is clearly only another 
 proof that the mucous tissues are more tenacious of life than 
 some others ; and is analagous with the growth of the beard 
 after death. In four protracted cases, which occurred during 
 the decline of the epidemic, I found the bladder containing 
 a considerable quantity of urine. 
 
 The ganglionic system of nerves doubtless plays an im- 
 portant part in the production of choleric phenomena ; after 
 considerable examination of them, however, I do not believe 
 that the scalpel reveals any perceptible changes in their 
 appearance or structure. The great posterior crural nerve, 
 in several instances where I examined it, was gorged with 
 blood. How far this is a pathological state I am unable 
 to say. 
 
 Such in general were the appearances found on examin- 
 ing the bodies of those who died in the cold stage, or alter a 
 short or an imperfect reaction. When a protracted reaction 
 preceded death, the autopsic appearances corresponded to 
 the supervening local affections observed during life, such as 
 water in the ventricles of the brain, and in some cases, un- 
 equivocal marks of inflammation of the stomach. 
 
 In cholera, is there inflammatioii of any part of the ali- 
 mentary canal ? After all that has been said on this subject 
 it is in some measure a dispute of words. Those of us 
 
 5 
 
34 
 
 who have seen much of the cholera, know very well what 
 the autopsic appearances are ; but until medical men agree 
 on what constitutes inflammation, it seems almost useless to 
 vex this question when speaking of cholera, especially when 
 we know, that this definition of words being settled, we are 
 not advanced one step in the treatment. I will however 
 devote a few words to this subject. 
 
 If we take the local affection, either of a gastro-enterite or 
 of dysentery, as the type of inflammation of the mucous 
 membrane lining the alimentary tract, we find that the de- 
 rangement of the innervation, and the draining of the fluids 
 of the system by means of this mucous membrane, (the 
 symptoms that constitute the essence of the disease, which 
 are, in a word, cholera itself,) exist without some of the 
 usual and important phenomena of inflammation. In 
 many of the severest cases, there is no pain from great 
 pressure on the abdomen ; the discharges are attended with 
 no local pain ; no tenesmus ; often with no sensation. — 
 Seemingly this does not arise from a want of sensibility, for 
 the patient retains this in most respects, as when in health. 
 The tormenting thirst, however, while the mouth is moist 
 and cold, may have an important connection with the pa- 
 thological state of the stomach. Whether there is a softening 
 or thickening of the mucous membrane, is a question of 
 sensation, and there is some liability to error. In examin- 
 ing this membrane, with reference to these points, I used 
 great care, and made several comparative observations, as 
 opportunities were afforded me by the death of patients from 
 other diseases. It is true, I did not find this membrane the 
 same in all ; but the difference I do not conceive to be great- 
 er than exists between the stomachs of the robust and tem- 
 perate and those of the enfeebled and intemperate. The sto- 
 mach was decidedly inflamed in many cases ; but this state 
 was accompanied in most, I believe in all, by the usual symp- 
 toms during life, and after death, presented the pointille 
 
35 
 
 appearance and other changes which are consequent on 
 the common form of inflammation of this tissue. These 
 phenomena occurred only in some cases of protracted re- 
 action ; I never saw them where the patient died in the cold 
 stage. Nor have I at any period seen inflammation termi- 
 nate in gangrene. 
 
 If, however, redness alone is evidence of inflammation, 
 then was there inflammation of some portion of the alimen- 
 tary tract, more or less marked in every case of cholera of 
 which I made a necropsic examination. This color existed 
 in some degree in the mucous membrane when separated 
 from the other coats of the intestines, but it was chiefly 
 situated in the subjacent cellular membrane or tissue. This 
 rose color of the intestines, which in the severest cases 
 approached a brick color, I consider analogous to the 
 lividity or deep crimson of some parts of the surface of 
 the body ; or rather, if I may so speak, as a part of the same 
 fact, and no more an inflammation in one case than in 
 the other. The redness of the intestines corresponded 
 to the external discoloration, and both were in proportion to 
 the drain of fluids from the body, and to the rapidity and 
 violence of the disease. As the epidemic declined, the 
 redness of the intestinal canal became a much less marked 
 autopsic appearance, though pain of the epigastrium was of 
 much more frequent occurrence, and of greater severity than 
 during the rise and stadium. 
 
 But the discoloration is not confined to the intestines and 
 surface of the body, it extends in many cases to the ute- 
 rus, bladder of urine, (fee. and even to the bones. It 
 depends, I believe, in some measure, on the stagnation 
 and imperfect coagulation of the blood after death. From 
 the analyses * of the blood given in the margin, we see in 
 
 * The following are the analyses of the blood made by Dr. Thomson of 
 Glasgow, and Dr. Reid Clanny of Sunderland. 
 
36 
 
 choleriques, a very noticeable diminution of the coagulating 
 part, and an increase of the coloring matter and carbon. 
 Nevertheless, we are not perhaps justified in supposing that 
 the aggregate of the latter is increased, unless from the 
 imperfect decarbonization of the blood in the lungs. But 
 I wish chiefly to insist on the deficiency of the coagulating 
 part of the blood as shown by these analyses, on its 
 non-separation into serum and coagulum, when drawn 
 from the living cholerique, and on its remaining liquid 
 wherever found in his body after death. The coloring 
 matter of the blood then, instead of being compressed into a 
 small space after death by the coagulating portion, as in 
 ordinary diseases, remains spread out upon, or diffused 
 in the different tissues of the body. No one will deny 
 the great compressibility of the coloring matter, who recollects 
 for a moment the large, feebly coagulated mass which 
 remains of blood drawn from choleriques, and the small 
 coagulum floating, in a large quantity of serum, into which 
 the blood separates that is drawn in some highly inflam- 
 matory diseases. I have been thus long, tedious I fear> 
 
 Dr. Thomson's analyses supposing 100 parts of water in each case. 
 
 Health. Cholera. 
 
 Water 100 100 
 
 Albumen 10.79 7.34 
 
 Fibrine 5.67 0.57 
 
 Coloring matter and albumen 9.42 41.51 
 
 Salts 1.65 1.81 
 
 127.53 151.23 
 
 Dr. Reid Clanny's analyses. 
 
 Sailor in Health. Cholerique. 
 
 Water 756 644 
 
 Albumen 121 31 
 
 Coloring matter 59 253 
 
 FreeCarbon 32 66 
 
 Fibrine 18 6 
 
 Salts ..' 14 00 
 
 1000 1000 
 
37 
 
 on the discoloration of the intestines, because it is so obvious 
 and constant an appearance, and so liable to lead a superfi- 
 cial observer into error. Were it not my wish to avoid 
 as much as possible speculation, I would trace some interest- 
 ing analogies between the small circumscribed petechias of 
 typhus petechialis and the diffused lividity of cholera, and 
 explain what I conceive to be the cause of this difference. 
 
 I could easily have been much more minute on the subject 
 of post mortem appearances, and had I designed to give 
 a complete account of them, I must have necessarily 
 been so. 
 
 Before describing the treatment of cholera, I shall make a 
 few remarks on 
 
 CHOLERINE. 
 
 From the slightest perceptible epidemic influence to the 
 severest forms of cholera, there is every shade of intensity. 
 It is consequently very difficult if not impossible, to draw 
 accurately a line of demarcation. In general, when one or 
 more of the essential symptoms of a fully developed case of 
 cholera, such as vomiting, purging or cramps are wanting, or 
 exist only in a very slight degree, the disease is termed 
 a cholerine. Even in the absence of one of these symp- 
 toms, should the others be exquisitely marked, and espe- 
 cially if accompanied with considerable prostration, the 
 disease is a decided cholera. When the peculiar decom- 
 position of the features, the discoloration of the extremities, 
 great refrigeration, or suspension of the urinary secretion 
 is present in a case, it may be confidently pronounced 
 cholera. In a cholerine however mild, the experienced eye 
 detects in a slight degree, the epidemic impress on the 
 features. 
 
 The stage of formation of cholera, such as has been 
 
38 
 
 described, is properly a cholerine, ready indeed to be con- 
 verted into cholera by any accidental exciting causes. 
 Sometimes a cholerine is ushered in suddenly, or with 
 a slight explosion, similarly to cholera ; at other times the 
 symptoms develop themselves gradually and successively, 
 augmenting in severity till they are checked by remediate 
 means, or terminate in an explosion of cholera. 
 
 A brisk watery diarrhoea without tenesmus, accompanied 
 with coldness of the feet and numbness or cramps of 
 the extremities ; a sudden sense of weakness with nausea 
 succeeded perhaps by vomiting ; nausea or vomiting with 
 pains in the calves of the legs ; coldness, colicky pains with 
 cramps : any of the foregoing combinations of symptoms 
 always attended with depression more or less considerable of 
 the physical and mental forces, are prominent features in 
 common forms of cholerine. To describe every form, would 
 require the detail of almost every possible combination of the 
 symptoms of cholera, taken several at a time, and of various 
 degrees of intensity. 
 
 After all, cholerine is either the predisposing state of 
 cholera, or it is the same disease in a milder degree, pro- 
 duced by the same epidemic influence, exhibiting the same 
 general characters, liable to put on its most aggravated 
 form, and requiring in general a very similar treatment. I 
 have given it a brief separate consideration, partly in com- 
 pliance with a very general custom, and partly because it is 
 a useful distinction in reference to treatment, and in com- 
 paring the statistical results of different methods of treat- 
 ment. Instead of employing more time in describing it I 
 will subjoin some cases. (See Appendix of Cases.) 
 
39 
 
 TREATMENT OF CHOLERA. 
 
 Surrounded with treatises whose authors vaunt their suc- 
 cess in combating this terrible scourge of our race ; in 
 fearful anticipation of encountering it, imbued with what 
 has been written, and decided on the treatment which he 
 will pursue, the practitioner hears that the cholera has 
 appeared in his neighborhood. Perhaps he is anxious 
 to grapple with it, an opportunity is soon forced on him. 
 His patients die in despite of his remedies, it may seem 
 to him, before they have time to produce any effect. He has 
 recourse to other means, and in the circle of change and 
 experiment, to some vaunted specific medicine or method. 
 These, so far from being crowned with success, may seem to 
 hasten the fatal termination. Nearly every individual dies, 
 or if here and there a single one escape, his recovery cannot 
 be attributed to any means which may be confidently 
 employed in the generality of cases. The practitioner is in 
 a state of most painful indecision, yet something must be 
 done. Perhaps he concludes that the first blow is mortal, 
 and that nothing of much use can be done. At least, he is 
 learning one truth, which is confessed by all practitioners in 
 cholera of good faith, on whom experience is not thrown 
 away, viz. that at the commencement of the epidemic, very 
 few of those in whom the disease is fully developed, recover 
 by any means yet known. 
 
 Though I bring forward no specific, and profess to know 
 no means which will not leave many to perish, in whom 
 there is a complete development of cholera, yet I hope 
 I have so improved my great and painful opportunities for 
 observation, as to be useful to my countrymen, should this 
 disease unfortunately appear among us,* by insisting on 
 
 * See preface. 
 
40 
 
 a recourse to medical aid in the stage of formation when 
 this stage exists, by pointing out the means which I have 
 found useless or prejudicial ; and by describing the remedies 
 and treatment, which, though they leave much to be desired, 
 are nevertheless followed by more favorable results than any 
 other which I have known and seen employed. 
 
 In the treatment of this disease, many medicines have 
 been extolled as specifics, and by men apparently of good 
 faith and respectable capacity. Yet one of the first facts 
 which we learn by observation, is that the same remedies 
 are not adapted to all cases, and that remediate agents of 
 an opposite nature are required in the different stages of 
 the same case. The best treatment of cholera, I adven- 
 ture to say after extensive observation, is to fulfil the obvious 
 indications by common medicinal means. I may go farther 
 and add, that looking at symptoms in connection with their 
 causes, as far as we are acquainted with the latter, the soundest 
 treatment consists in obviating these symptoms as they rise. 
 
 A large proportion of the cases in which the disease 
 exists in its severe form, are necessarily fatal, whatever 
 treatment be pursued. And many such cases occurred 
 during the first period of its epidemic existence, since then 
 especially, there were explosions without a previous stage 
 of formation. But when the stage of formation exists, 
 as it does in almost all cases since the first few days, 
 I know no severe disease more certainly curable. 
 
 During the prevalence of cholera, no diarrhoea or other 
 considerable derangement of digestion should be neglected, 
 as it may prove a precursor of the cholera in form. I believe 
 the principal reason, why the poorer classes have furnished 
 so disproportionate a number of victims, is to be found in 
 their neglect of premonitory symptoms. 
 
 When the stage of formation exists, it is of the last 
 importance to have immediate recourse to medical aid, 
 to strangle the disease in its birth. If taken at this period, 
 
41 
 
 the cholera is certainly curable, or its explosion is prevented 
 by timeous remedies. In this stage, which frequently con- 
 tinues for days, an hour or half hour is sometimes of the 
 utmost consequence. M. L. professor of chemistry at the 
 garden of plants, had a slight cholerine of some days dura- 
 tion ; while preparing to take some remedy, he was seized 
 with an explosion of cholera, which was shortly fatal. 
 
 Upon the occurrence of any of those symptoms which I 
 have described as constituting the precursory stage, or ren- 
 dering a person very liable to an attack, the patient should 
 confine himself to the house, at least he should avoid con- 
 siderable atmospheric vicissitudes, especially the night air — 
 if they are at all severe, he should resort to the equable tem- 
 perature of a bed; and in all cases, he should be restricted 
 to a moderate regimen, avoiding the least excess in eating 
 or drinking, and any considerable fatigue of mind or body. 
 Slight irregularities of diet, which in common times would 
 be harmless, may produce an explosion of the cholera. In 
 a very great majority of cases, diarrhoea is the precursory 
 symptom, and to this the most careful attention should be 
 given. There is a neglect of this diarrhoea amounting al- 
 most to a delusion, explicable partly by the fact that it is 
 very rarely painful. It should be obviated by remaining in 
 an atmosphere of uniform temperature, by moderate diet 
 and opiate injections. I have not known any ill conse- 
 quences succeed the sudden checking of the diarrhoea, by 
 opium thus administered, as a moderate diet has been en- 
 forced at the same time. 
 
 To remove digestive derangement accompanied with vitiated 
 secretions of the mouth, anorexia, headache, dry skin, (fee. a 
 few grains of ipecacuanha should be administered. If a diar- 
 rhoea accompany the preceding symptoms, it will generally 
 disappear after the operation of the ipecacuanha. There is no 
 danger of the vomiting producing an explosion of cholera. 
 The state of the stomach in vomiting produced by ipecac, 
 
42 
 
 seems to be different from that pathological state which 
 exists in cholera. 
 
 Colics, borborygmies, and nausea, with inconsiderable de- 
 rangement of the secretions, are best relieved by mint water 
 and paregoric with quiet and abstinence. While the epi- 
 demic was at its height, a sensation of numbness in the 
 calves of the legs, more or less severe at times, and occa- 
 sionally amounting to a slight spasm, occurred almost as a 
 solitary symptom in my own person, and in several of my 
 acquaintances. For this, I found in my own case, relief 
 from frictions, but chiefly from walking briskly half an hour. 
 When the patient complains of coldness, depression of the 
 moral and physical forces, and of the other symptoms which 
 I mentioned in describing this stage, he should go to bed and 
 take some warm tea, containing a few drops of paregoric ; 
 and make use, in short, of those means with which every 
 person is acquainted. 
 
 In very many cases, simple repose and a mild diet for 
 twenty-four or forty-eight hours, are sufficient to cause the 
 disappearance of those indispositions and symptoms which 
 are so often the prodromes of the disease — and which there- 
 fore, though slight in themselves and easily removed, are not 
 unimportant in their consequences. 
 
 To arrest the diarrhoeas, which are of so frequent occur- 
 rence during the existence of epidemic cholera, recourse is 
 sometimes had to purgatives. These I am convinced are 
 much less safe and efficacious than opiate injections. If a 
 vitiated state of the secretions demands their use. we should 
 give rhubarb and magnesia in some mint water. Saline 
 cathartics are attended by the danger of exciting the disease 
 they were intended to prevent. 
 
43 
 
 TREATMENT OF THE COLD STAGE. 
 
 If the precursors have been neglected, or if the disease 
 opens by the cold stage, a new set of symptoms is ushered 
 in, infinitely more formidable, and far more difficult to be 
 successfully combated. 
 
 On approaching the bedside of a patient, cold as marble, 
 and pulseless, with universal and extreme prostration, ago- 
 nized with horrid cramps, the surface of his body shrunk, 
 and deserted as it were by the fluids, to supply the great and 
 incessant drain of vomiting and purging, several indications 
 present themselves to be fulfilled. The most important, 
 indeed the essential indication of this stage, is to restore 
 warmth and action to the surface, in other words, to establish 
 reaction. At the same time, we must obviate those symp- 
 toms which torture and exhaust the patient. To accomplish 
 these ends, the patient should be put in a warm bed ; there 
 should be administered internally a portion consisting of 
 laudanum, mint-water, and sulphuric ether, once every hour, 
 or at longer or shorter intervals, pro re nata. Each dose 
 should usually contain about twelve drops of laudanum. 
 The action of the surface should be excited, and the return 
 of warmth solicited, by frictions made with the hand fre 
 quently, wet with French brandy, laudanum, camphorated 
 spirits, or something similar ; and by the applications, dur- 
 ing the intervals between the frictions, of external warmth, 
 by means of bottles of warm water, small sacks of warm 
 sand, &c. Frictions, repeated from time to time, whether 
 made as just described, or in a manner hereafter to be men- 
 tioned, have appeared to me by far the most efficacious 
 means of restoring warmth and action to the surface. They 
 answer another important indication, viz. the alleviation of 
 the cramps. To the remedies just mentioned, we should 
 
44 
 
 add the use of opiate injections, and repeat them according 
 to the urgency of the case. 
 
 I have often conveyed currents of warm dry air, and of 
 steam, under the bedclothes, by means of a small portable 
 cheminee. But some caution is necessary in its use. The 
 temperature should not be raised above blood heat. When 
 somewhat elevated above this point, it has appeared to 
 smother and extinguish the small remnant of vitality of the 
 surface, which it was intended to cherish and sustain. And 
 the more complete the refrigeration, the greater this danger 
 apparently becomes. In this case the patient is annoyed 
 with a sense of suffocation, and endeavors to throw off the 
 bedclothes ; soon he is covered with a viscid perspiration, 
 sinks into a quiet stupor, and dies in a few hours.* In de- 
 termining the degree of heat to be applied, I believe our best 
 guide, in general, is the sensation of the patient. When the 
 
 * At first, I supposed these sinister consequences to be produced by ex- 
 cessive excitation from the heat. The sense of suffocation experienced by 
 the patient when his body is surrounded by this hot irrespirable air, and 
 the refreshment he feels on exposure to the surrounding atmosphere, at 
 a moment, too, when perhaps he complains of cold, have led me to a dif- 
 ferent opinion. It is a fact, confirmed by numerous experiments and 
 abundant observation, that the skin performs a vicarious function of the 
 lungs. Any one may convince himself of the fact, by recollecting the 
 great refreshment and alleviation of his respiration which he experiences, 
 independently of the coolness, on baring his arms and chest, or the whole 
 of his body, when his respiration is affected, either in a fever, or after con- 
 siderable exertion — or when the atmosphere is very rare, as in hot weather, 
 or suffocating, as during the prevalence of certain winds. Indeed, when- 
 ever the respiration is embarrassed, from any cause whatever, a person 
 seeks relief in exposing the surface of his body to the atmosphere. The 
 physiological experiments on this point are quite conclusive, but I have 
 not time to touch on them. 
 
 Whatever be the true theoretical explanation of this subject, the fact is, 
 that experience soon led us to renounce the practice of surrounding the 
 patient's body with hot dry air, as well as the use of general frictions with 
 oily liniments. 
 
45 
 
 prostration is so considerable that he is regardless on this 
 point, we should use the greatest caution. Such cases, how- 
 ever, are almost always fatal, whatever we do. Still, it is an 
 error leading sometimes to fatal consequences, to suppose 
 that we should apply a degree of heat elevated in proportion 
 to the refrigeration of the patient. 
 
 Nothing is gained by covering the patient with many 
 bedclothes, for there being no disengagement of animal heat, 
 the warmth must be produced and kept up by external 
 means. 
 
 To allay the thirst, which is always very urgent, some 
 beverage is necessary. This may be some tea, slightly aro- 
 matic, as an infusion of camomile, the flowers of the linden 
 tree, orange leaf water, &c. according to the taste of the pa- 
 tient. When the sensation of heat externally is very great, 
 lemonade, ice-cold, or small pieces of ice to be dissolved in 
 the mouth, are very grateful. I forbear to detail a list of 
 teas, tisans, &c. as they are known to all, and may be em- 
 ployed according to the judgment of the physician or taste 
 of the patient, the general indications, however, being always 
 kept in view. In some cases an infusion of serpentaria ; in 
 others carbonated waters would, I should suppose, be va- 
 luable auxiliaries. As the demand for drink is frequent and 
 importunate, and as it tends, when taken in considerable 
 quantities, to keep up the vomiting, it should be given but 
 little at a time. It should be warm or cold, as preferred by 
 the patient. When the desire for cold beverages is strong, 
 warm ones aggravate the vomiting. From ice, melted in 
 the mouth and swallowed, I have seen no very decided 
 effects, except the gratification of the patient's appetite. It 
 very frequently fails to arrest the vomiting. 
 
 The same means that are employed to produce reaction, 
 are also efficacious in checking the vomiting. A composition 
 frequently given for this double purpose, and containing the 
 
46 
 
 articles formerly mentioned, was made according to the fol- 
 lowing formula : 
 
 No. I. fy. Sir. Cort. Aurant. 
 
 Vin. Malaga Opt. 
 
 Aq. Menthee aa |i. 
 
 Aq. Tiliffi Europ. ^i. 
 
 Etheris Sulfurici. 
 
 Tinct. Opii de Rousseau aa 3i. M. 
 
 When a less stimulating one was indicated we used the 
 following effervescing mixture : 
 
 No. II. J£. Aq. distillatse |iv. 
 
 Aq. flor. Aurant. |ss. 
 
 Sir. Gummi Arab. ^iss. 
 
 Sodse Carbonas 3iss. — 3H. M. 
 
 To each table spoonful of this mixture, in a little water, 
 add one teaspoonful of lemon juice. 
 
 These are formulae that have been frequently employed 
 in the wards of 3VL Bricheteau ; and, for the sake of brevity, 
 I shall hereafter, when I have occasion to refer to them in 
 the cases given in the appendix, distinguish them as mixture 
 No. I, and No. II. 
 
 The proportions of some of the articles were occasionally 
 varied to adapt them to the circumstances of the individual 
 case. I am clearly of opinion, that in some cases, there are 
 advantages in selecting the most efficient articles and giving 
 them in a less bulky form. 
 
 To alleviate the cramps I know nothing equal to frictions. 
 After a very extensive use of vesicatories and sinapisms, 
 my opinion of them is not very favorable. They interrupt 
 the employment of frictions, and are far less efficacious than 
 the latter. In the severest cases they do not draw ; when 
 they do, they are painful without controlling the cramps. It 
 is true that frictions require frequently to be repeated, but 
 the relief afforded by them is so great, that the patient often 
 requests them, when his prostration renders him regardless 
 
47 
 
 of almost every thing else. To them as a powerful means 
 of establishing reaction I have adverted above. Frictions 
 made with highly stimulating, oily matters I have not 
 thought, on the whole, equal to those made in k the manner 
 and with the substances above mentioned. I have not seen 
 any greater, nor any narcotic or antispasmodic effects from 
 extract of hyoscyamus employed in frictions. Several trials 
 were made of careful bandaging of the limbs, to control the 
 cramps, but without success. 
 
 To arrest the purging, to complete and sustain the reaction, 
 a task often very difficult and requiring assiduous attention, 
 an injection of laudanum and starch repeated pro re nata, 
 is highly serviceable. Injections with decoctions of vegeta- 
 ble astringents as rathania, have been employed, but they 
 are less efficacious than those of opium. 
 
 A supposed analogy in the state of the cutaneous vessels 
 to those of a person who has been exposed to extreme cold, 
 has led to the employment of frictions with pieces of ice. 
 These were made with great briskness over the whole body ; 
 and operated doubtless in some measure as frictions made 
 with the hand or any other substance. The results of this 
 means appear to me more favorable in some respects, than 
 those of any other I have seen employed, especially in cases 
 where the refrigeration was very great. In these cases no 
 treatment could boast of much success — nevertheless, ice 
 frictions, though a forlorn hope, offer some chances of re- 
 covery. Certain I am, that more than any means with 
 which I am acquainted they seem to husband and augment 
 the small remnant of cutaneous vitality, instead of extin- 
 guishing it as does the injudicious application of heat. I 
 have seen the pulse at the wrist which was previously im- 
 perceptible, develope itself during the ice frictions and for a 
 few minutes afterwards — then disappear, again become per- 
 ceptible on the renewal of these frictions, and after several 
 alternations, the patient ultimately recover. Under their 
 
48 
 
 employment the skin loses its blue tint, and becomes red 
 and warm ; the cramps are temporarily relieved, and there 
 follows a sense of refreshment. There is also another very 
 important fact connected with them, viz : the stage of reac- 
 tion which follows their successful employment, is mild and 
 short. 
 
 Ice frictions are made by one or two persons on each side 
 of the patient, with pieces of ice as large as the fist ; with 
 great briskness over the whole surface, particularly of the 
 extremities, and continued from five to ten minutes. The 
 time should be determined by the fatigue of the patient and 
 the effect on the general and cutaneous circulation. The 
 patient should be immediately wiped dry and placed between 
 woollen blankets. They should be repeated about once an 
 hour, till reaction is established. In the intervals between 
 their employment, bottles of warm water may be applied 
 externally. The internal remedies before mentioned, should 
 be administered at the same time. 
 
 Cold affusions I have seen employed, but have not watched 
 their effects with sufficient attention to describe them accu- 
 rately. The results were not such as to induce the continued 
 use of them. 
 
 The great number of patients received daily into the hos- 
 pital, rendered the general employment of warm baths 
 impracticable. The effects of the introduction of steam 
 under the bedclothes, and the results of a very few trials, 
 did not lead us to anticipate any extraordinary success from 
 them. I can readily believe however, that in some cases, 
 they would be found very efficacious. 
 
 By means of the arm bath, rubbing the arm, and agi- 
 tating the body of the patient, we have succeeded in many 
 cases in obtaining several ounces of blood in this stage. For 
 though the blood will not flow from the circulatory powers, 
 yet having lost in agreat degree its coagulability, it is pressed 
 out mechanically without much difficulty. From a theo- 
 
49 
 
 retical conjecture that the organs of life were obstructed in 
 their play by the blood dammed up in the large vessels, and 
 from the great fatality of the disease under other treatment, 
 this experiment of venesection was continued longer than 
 any apparent success would otherwise have justified. Of a 
 great many patients who were bled while cold and pulseless 
 or nearly so, I have not seen one, in whom this operation 
 was followed by any advantage. Indeed I know not what 
 advantage could be rationally anticipated from abstracting a 
 few ounces of blood from a mass unfitted in a good degree 
 for the purposes of life, and when drawn presenting appeal 
 ances and possessing qualities, unlike or quite the reverse of 
 those of the sizy blood drawn in inflammatory diseases. At 
 the moment of explosion or very soon after, when the violent 
 derangement of the circulation and flight of the blood from 
 the surface are commencing, while radial pulsation is still 
 pretty strong, and before refrigeration has taken place, vene- 
 section as a perturbator of the perturbed action, if I may so 
 speak, may be of considerable service, as I have seen in 
 several cases. In these cases, the pulse was full, and in 
 general neither hard nor frequent ; though each pulsation 
 was made with a kind of hurried excitement. 
 
 An attendant was attacked in the hospital with vomiting, 
 purging, cramps in the calves of his legs, and a sensation of 
 immense weight upon the praxordia, simultaneously. His 
 pulse was full, not frequent, rather agitated. Coldness 
 of the extremities commencing ; surface of the body other- 
 wise warm. He was immediately bled twelve ounces ; 
 fifteen leeches were applied to the epigastrium, which were 
 followed by the alleviation of the weight on the prsecordia. 
 The internal remedies already mentioned were given, 
 frictions and warmth were applied externally. Refrigeration 
 in this way was prevented ; the action of the heart and 
 arteries sustained, and the particular symptoms obviated. 
 
 7 
 
50 
 
 The patient was subsequently bled a second time twelve 
 ounces, and recovered without any adverse symptom. 
 
 When, however, the circulation is noticeably more feeble 
 than in health, or refrigeration prevails to any great extent, 
 as happens in all cases shortly after the attack, if they 
 are neglected, venesection is prejudicial. 
 
 Sinapisms and blisters, which have been considerably 
 employed in this stage, I have found of but little efficacy in 
 controlling the cramps. — As external excitants to prevent re- 
 frigeration, and subsequently when the system is making fee- 
 ble efforts at reaction, sinapisms applied so as not to interfere 
 with the use of frictions, and only long enough to redden the 
 skin, are of service. A sense of oppression and weight about 
 the praxordia is mitigated by stimulating poultices, made of 
 linseed and mustard, powdered and moistened with aq. 
 ammonise. 
 
 Excitation along the spine I have produced in various 
 ways and in different degrees without any benefit. 
 
 Galvanism I have seen employed at first with the 
 appearance of some benefit, but its use was soon renounced. 
 
 Ipecacuanha, while the coldness and prostration are 
 great, the vomiting urgent, and before any attempt of the 
 system is made at reaction, is rejected in the course of 
 the vomiting without any perceptible effect. The precious 
 moments immediately succeeding the explosion, I should be 
 very unwilling to waste in the tardy operation of ipeca- 
 cuanha. When reaction is imperfectly developed, and the 
 patient is passing from one to the other, or struggling 
 between the two stages, a dose of ipecacuanha opportunely 
 administered arouses the powers of the system as it would 
 seem by concussion, and enables the patient to clear the 
 limits of the cold stage, and enter those of reaction. 
 
 Punch so highly commended by M. Majendie, I have not 
 seen employed, as all the advantages that could be expected 
 
51 
 
 from this kind of remedy, we obtained with the mixture 
 before mentioned and good Malaga wine. 
 
 Charcoal was administered in several cases, but with 
 effects so unimportant as not to lead us to persevere in its use. 
 
 Individual recoveries are pompously announced of persons 
 who have breathed some of the gases, as oxygen, and 
 nitrous oxyde go,ses. But the success of their patrons 
 has not yet been so great as to lead to their employment by 
 practitioners, who, though extremely anxious to discover 
 a method of curing the cholera, are not pledged to patronize 
 any exclusive treatment. 
 
 I have not yet seen saline injections into the veins 
 employed. It appears from the result of some experiments 
 made in Paris, as well as statements received from London, 
 that the shout of victory has been prematurely raised. Nor 
 do I perceive the necessity of this method of medication, 
 since absorption, though less active in the cold stage than in 
 health, is still performed. 
 
 Camphor, cajeput oil, and the host of specifics, I will 
 dispatch with remarking the fact, that they have not 
 sustained a use of forty-eight hours, in the hands of those 
 who profit by experience. 
 
 In summing up the treatment of the cold stage, we 
 find that the leading indication is to establish reaction, that, 
 as this takes place, the vomiting, purging and cramps 
 are gradually diminished or entirely subside ; that these 
 ends are effected, not by any single medicine, or exclusive 
 method of treatment, but by common remediate means, 
 selected and employed according to the intensity of the 
 symptoms, and adapted to the circumstances of each case 
 individually considered. 
 
 The leading points of treatment, I will adventure to 
 repeat, in order to present them under a single coup oVceil. 
 
 The patient on being taken should be immediately put to 
 bed, warm applications made externally, frictions frequently 
 
52 
 
 and briskly made, twelve or fifteen drops of laudanum, 
 with some oil or water of mint, administered in some warm 
 brandy or generous wine, and repeated pro re nata ; 
 injections containing from twenty to sixty drops of laudanum 
 should also be administered and repeated if necessary ; 
 as a beverage, some mild aromatic tea, in small quantities, 
 and warm or cold to suit the taste of the patients. If 
 unfortunately the patient has become quite cold, caution is 
 required in the application of heat, or this may be replaced 
 by ice frictions. If the patient is seen immediately after the 
 invasion, and the pulse be full, pretty strong, and somewhat 
 excited, as I have seen it in a small number of cases, he 
 should be bled. When by these means varied according to 
 circumstances, the pulse becomes perceptible or fuller, the 
 surface gradually warm and losing its discoloration, and the 
 other symptoms are diminishing or disappearing ; our reme- 
 dies should be modified, gradually diminished or withdrawn. 
 
 The difficult point in the treatment of cholera is the pro- 
 ducing of a complete and free reaction. When this is fully 
 developed, though the state of the patient is attended with 
 danger of life, and requires a very careful and timeous ad- 
 ministration of remedies, we may in general pronounce him 
 recoverable. 
 
 When the treatment which I have detailed is put vigor- 
 ously into execution, at the commencement of this stage, 
 before the patient becomes cold and the circulation greatly 
 enfeebled, we may anticipate a favorable issue of a large 
 proportion of cases. But when the refrigeration is complete, 
 and that assemblage of symptoms exists, which I have at- 
 tempted faintly but faithfully to describe, I am most fully 
 persuaded, that human means are inadequate to the restora- 
 tion of many of the patients. Many hours even, before 
 they are moribund, there does not remain sufficient vitality 
 to produce reaction ; or, if this is forced for a few minutes, 
 the common play of the functions soon exhausts the small 
 share of excitability that is left. 
 
53 
 
 I have insisted from time to time in the course of my 
 remarks on the great, and to a considerable extent, unavoid- 
 able mortality of cholera, because it is a. fact, and my object 
 is to relate facts ; because authors in vaunting remedies and 
 methods of treatment, lead us to anticipate results, which it 
 is certain they themselves never obtained ; and, because I 
 wish as much as in me lies to urge the necessity of employ- 
 ing remedies, the moment any choleric symptom shall pre- 
 sent itself, during the prevalence of this epidemic. 
 
 TREATMENT OF THE STAGE OF REACTION. 
 
 In the treatment to be pursued during reaction, it is ne- 
 cessary to bear in mind the different forms or degrees of 
 reaction into which I divided this stage when speaking of 
 its symptomatology. As it is being developed, we should 
 diminish or discontinue the remedies employed in the second 
 stage, carefully watching its progress, doing nothing while 
 it appears to proceed and be sustained by the powers of the 
 system, cautiously aiding these powers if they are insuffi- 
 cient, and ready to interpose if it becomes excessive. In 
 this manner by judiciously refraining from injurious inter- 
 ference, or by delicately directing nature in her operations, 
 the skilful practitioner conducts his patient to a favorable 
 termination of the disease ; while the meddlesome charlatan 
 hurries on his to a catastrophe, under the delusion that severe 
 diseases require at all times heroic remedies. 
 
 Not unfrequently when judiciously managed, the reaction 
 continues to augment to the balance of health and then to 
 cease ; leaving the patient feeble but with no adverse symp- 
 tom, in the manner heretofore described. In this case, he 
 should remain a few days in bed, very slowly and gradually 
 
54 
 
 returning to his usual diet. For three or four days he should 
 take in moderate quantities, light animal broths. He should 
 carefully avoid any exposure, or any fatigue of mind or body. 
 The great liability to a relapse renders these precautions 
 very necessary. Even slight irregularity or excess in diet 
 endangers a relapse. 
 
 In some cases, as I have before mentioned, the powers 
 of the system are so prostrated or oppressed, that reaction 
 is imperfectly developed ; the surface is not completely 
 warmed, especially the feet ; the vomitings, though much 
 abated in frequency and severity, occur from time to time, 
 and generally consist of a bright green, or of bilious matter ; 
 the cramps have not entirely disappeared ; there is more or 
 less mental torpor ; the system seems struggling under a 
 load too great for its energies. This state of imperfect reac- 
 tion is, in short, a continuation, in many of its symptoms, of 
 the preceding cold stage, and it requires the same treatment, 
 modified according to the urgency of the existing symptoms. 
 
 In this state, particularly where there is much precordial 
 oppression, ipecacuanha is highly serviceable ; it produces 
 a general salutary shock and excitation, frees the large ves- 
 sels of the blood dammed up in them, and increases capillary 
 and cutaneous action. After its operation the vomiting is 
 diminished or entirely ceases. To sustain the good effects 
 of the ipecacuanha, and to allay the vomiting where it still 
 persists, we should employ something similar to the mixture 
 ture No. II. page 46. When a more stimulating one is 
 thought necessary, we may substitute in its place No. I. of 
 the same page. For tenderness of the epigastrium, which 
 is a pretty frequent symptom in this state, we may ap- 
 ply leeches or blisters. This tenderness of the epigastrium 
 should not prevent us from employing the mild stimulating 
 treatment demanded by the condition of the patient in other 
 respects. As excitants, or as derivatives, when there is much 
 
55 
 
 mental torpor, or tenderness of the epigastrium, blisters are 
 very serviceable. They should be applied to the insides of 
 the legs, and when intended for excitants, removed before 
 vesication has taken place. After what I have said on the 
 treatment of particular symptoms in the preceding stage, I 
 do not conceive it necessary to dwell on this point at the 
 present time. As the patient approaches convalescence,, 
 or the development of a more perfect reaction, he should be 
 treated in the careful manner before described. 
 
 When the reaction is full and complete, we have often 
 only to moderate its force by diluent drinks, and leave the 
 patients, for the most part, to the efforts of nature. In other 
 cases, grave local affections, or general states of the system, 
 are to be obviated. The danger most to be feared is the 
 supervention of a cerebral affection, one, two, three, or four 
 days after the development of free though moderate reac- 
 tion, manifested at first by drowsiness, redness of the face, 
 and injection of the conjunctiva. The pulse is generally 
 pretty full, though neither hard nor frequent. It is often 
 accompanied by several severe typhoid symptoms. What 
 constituted the most difficult feature in the treatment of this 
 cerebral affection, was its obstinate recurrence, after having 
 been several times obviated. Patients could not sustain the 
 repeated loss of blood necessary when venesection was relied 
 on to remove it. Consequently it was usually fatal in the 
 early period of the epidemic. We afterwards used a remedy, 
 the results of which have been more flattering than any 
 other I have known employed against any symptom what- 
 ever of cholera. This was a bladder of ice applied to the 
 head. It was refreshing to the patient, admitted of fre- 
 quent reapplication without exhausting his strength, and 
 was effectual to the removing of the affection. The fre- 
 quent and obstinate return of this affection, in whatever 
 way it might have been combated, rendered the ice an 
 
56 
 
 invaluable remedy. Six or eight leeches were generally 
 applied behind each ear, and appeared to be valuable coadju- 
 tors-. We have frequently practised general bleeding against 
 affections of the head and stomach, in this state, with appa- 
 rent temporary advantage, certainly without marked injury ; 
 nevertheless, my observation has not led me to be very pro- 
 digal of blood in cholera. In some few cases, there is a frank 
 and decided inflammatory state of the system, with a full, 
 strong pulse, rendering venesection necessary. Derivative 
 blisters to the calves of the legs seemed also beneficial. They 
 were accompanied with few inconveniences, for I saw no 
 tendency to gangrene in any stage of the disease. But it 
 was the ice to which the patient attributed his relief. Under 
 its influence the stupor declined, and, at the same time, 
 the dryness of the mouth, the heat of the surface, and the 
 sordes on the teeth autd lips, when it existed, disappeared 
 also. The ice, contained in a bladder, was applied to the 
 fore and upper part of the head. When its use for a longer 
 period than two hours of the twenty-four was judged neces- 
 sary, an interval of two hours was permitted to elapse be- 
 tween the successive applications. 
 
 The tenderness of the epigastrium, which was of frequent 
 occurrence, easily yielded to the application of a few leeches, 
 and the quiet and abstinence which the patient observed. 
 In some few cases, however, venesection was judged neces- 
 sary. 
 
 Towards the favorable termination of this stage, there 
 occasionally appeared a slight cough, rarely so severe as to 
 require more than the usual mild regimen, with some diluent 
 and mucilaginous drinks. 
 
 As a beverage in this stage we may give gum water, 
 lemonade or carbonated water — or something that shall fulfil 
 at the same time some indication that may exist. If the heat 
 of the patient is great, the lemonade, &c. may be ice cold. 
 A return of the purging which was not unfrequent, I some- 
 
5? 
 
 times suspected to be occasioned by considerable quantities 
 of cold lemonade taken into the stomach ; but of this I am 
 not sure. The purging when it recurs, should be immedi- 
 ately arrested by laudanum injections ; for it does not relieve 
 the local congestions or inflammations if any happen to 
 exist, but endangers a return of the state of collapse. 
 
 The suppression of urine, which often continues for some 
 days after the full development of reaction, not giving the 
 patient any uneasiness, nor being in any way an urgent 
 symptom ; and its return though of very favorable au- 
 gury, rarely producing any marked crisis, was seldom 
 attempted to be obviated by any means specially directed to 
 this object. In one case, where the urine had been sup- 
 pressed many days, it speedily reappeared on the use of 
 nitric ether. In several other cases I have thought that this 
 remedy hastened its reappearance. 
 
 Typhoid symptoms, such as sordes of the lips and teeth ; 
 dry, red tongue, covered with a harsh dark fur, <fcc. with 
 some confusion and slight wandering of the ideas which 
 not unfrequently accompanied cerebral affections, yielded in 
 general to the means put in use against the latter, and to 
 the treatment adapted to the general state of the system. 
 Camphorated emulsions and beverages containing nitric 
 ether frequently formed a part of this treatment. 
 
 Camphor administered in emulsion and by injection, pow- 
 erfully aided in the prompt removal of a severe nervous deli- 
 rium. At the same time, ice to the head and leeches to the 
 mastoid processes were employed. 
 
 Calomel and opium combined, I have not known em- 
 ployed, though I think they might be a valuable addition to 
 our therapeutic resources in this stage. There exists in 
 France a prejudice against the use of calomel, which 
 deprives its citizens, in some diseases, of one of the most 
 efficient agents of the materia medica. Preparations of mer- 
 cury were tried in the cold stage, for a short time ; but its 
 
 8 
 
58 
 
 inemcacy, owing perhaps to the rapidity of the disease, and 
 the fact that persons mercurialized for certain disorders were 
 not exampted from attacks of cholera, soon led to its aban- 
 donment. 
 
 CONVALESCENCE. 
 
 After what I have said incidentally in the course of my 
 observations on the importance, of returning slowly and 
 gradually to the use of solid food, after an attack of cholera ; 
 of avoiding exposure and fatigue ; of the liability to relapse, 
 &c. I will despatch the subject of convalescence in a very few 
 words. Sometimes the reestablishment in health is prompt 
 and complete ; at others, very protracted and interrupted with 
 chronic inflammations and local congestions, keeping the 
 patient in a state of debility, and sometimes terminating 
 fatally. There are at the present time in the hospitals pa- 
 tients who have been free from choleric symptoms for two or 
 three months. These protracted convalescences should be 
 guarded against, by husbanding as much as possible the 
 resources of the patient during the previous treatment. I 
 do not know that the consecutive affections of cholera, to 
 which I have just adverted, require, as such, any peculiar 
 management, I shall therefore dismiss this subject. 
 
 The principles which should guide us in the treatment of 
 cholera, being entirely applicable to cholerine, with only such 
 modifications as may be demanded by the mildness or ab- 
 sence of particular symptoms, I conceive it unnecessary to 
 make any repetition under the head of treatment of the 
 latter affection. 
 
59 
 
 I might easily have been more minute on the subject of 
 treatment, but my object has been to lay down some princi- 
 ples, not to make a nourish of learned formulae. 
 
 Predisposing Causes of Cholera. I have little to add 
 under this head to the remarks I have already made, chiefly 
 in describing the precursory stage. The predisposing causes 
 are whatever diminishes the tone of the system, as fear, 
 excessive fatigue, sexual indulgence, &c. — especially diges- 
 tive derangements, drunkenness, and excess in eating. 
 Exposure to the night air, after a drunken debauch, is very- 
 sure to produce an attack of cholera during its epidemic 
 prevalence. A great increase in the number of cases was 
 quite noticeable after Sundays and other holidays. The 
 best course to be pursued during the prevalence of cholera, 
 is doubtless to use a plain, good, substantial diet, drink- 
 ing water or wine, and in other respects conforming to the 
 previous habits of living, unless they have been irregular 
 or too free. To avoid any excess in eating is of far more 
 importance than the choice of this or that sort of food. Any 
 great changes, as from a diet chiefly vegetable to one con- 
 sisting mostly of meat, and vice versa, is not advisable. 
 
 Persons of all ages are attacked, from two months and 
 upwards. There was one recovery at Necker Hospital of a 
 woman aged eighty-four years. Children under the age of 
 puberty, are most exempt. Persons who have arrived at, or 
 passed the middle period of life, I think are most liable to 
 an attack. Persons laboring under pulmonary affections 
 appear to be less liable than others, though I have found 
 softened tubercles in some cholerics. The insane and the mer- 
 curialized do not enjoy any peculiar exemption from cholera. 
 
 Diagnosis. On this point I think it sufficient to refer to 
 the symptoms and appearances which I have described as 
 characteristic of the cold stage. These are so marked that 
 
60 
 
 I think it almost impossible to commit a mistake on this 
 
 subject. 
 
 Prognosis. When the characteristic symptoms of the 
 cold stage are all present in a considerable degree, the prog- 
 nosis is very unfavorable. Of the intensity of the disease, 
 perhaps the refrigeration, as a single symptom, is the best 
 index. Recoveries are very rare of cases in which the respi- 
 ration is perfectly cold. Copious perspirations in the cold 
 stage are fatal. Ecchymoses forming under the conjunctiva 
 betoken great danger, but are not always a fatal sign. The 
 very few cases in which I saw delirium in the cold stage 
 were all fatal. Complete stupor and total deafness are always 
 fatal. Of the evacuations, the brick- colored, and after them 
 those of a fish odor, were of the most unfavorable omen, and 
 very generally fatal ; the green stools denoted great danger, 
 but less than those of either of the previous characters. Bile 
 appearing in the matters purged or vomited was a favorable 
 sign. The return of warmth to the surface, without a copi- 
 ous clammy perspiration, the diminution of its discoloration, 
 and of the decomposition of the features, justify an increase 
 of the hope for a favorable issue. When the resources of art 
 are at hand at the moment of explosion, we may generally 
 anticipate a termination in health. Advanced age, or dilapi- 
 dated constitution, renders the prognosis very unfavorable. 
 Between the age of puberty and twenty years, the prognosis 
 is generally favorable. I am unable to decide whether it 
 is more favorable in proportion as the patient is younger, 
 for children were not received at Necker Hospital. Certain 
 it is, however, that youth and a good constitution were 
 very favorable to a fortunate prognosis. The return of 
 the urinary secretion (which occurs only after reaction is 
 established) is of very favorable omen : also a breathing per- 
 spiration, w T ith a return of the healthful secretions of the 
 mouth. Swelling of the glands is very rare, so much so, 
 
61 
 
 that I am unable to form any prognosis therefrom. I have 
 seen epistaxis in only three ; it was slight ; they all recovered. 
 Pregnancy was unfavorable. Four pregnant women were 
 received at Necker Hospital. They all aborted, three died, 
 one recovered. Of five who gave suck, three recovered and 
 two died. But it is useless to dwell on this subject, as our 
 prognosis must be formed from the ensemble of symptoms, 
 and not from single ones separately viewed. 
 
 Contagion. The cholera is not contagious. I had in- 
 tended to consider this question, or fact, — for I conceive it 
 now put beyond controversy — at great length, but it would 
 occupy more space than I am willing to allot to the whole 
 of my pamphlet. My opportunities for observation have been 
 great, and I have had the contagiousness of the disease at 
 all times in view. I have collected a mass of facts, many of 
 which fell under my own observation, others were com- 
 municated to me by my friends : not one of them goes to 
 establish the contagiousness of cholera. 
 
 As this subject requires for its full elucidation minute and 
 tedious details of facts and circumstances, and as the few for 
 which I have room at present would, from their small num- 
 ber, be insufficient to decide so important a point, I reserve the 
 whole, to be presented in a digested form, if it should here- 
 after appear to me worth while. I will, however, mention a 
 very few facts of a general nature, bearing on this subject. 
 Immediately on rising from my bed, to which I had been 
 confined a few days by some severe choleric symptoms, occa- 
 sioned by a change of diet, I resumed my duties in the hos- 
 pital. For weeks in succession I spent a considerable part of 
 the twenty-four hours in the choleric wards, examining the 
 patients, performing very frequently the offices of a common 
 attendant, inhaling the breath of the sick and dying. I passed 
 some hours every day in the dead room, making post mortem 
 examinations, breathing the exhalations from the dead bodies. 
 
62 
 
 I wounded myself, by running spicula of bones into two of my 
 fingers ; and notwithstanding the great liability to relapse, I 
 enjoyed good health. The Sisters of Charity at Necker Hos- 
 pital, who remained for months in succession, nearly all the 
 time, not devoted to sleep, in attendance on the cholera 
 patients, I believe all escaped any severe choleric symptoms. 
 The hospital is situated in one of the streets ravaged with the 
 greatest fury. Almost all the medical men of Paris agree in 
 the opinion that cholera is not contagious : this unanimity 
 is of more weight, when we consider that this is almost the 
 only question pertaining to cholera on which they accord. 
 The surgeons and physicians of Hotel Dieu, of St. Louis, of 
 la Pitie, and some other hospitals, have declared this opinion 
 in the public journals. The disease appeared in Paris, first 
 in a part of the city least in communication with strangers, 
 and before the disease existed in any other part of the 
 kingdom. The French physicians sent to Poland are of 
 opinion that it is not contagious. At Greville-street hospital, 
 in London, which is exclusively appropriated to choleriques, 
 and situated near the middle of the city, I was told that not 
 an individual employed in the hospital, or in any way con- 
 nected with it, had been attacked. 
 
 In the absence of known causes, I have adopted the belief 
 that cholera is produced by some general, constitutional state 
 of the atmosphere in those districts where it prevails. It is 
 true that eudiometrical experiments throw no light on this 
 point ; but this fact militates as strongly against the ex- 
 istence of miasmata in general. No eudiometrical changes 
 are discoverable in the air of wards crowded with choleriques. 
 
 Nothing can be expected from quarantine regulations, for 
 as if in mockery of them, the cholera leaps over the 
 sanatory cordons enforced by an European police. 
 
 It would be curious to trace several striking analogies, 
 with some dissimilarities, between the spasmodic cholera 
 
63 
 
 of the old world, and the spotted fever of our eastern states, 
 or the "cold plague in the bowels" of our southern states. 
 Some cases of adynamic fever, which Drs. Latham and 
 Burrows were kind enough to show me in their wards 
 at St. Bartholomew's Hospital, presented the same symp- 
 toms as I have seen in some cases of spotted fever in 
 the eastern states of our own country. So complete is 
 the resemblance, that I feel confident that the disease I 
 saw in London is identical with that which has prevailed 
 epidemically on the Connecticut river at different times, as I 
 am informed, since 1805 or 7. These gentlemen told me, 
 that fevers of this type have been of common occurrence 
 at London for several months, i. e. coexisting with epidemic 
 cholera. These facts I think interesting, as they show a 
 somewhat similar epidemic constitution of the air in some 
 parts of our country, and in some of those countries where 
 cholera now prevails. 
 
 I saw a cholerique whose body was covered with small 
 well defined petechiae, extending to his thighs, while these, 
 as well as his arms and legs, presented large patches of 
 diffuse lividity. 
 
 STATISTICS OF CHOLERA. 
 
 All that the most practised skill and enlightened theory 
 could suggest ; all that charlatanism could conjecture, we 
 have seen in Paris employed against the cholera, on a scale 
 as regards numbers, of frightful extent, with results hum- 
 bling the pretensions of the healing art. Doubtless the 
 mortality was increased by this latitude of experiment, which 
 was in part justified by the ill success of the most rational 
 treatment. It was moreover much aggravated at Paris by 
 the necessities of the times and circumstances. Cholera 
 is too rapid in its progress: the different stages, requiring 
 a variation in the treatment, succeeded each other too quickly 
 
64 
 
 for the daily visits of hospital practice. It is to be observed 
 also, that the mortality was doubtless much greater in the 
 hospitals than in private practice. Though the medical 
 men and citizens exhibited a courage and devotion worthy 
 of all praise, the patients suffered much from neglect and 
 confusion. Each patient requires for a time at least one 
 attendant; and this was impossible without so encumbering 
 the wards as to prevent any thing being done. Patients 
 too were brought into the wards sometimes faster than they 
 could be registered. I mention these facts to suggest the 
 propriety of anticipating the like inconveniences, should the 
 disease appear among us. 
 
 As an offset to the facts just presented, I should add, that 
 when taken in its forming stage, or even at the moment 
 of explosion, few diseases are more curable. Delay is 
 death. 
 
 That the cholera should be unusually fatal at Paris, 
 other circumstances being equal, was confidently to have 
 been expected, from the great irritability of the gastro- 
 intestinal mucous membranes of its citizens. This is shown 
 by several facts, among which is one I am convinced of by 
 ample observation, viz. that they do not bear the operation 
 of severe cathartics with the same impunity as the Ame- 
 ricans. 
 
 I regret that it is impossible for me or any other person to 
 furnish accurate statistics of the mortality of cholera, com- 
 pared with the numbers attacked. The official bulletins of 
 cholera will never, I fear, destroy the proverb of " false as a 
 bulletin." From what fell under my observation at London 
 and from what I was informed by medical gentlemen there, 
 I am persuaded that there is even more uncertainty in the 
 English than in the French accounts. 
 
 The chief source of uncertainty in the statistics of cholera 
 is, that in order to swell the proportion of cures, mild 
 cholerines are sometimes included, under the name of 
 
65 
 
 cholera. There are other examples of a direct and extra- 
 ordinary want of good faith.* 
 
 In the following statistical account of the choleriques 
 treated in all the hospitals of Paris, it is important to bear in 
 mind, that there are included all persons who entered the 
 hospitals for any choleric symptoms whatever. 
 
 From the 26th of March to the 30th of April, a period of 
 thirty-six days, there were admitted into the different 
 hospitals of Paris, 10,275 choleriques. Of these, 3065 were 
 cured, 5285 dead, and 1925 under treatment the 30th of 
 April. Little flattering to the efforts of our art, as this 
 statement is, how very much less so would it be, could 
 we subtract from the cures the mild cases of the epidemic 
 influence ! 
 
 If again, we subtract from the number those who die of a 
 relapse, and relapses are very numerous, and those who die 
 of consecutive diseases, where shall we be ? 
 
 The following is the statement for Necker Hospital, from 
 the invasion of the epidemic to the 7th of July. Admitted, 
 479 ; of these, discharged cured 170 ; dead 283 ; under treat- 
 ment, 26. During the rise of the epidemic, that is from the 
 invasion to the 10th of April, there were admitted into 
 Necker Hospital 200 choleriques ; of whom 156 died, and 
 44 were cured. 
 
 Of the first hundred of choleriques admitted into Hotel 
 
 * There is one example so noticeable, that I think the cause of truth 
 and humanity requires it to be particularly mentioned, invidious as this 
 duty is. Nothing but the celebrity of the author, in some respects well 
 merited, and likely to produce an ill founded reliance on the treatment 
 commended by him, could induce me to perform so disagreeable a task. 
 M. Broussais, to sustain his well known doctrines, asserts that he cured 
 during the first period five out of six choleriques, and subsequently thirty- 
 nine out of forty. It has since been shown by the official documents of his 
 hospital, signed by his own hand, that he has been on the whole much less 
 successful than many other practitioners.' 
 
 9 
 
66 
 
 Dieu, it was not pretended that more than four were cured, 
 and it has been shown that three of these four never had 
 the cholera : one cure in 97 cases. From the invasion of 
 the epidemic up to the 10th of April, there were admitted 
 into the same hospital as choleriques, 1365 persons. Of 
 these, 135 were discharged as cured ; 751 were dead ; and 
 479 under treatment on the 10th of April. 
 
 From the invasion to the 30th of April, there were treated 
 at the Hotel des Invalides, 167 choleriques. Of these, there 
 were on the 30th of April, 12 cured ; 135 dead ; and 20 
 under treatment. This is a mortality unexampled in the 
 other hospitals, and is explicable chiefly if not entirely by 
 the fact, that the patients were all dilapidated soldiers. 
 
 The cause of the greater mortality during the first period 
 of the epidemic than subsequently, is to be sought partly in 
 the fact that the disease then raged in its greatest severity, 
 and partly in the fact that cholerines were comparatively 
 rare till a day or two before the epidemic had arrived at its 
 stadium. 
 
 It is also highly important to add that during the first days 
 of the epidemic, there was a great backwardness in remov- 
 ing patients to the hospitals ; so that many when admitted 
 were in a hopeless state, and not a few moribund. And in 
 those cases, where all possible dispatch is used to transport 
 the patient to the hospital the moment he is attacked, so 
 much of that time is unavoidably lost, in which our art 
 offers great resources, and that state approaches from which 
 very few recover ; that I believe the patient will, in general, 
 do better to remain at home and risk what attendance he 
 can get there. In Paris, however, there are thousands who 
 have no home in sickness but the hospitals. 
 
 While thus describing in unmitigated truth the fatality of 
 the cholera at Paris, I have pointed out some causes by 
 which that fatality has been greatly aggravated, and which 
 under other circumstances may be avoided. 
 
CASES. 
 
 Case. — Cholera. — Me. Tabouret, aged 42 years, of middle stature, and 
 generally enjoying good health, has had a diarrhoea for three weeks. Not- 
 withstanding this she considered herself as well, and was employed yes- 
 terday, April 12th, in her trade of sempstress. She supped last night, 
 and went to bed as usual. She awoke this morning, 13th of April, about 
 5 o'clock, with an urgent inclination to have a passage. She was seized 
 with colics while on the pot; at the same moment she perceived the great 
 change of her voice. A short time after there supervened nausea and 
 retchings, with cramps in the feet and calves of the legs. On arriving at 
 the hospital at half-past eight o'clock, she presented the following state : 
 frequent watery discharges from the bowels ; occasional nausea and vo- 
 mitings ; severe cramps ; pulse imperceptible ; suppression of urine since 
 last night; voice feeble, and much changed ; face somewhat cadaverous ; 
 •cold about the mouth, and especially the end of the nose; lips of a violet 
 color; tongue moist, furred with white; hands and feet wrinkled, and of a 
 livid marbled appearance; no head-ache; intellectual faculties sound; 
 pain at the epigastrium, in the right hypochondriac, and in the lumbar 
 regions ; abdomen sunk, and of a doughy feel ; thirst urgent ; she prefers 
 warm drinks to cold; respiration slow, and performed by the costal 
 muscles ; she had a slight chill immediately after her arrival in the hos- 
 pital. Leeches were applied to the epigastrium,- and we succeeded in 
 drawing six or eight ounces of blood from a vein of the arm. The blood 
 was black, and flowed with difficulty ; sinapisms were applied to her feet ; 
 she took a spoonful of the mixture No. I. page 46, from time to time; 
 as a beverage she drank a warm infusion of camomile and linden-tree 
 flowers. 
 
 At twelve o'clock the pulse was perceptible, but extremely feeble ; the 
 surface was more warm, and reaction seemed about taking place. 
 
 At half-past one she suffered atrocious pain in the loins ; pulse was al- 
 most imperceptible. A sinapism was applied to the lumbar region, and 
 the pain abated. 
 
 At six o'clock she was lying on her back, regardless of every thing ; her 
 forehead contracted into a frown ; her eyes a little injected; respiration a 
 little stertorous ; she was soon moribund, and died at 7 p. m. The blood 
 drawn in the morning resembled a dark jelly, and was without any serum. 
 
 Examination of the body fourteen hours after death. The body was 
 warm and rigid, and the surface presented the usual discoloration. Aruch- 
 
68 
 
 noid membrane injected ; substance of the brain firm, and a little injected ; 
 the section of it, when cut, was very smooth ; the ventricles contained about 
 an ounce of serum; lungs sound, except some ancient adhesions ; heart, 
 and first portion of the large blood-vessels, filled with black liquid blood; 
 peritoneum sound and dry; stomach externally rose-colored in patches, 
 contained a large quantity of a greenish liquid ; its mucous membrane 
 was colored in the same manner as the external surface; this was chiefly 
 owing to the injection of the subjacent cellular tissue ; the mucous mem- 
 brane was of the usual thickness and firmness. The external tunic, as 
 well as the mucous membrane of the small intestines, was of a deep rose- 
 color, approaching to that of Spanish brown ; this was chiefly owing to 
 the injection of the subjacent cellular coat, and in a less degree, of the 
 mucous membrane itself; the latter was covered with a thick creamy mu- 
 cus ; the intestine contained a large quantity of a turbid liquid of a deep 
 brick red color ; the discoloration of the intestine became less as we de- 
 scended; at the commencement of the large intestine it was white; the 
 sigmoid flexure was of unusual whiteness. As we descended, the fluid found 
 in the intestines became lighter colored, and of greater consistence ; in the 
 lower part of the small intestines it was grayish ; in the sigmoid flexure 
 it resembled a white thick unboiled starch; the spleen and kidneys were 
 natural ; the liver contained a small quantity of dark blood in its large 
 vessels; the gall bladder contained the usual quantity of a dark colored 
 bile. 
 
 Case. — Cholera. — A robust woman, aged about 50 years, was brought 
 into the ward St. Louis, of Necker hospital, the evening of April 17. She 
 was in a state of profound stupor, from which she could not be roused; on 
 being placed in bed, on her back, she remained motionless in that posture ; 
 she was perfectly deaf and speechless ; face cadaverous ; pupils dilated ; 
 hands and feet cold and livid ; pulse very slow, large, and easily compres- 
 sible; respiration very slow and quiet; she manifested no uneasiness on 
 pressure of the abdomen ; neither cramps, vomiting, nor purging. "We 
 could obtain no information respecting her, except that when first disco- 
 vered she was in the same condition. Bottles of warm water were ap- 
 plied externally, and the ordinary potion given. The next morning her 
 condition was absolutely the same. She was bled at nine o'clock, and 
 died two hours after, that is, about fifteen hours after entering the hospital, 
 without having uttered a single word, or hardly made a single motion. 
 
 Case. — Cholera. — April 19, 1832. Me. Coubard, aged 55 years, lean, 
 of middle stature, and tolerable constitution; was brought into the ward 
 St. Louis, of Necker hospital, at eleven o'clock this morning. She has 
 had a diarrhcEa for about fifteen days. Last night, about ten o'clock, this 
 was suddenly augmented, and accompanied by retching and vomiting. 
 Upon the vomiting and purging, which were renewed from time to time, 
 there supervened about eight o'clock this morning, cramps of the soles of 
 the feet, and subsequently, of the calves of the legs. On entering the 
 hospital she presented the following state : considerable prostration ; pulse 
 
69 
 
 feeble, 90 a minute ; surface of the body cool, rather than cold ; the hands 
 and feet cold and stiff; the skin wrinkled and somewhat marbled ; slight 
 choleric decomposition of the features ; tongue covered with a little white 
 fur; slight deafness and tinnitus of the left ear; cephalalgia confined to the 
 left side of the head; voice weak, and of the choleric shrillness ; epigas- 
 trium slightly sensible on pressure. — She was put in bed, and bottles of 
 warm water placed at her feet and sides ; frictions of the limbs were suc- 
 ceeded by sinapisms ; a spoonful of the compound mixture of laudanum, 
 mint-water and ether, was administered from time to time, pro re nata, as 
 were also opiate injections. She vomited several times during the day ; 
 during the night she drank very little, and the vomiting ceased ; though 
 she had occasional retchings. The cramps ceased in the course of the 
 day. The purging was gradually diminishing, though it still existed the 
 next morning at seven o'clock. 
 
 April 20, seven o'clock a. m. — She has become gradually warm ; she, 
 however, complains of cold feet, and demands a frequent renewal of the 
 warm applications. Her hands are warm, and nearly of their natural ap- 
 pearance. The purging is considerably moderated ; in place of vomit- 
 ing, she has only occasional nausea and retching ; the cramps have ceased. 
 She has not urinated since an early hour yesterday morning. She com- 
 plains of general weakness and prostration, that her head is weak, but 
 not the seat of pain. Pulse small, feeble, and rather frequent ; the natural 
 intonation of her voice is much changed, and shrill; tongue is covered in 
 its centre with a yellowish fur ; epigastrium a little sensible on pressure. — 
 As a beverage from time to time, a decoction of salep with gum-water — 
 the mixture consisting of orange leaf water, syrup of gum arabic; carbo- 
 nate of soda, and lemon juice ; injection, containing ten drops of laudanum. 
 
 April 21, eight o'clock, a. m. — Purging, vomiting, nausea, cramps have 
 entirely disappeared. She has slept two or three hours the last night. 
 Pulse excited, frequent and a little tense. Thirst considerable ; and she 
 drinks freely without its producing nausea. The surface generally is 
 warm, though she still asks for warm applications to her feet. She is a 
 little drowsy ; face flushed, warm, and has lost the choleric appearance ; 
 left eye a little injected; slight pulverulence of the nasal fossae; a pain 
 mounts from the left shoulder and occupies the left half of the head, pro- 
 ducing tinnitus of the ear of that side. She discharges a good deal of flatus 
 by the mouth. Epigastrium no longer sensible. Suspension of urine 
 continues without causing her any inconvenience. She complains of 
 general debility. Decoction of salep with syrup of gum. A potion 
 containing twenty drops of nitric ether. Abstinence. About noon she 
 discharged about half a tumbler of urine. 
 
 April 22. The slight drowsiness of yesterday and the other signs of 
 determination to the head are nearly dissipated. She slept about three 
 hours last night. She continues to urinate pretty freely. The tinnitus 
 and deafness of the left ear persist, with a sensation as if a current of air 
 were blowing through it. The right half of the head is free from pain. 
 There is a sensation of heat in the loins. Thirst considerable j tongue 
 
70 
 
 moist; pulse frequent; no vomiting, purging, or cramps. — Same pre- 
 scription as yesterday. 
 
 April 23. Eight a. m. Considerable discharge from an abscess which 
 formed in the left ear. She slept well ; urinates well ; has had no passage; 
 epigastrium indolent on pressure. The surface has its natural feel ; pulse 
 is good, soft; countenance is good ; general debility considerable. — Edul" 
 corated decoction of salep. Rice soup. 
 
 April 24. Convalescence continues. Discharge from the ear is abun- 
 dant; feet preserve their warmth without external applications. Pulse 
 feeble, in other respects good. General debility. Very little appetite. — Same 
 prescription as yesterday, with a small portion of solid food. 
 
 April 25. Diarrhoea returned yesterday, and after three stools was 
 checked by an opiate injection. Copious discharge from the ear at the 
 same time. She perspired freely in the night ; had occasional refreshing 
 slumbers ; and this morning complains of no pain. — Food, &c. the same 
 as yesterday. 
 
 April. 27. Diarrhoea has returned since yesterday five o'clock p.m. 
 Each passage is preceded by a dull colic, but it is discharged almost with- 
 out sensation. Abdomen indolent on pressure. She was suddenly seized 
 with the diarrhoea without any precursory symptom. The discharge from 
 the ear is not diminished since the return of the diarrhoea. She expectorates 
 a considerable quantity of clear glairy saliva. Her tongue is a little 
 charged in the centre. — Decoction of salep with the syrup of gum. Opiate 
 injections pro re nata. Abstinence. 
 
 From some cause only one injection was given, notwithstanding which 
 the diarrhoea continued about once an hour till midnight, when it ceased 
 without the use of any remedy. 
 
 April 28. No passage since midnight. Abdomen sunk but soft, and 
 not at all painful. No sleep last night. The discharge, deafness and 
 slight tinnitus of the left ear continue, except which she complains only of 
 general debility. — Injection of six drops of laudanum : two soups, de- 
 coction of salep, with the syrup of gum. 
 
 April 29. To-day she has had one passage. — Prescription same as 
 yesterday. 
 
 April 30. Diarrhoea ceased entirely; discharge from ear diminishing; 
 she complains only of feebleness. — Decoction of salep with syrup of gum. 
 Two soups. 
 
 May 1. No alvine discharge since day before yesterday. — Same pre- 
 scription as yesterday, with the addition of a little solid food. 
 
 May 3. Convalescence has resumed its march. The patient suffers 
 only from general debility. 
 
 May 10. Convalescence continues without any very adverse symptom, 
 but proceeds very slowly. The patient complains chiefly of general 
 debility. Some time afterward the patient left the hospital to try the effects 
 of change of air and scenes in restoring her strength. 
 
 I have given this case as an example of protracted convalescence, which 
 we not unfrequently see following an attack of cholera. This state 
 sometimes continues for several months. 
 
71 
 
 Case.-— Cholera. — A woman named Bezar^ aged 50 years, of moderate 
 embonpoint, and pretty good constitution, married, and mother of several 
 children, was brought into the ward St. Louis, about 4 p. m. to-day, 
 April 17. She slept well last night, and was engaged in her usual busi- 
 ness, that of sweeping the streets, this morning, till half-past nine o'clock. 
 Returning home, she felt an uneasy sensation at the stomach, and drank some 
 coffee. Immediately on taking the coffee she was seized with a diarrhoea, 
 at first of common fecal matter, but it soon became very liquid, and is de* 
 scribed by the patient as water. About two o'clock she drank a little 
 wine, which was immediately vomited. She was seized with cramps at 
 the moment of entering the hospital, first in the soles of the feet, and 
 successively in the calves of the legs and thighs. Condition at five 
 p. m. of the same day : features cadaverous and cold ; eyes sunk, and 
 surrounded with a livid circle ; eyelids half closed when she reposes ; 
 nose and prolabia livid and cold ; tongue moist, cold, and a little charged 
 with a whitish fur; feet and hands cold, and livid; she lies on her back, 
 and says she is very weak; no head-ache; somewhat deaf; thirst not 
 very urgent; voice very feeble, and much altered ; abdomen and epigas- 
 trium somewhat sensible; no colic; respiration slow; radial pulsation 
 extremely feeble, almost extinct; urinary secretion suspended; intellec- 
 tual faculties well preserved; she complains of cold, and prefers warm 
 beverages; great prostration; the purging is almost continual, of a 
 whitish watery liquid, which has penetrated a thick bed, and is running in 
 a stream on the floor ; cramps and vomiting are renewed at short intervals. 
 Sinapisms were applied to her lower extremities; she was enveloped in an 
 atmosphere of warm vapor conveyed under the bedclothes. — A table- 
 spoonful of the mixture, No. I, was administered every hour, and she 
 drank of an infusion of camomile. An hour and-a-half after she was co- 
 vered with an abundant cold viscid perspiration. 
 
 April 18. a.m. — Pulse imperceptible; voice nearly extinct; eyes in- 
 jected; ecchymosis under the conjunctiva of the left eye; face cold; pro- 
 labia livid; tongue cold, very moist and soft; pulverulence of the nasal 
 fossae; extremities cold, livid, and wrinkled ; abdomen sensible on con- 
 siderable pressure ; only slight cramp since yesterday evening ; vomiting 
 has ceased; diarrhoea continues. — Continue the mixture, to which add xx 
 drops of aq. ammonise; opiate injection; sinapism moistened with aq. 
 ammon. along the spine. 
 
 At eleven o'clock ecchymoses had formed in both eyes ; she sunk into 
 a stupor, and died quietly the same evening, twenty-four hours after en- 
 tering the hospital, and thirty after the attack. 
 
 Autopsy sixteen hours after death. Body and limbs very rigid and 
 somewhat discolored. Brain not examined. Lungs natural. Heart and 
 aortagorged with black uncoagulated blood. Stomach contained a consider- 
 able quantity of a whey colored troubled fluid; its color externally was of 
 a rosy hue in patches, in other parts natural ; internally the color was the 
 same as externally, depending in part on some injection of the mucous 
 membrane, but chiefly on that of the subjacent cellular tissue. The small 
 intestines externally were red ; on raising their peritoneal covering this 
 
72 
 
 coat was found dry and sound. The small intestines contained a whitish 
 creamy liquid in their upper portion, this changed into a dirty brown, and 
 reddish or brick colored fluid as we descended. Their internal surface was 
 of a deep brick color, and owing to the same causes as that of the stomach. 
 The mucous membrane was neither thickened nor softened. The large 
 intestine was contracted ; the mucous membrane of the ascending colon was 
 of unusual whiteness ; the transverse colon was red and injected similarly 
 to the stomach. Bladder empty and contracted. Liver sound, free from 
 blood. Gall bladder contained the usual quantity of bile, of a color darker 
 than it is commonly found. Other abdominal viscera sound. 
 
 I have related the foregoing as a specimen of the progress of the disease 
 in a great proportion of severe cases, and of the appearances they offered 
 on examination after death. 
 
 Case. — Cholera. — AGermanwoman, aged about thirty years, of arobust 
 constitution, married, bore a child the 29th of January last, which she 
 now suckles. She was attacked with cholera the 9th of April about 
 seven o'clock in the morning. Colics, vomiting and purging followed 
 each other in quick succession. Cramps supervened in the evening. On 
 being brought into the hospital the next day she presented the usual state, 
 viz. persistence of the symptoms just mentioned with prostration, coldness 
 of the extremities, suppression of urine, sensibility of the epigastrium, 
 choleric features, great alteration of the voice, urgent thirst. Reaction 
 however appears to be commencing under the use of frictions, external 
 warmth, the mixture of laudanum, ether, &c. and of opiate injections. 
 
 April 11. Cessation of cramps, vomiting and purging; heat of the 
 surface is returning, though reaction is not yet fully declared. — Lemonade. 
 Ipecacuanha, thirty-six grains in two doses. 
 
 April 12. Reaction is moderate yet completely sustained, and without 
 any adverse symptom. Her breasts which have been neglected heretofore, 
 are now found to be distended with milk. A small puppy on being 
 applied to the nipple sucks the milk with avidity. — Lemonade. 
 
 April 13. Her favorable state continues. The secretion of urine 
 returned to-day. — Lemonade. Vermicelli soup. 
 
 April 14. Decidedly convalescent. The puppy continues to draw the 
 milk from her breasts. — Lemonade and vermicelli soup. 
 
 April 15. Convalescence proceeds rapidly. Her pulse is good ; skin 
 natural; no thirst; voice has nearly recovered its usual sound ; sensibility 
 of the epigastrium has disappeared, though she has had no passage since 
 the 12th. There remains only a want of strength. — Lemonade; soup and 
 a small quantity of solid food. 
 
 April 19. Convalescence has proceeded very rapidly, the quantity 
 of her food has been gradually augmented ; her breasts drawn by the small 
 dog; and she was discharged to-day cured. 
 
 In this case, the characteristic symptoms of cholera were all present, but 
 not in a very aggravated form. The reaction was gradually developed; 
 the choleric symptoms at the same time disappearing, and the suspended 
 functions resuming their play, without the supervention of any new 
 
73 
 
 adverse symptom, and the disease speedily terminated in convalescence. 
 There was, properly speaking, no stage of reaction ; for, that state which 
 I have so styled in this case, was merely the gradual disappearance of the 
 cholei-ic symptoms, and renewal of the play of the functions as in health, 
 without any intervening symptoms. 
 
 Case. — Julie Puin, a domestic, aged 27 years, unmarried, of low sta- 
 ture and robust constitution, has had a diarrhoea, some head-ache, with 
 depression of her physical forces for the preceding four days. She was 
 attacked with a very severe cholerine about eight o'clock this morning, 
 April 14th. She was engaged in her usual labor yesterday, and slept well 
 last night. The invasion of the disease was very sudden, and compared 
 by the patient to a blow. There occurred simultaneously, or in quick suc- 
 cession, prostration, chills, nausea, succeeded by vomiting, very abundant 
 watery stools, without colic or local pain. She has been to the water- 
 closet five times this morning before being brought to the hospital. On 
 arriving at the hospital, two hours after the invasion, the following is her 
 state : — slight refrigeration of the lower extremities ; pulse weak, small, 
 sixty a minute ; respiration a little embarrassed, and slow ; prostration 
 considerable ; mind agitated and depressed ; head-ache ; no pain of the 
 epigastrium ; neither numbness nor cramps ; face nearly natural, there is 
 a slight choleric circle around the eye ; tongue moist, warm, with a whitish 
 fur ; voice tolerably strong ; no thirst; vomiting, purging, and cramps are 
 renewed at intervals. 
 
 She is put in a warm bath ; frictions with the hand are made on the 
 lower extremities ; the mixture composed of ether, laudanum, &c. is ad- 
 ministered ; also an opiate injection. Under this treatment the choleric 
 symptoms soon disappeared. 
 
 April 15. Passed a comfortable night. No adverse symptom remains. 
 Her pulse is good, her skin soft, she urinates freely, and has no thirst. 
 Inf. camomile and orange flower water. 
 
 April 21. She slowly returned to the use of solid food, and left the 
 hospital to-day, cured. 
 
 In this case, the disease yielded promptly to the remedies mentioned 
 above. Had it been neglected, it would doubtless have exhibited in a few 
 hours all the symptoms of aggravated cholera. As there was no suppres- 
 sion of the urinary secretion, no alteration of the voice, no considerable 
 refrigeration nor discoloration of the surface, and the vomiting and cramps 
 were not severe, I have called it a severe cholerine ; it might be properly 
 denominated the stage of invasion of cholera. The voice was scarcely 
 affected: in other cases I have known, the voice suddenly becomes nearly 
 extinct simultaneously with the earliest symptoms noticed. As an ex- 
 ample of the other extreme, or a very mild cholerine, I subjoin the 
 following: — 
 
 Case of Cholerine. — Miss aged 13 years, arose in the morning 
 
 in the full enjoyment of her usual health. An hour afterwards, when de- 
 scending a flight of stairs, she was seized with a sudden sensation of great 
 
 10 
 
74 
 
 weakness, and fell. Nausea, with slight retching, occurred at the same 
 time. She was immediately put in bed — a mixture containing mint water 
 and sulphuric ether was administered, and warmth applied externally. 
 When I saw her an hour after, mild reaction was already taking place. 
 She remained in bed, and observed a mild regimen for two days, and no 
 adverse symptoms followed. 
 
 In this case the epidemic impress was quite manifest, though very slight; 
 and it is merely as an example of a very mild cholerine that I introduce it. 
 
 Case. — April 13. — M. Lefevre, aged 25 years, of small stature, and a dry 
 temperament, was suddenly seized about twelve o'clock last night, with a 
 diarrhoea, at first liquid, but gradually becoming more clear and watery. 
 At the same time there existed pretty severe colics, and shortly afterwards 
 coldness and numbness, with very slight cramps of the feet and legs, cold- 
 ness of the hands, nausea, and slight head-ache. Frictions of the lower 
 extremities were briskly performed ; a spoonful of the mixture containing 
 sulphuric ether, malaga wine, &c. was given him from time to time, also a 
 decoction of poppies by injection; for a beverage he drank an infusion of 
 camomile. 
 
 At ten o'clock to-day the diarrhoea, nausea, and coldness had disappeared; 
 the surface of his body generally, was warm and dry ; his pulse full, strong, 
 and somewhat accelerated ; considerable thirst ; urinates as usual ; coun- 
 tenance and voice nearly natural; says that the mixture excites him ; no 
 tenderness on pressure of the abdomen ; venesection xii ounces. — With- 
 draw the mixture. 
 
 April 14th, 10 a. m. He has slept a little the past night. Except colic, 
 and a little numbness of his legs yesterday evening, and coldness of them 
 this morning, which has since passed away, he has had no choleric symp- 
 toms since he was bled yesterday. — Gum water. Two soups. 
 
 April 15. Has passed a comfortable night; no choleric symptoms. 
 He left the hospital some days after, cured. 
 
 In this case the disease was promptly arrested in the commencement, 
 and subsequently put on a form frankly inflammatory, requiring bleeding. 
 Cases like the present, attended with arterial excitement, are sometimes 
 though rarely met with. It is also to be remarked, that there was at no 
 time any tenderness of the abdomen, though the diarrhoea was suddenly 
 arrested, and the patient in the completest possession of his sensibility. 
 
 Case. — Cholera. — Me. Coquet, aged twenty-six years, of middle stature 
 and good constitution, has been married seven years, has had three children 
 and one miscarriage, viz. of her second pregnancy, and is now four months 
 gone in her fifth pregnancy. 
 
 April 10, 1832. She has endured great fatigue, and slept but little for 
 several days past, in attending her sick daughter. Fatigue excepted, she 
 was in good health yesterday. Yesterday evening she dined on salad and 
 boiled meat. Last night she felt some general indisposition. This morn- 
 ing she took some fat broth without much appetite. Neither headache nor 
 diarrhoea before the invasion. About ten o'clock this morning she was 
 seized with vomiting and purging simultaneously, without colic or tenes- 
 
75 
 
 ttius. Two or three hours afterwards, extremely violent cramps supervened 
 in the feet, calves of the legs, thighs, hands and arms successively. Her 
 limbs are numb, and livid or marbled. She experiences a sensation of 
 coldness, particularly of her extremities. Her features are shrunk, cold, 
 and of a deep livid hue; eyes hollow, sunk in and surrounded with a livid 
 ring; tongue cold, moist, livid and covered with a whitish fur; voice 
 nearly extinct; conversation is fatiguing; pulse imperceptible; urine sup- 
 pressed ; thirst excessive ; abdomen sunk and of a doughy feel ; she lies on 
 her back regardless of what passes about her, except to request persons not 
 to disturb her. — Mixture No.l, a spoonful every four hours. Sinapisms. 
 Warmth externally. Opiate injection. 
 
 April 11. Her state is in general nearly the same as yesterday; her 
 thirst is extreme, and she swallows with equal avidity cold or warm drinks ; 
 prostration very great; purging is less urgent. — Same prescription as yes- 
 terday, with the addition of thirty-six grains of ipecacuanha, to be taken in 
 two doses ; and cold lemonade as a beverage. 
 
 April 12. Symptoms the same, except somewhat abated in violence. 
 The ipecac, appears to have produced no effect. Except the ipecac, con- 
 tinue the same treatment. 
 
 April 13. Pulse perceptible ; very weak ; slight reaction is commencing ; 
 no cramps to-day; drowsiness; eyes somewhat injected; tongue white 
 slight difficulty of respiration. Six leeches behind each ear. Sinapisms to 
 her legs. General treatment same as before, viz. an occasional spoonful 
 of mixture No. 1, page 46. 
 
 April 14. Drowsy; face flushed; eyes injected ; flighty dreams during 
 the night. Reaction is slowly taking place ; surface warm; pulse feeble. 
 Ipecac thirty-six grains at two doses. Blisters to the calves of the legs. 
 Bladder of ice to the head. General treatment same as heretofore. 
 
 April 15. Aborted a dead child. The drowsiness which yielded for a 
 time to the application of ice, has returned in some degree ; her pulse is 
 tolerably strong, and eighty-five a minute ; reaction is freely declared ; she 
 has rendered a considerable quantity of urine this morning, for the first 
 time since the invasion of the disease ; vomited a viscid yellow matter ; 
 tongue red and dry ; thirst though considerable is much less urgent ; purging 
 has nearly disappeared. Tisan of the flowers of the linden tree, with 
 orange flower water. 
 
 April 16. Purging, vomiting and cramps have ceased ; one alvine evacu- 
 ation since yesterday morning; tongue moist, fresh ; pulse good ; surface 
 of the natural temperature; abdomen not painful on pressure; urinates 
 freely ; much less drowsy than yesterday. Treatment same as yesterday, 
 with the addition of an infusion of camomile. 
 
 April 17. Three or four passages since yesterday ; some nausea with- 
 out vomiting; pulse a little excited; slept without being harassed by 
 flighty dreams. General state favorable. Syrup of gum arabic. Injec- 
 tion containing ten drops of laudanum. 
 
 April 18. A little drowsy ; eyes slightly injected ; slight epistaxis from 
 efforts made in coughing; occasional retching ; no sensibility of the abdo- 
 
76 
 
 men; pulse a little excited ; tongue rather red, moist, and a little swollen. 
 Syrup of gum arabic. 
 
 April 19. Slept well last night; has discharged considerable quantities 
 of bile upwards and downwards; pulse good; a little appetite ; face less 
 flushed ; eyes not injected. Orange flower water in atisan of the flowers 
 of the linden tree. 
 
 April 21. Slight cough with occasional bleeding of a few drops from 
 the nose, since day before yesterday. She suffers no pain whatever, and 
 complains only of the cough and general debility. From this time she com- 
 menced taking nourishment. 
 
 April 24. About eight o'clock in the morning, and again about mid- 
 day she had a violent fit of shivering. Each fit lasted about an hour. She 
 felt no inconvenience after they were past. Syrup of gum arabic. Tisan 
 of linden tree flowers. The eighth of a portion of food. 
 
 April 25. She had another chill without shivering about nine a.m., 
 which was followed by fever and headache. Same prescription as yes- 
 terday. About seven o'clock this evening, after a momentary sensation of 
 icy coldness pervading the whole body, she was seized with very violent 
 shivering without pain, which ceased almost instantly after the application 
 of ligatures to the right thigh and left arm, so tight as to arrest the 
 circulation. 
 
 April 26. She slept but little last night ; feels pretty well however to 
 day. Syrup of gum arabic ; soup ; and a small portion of solid food 
 From this time she improved in health very rapidly, and left the hospital 
 May the 1st, perfectly cured. Before reaction was fully declared, she took 
 from time to time, every four or six hours, a spoonful of the mixture No. 1. 
 The external means for promoting warmth were also assiduously em- 
 ployed. The determination of blood to the head was subdued first by the 
 leeches, and subsequently with great promptness by the application of ice. 
 The lochial discharge which existed after the abortion, was doubtless a 
 very important derivative. Of the four pregnant women attacked with 
 cholera and received at Necker hospital, this is the only recovery. 
 
 Case. — Cholera. — May 3. Victorine Paulin, a beautiful orphan girl, 
 aged fifteen and a half years, of moderate embonpoint, and good constitu- 
 tion, menstruous about a year, was seized with a simple diarrhoea on Sun- 
 day, April 29 ; this continued till last night, when on it there supervened 
 vomiting and cramps. She was brought into the hospital this morning at 
 seven o'clock, May 3d — it being about six hours after the invasion. At 
 this time she presented the following symptoms, &c. Vomiting of a 
 greenish matter, in moderate quantity, is repeated about every twenty 
 minutes or half-hour; diarrhoea of a similar character; cramps in the 
 calves of the legs very severe, and almost continual ; cadaverous decom- 
 position of the features ; the eyes sunk, and surrounded with a livid circle ; 
 when she reposes for a moment, the eyelids are but half closed — nose 
 pinched up, and cold; tongue cold; blueness of the prolabia ; refrigeration 
 of all the surface of the body, with lividity of the extremities ; pulse im- 
 
77 
 
 perceptible; respiration at times a little anhelating, but unfrequent; the 
 air expired is of a peculiar sourish odor ; voice weak, and on being ex- 
 erted, raucous, or harsh ; urinary secretion suspended ; thirst excessive ; 
 complains of burning internal heat, and swallows ice with the greatest 
 avidity ; neither pain of the head, tinnitus aurium, nor sensibility of the 
 epigastrium; alternate somnolence and cries, with violent agitation in the 
 bed ; intellectual faculties unharmed. 
 
 On entering the hospital, frictions were made over the whole surface 
 with ice, for the space of ten minutes, and with great briskness. She was 
 then wiped dry, and enveloped in warm woollen blankets, and bottles of 
 warm water were applied to her feet. There was a momentary reaction, 
 which was not sustained ; the pulse was perceptible, and the refrigeration 
 less ; but she soon relapsed into the same cold and pulseless state as previ- 
 ously to the frictions. An hour afterwards the frictions were repeated in the 
 same manner, and with the same temporary amelioration. In the mean 
 time she took occasionally a little wine and water, ice-cold, as a beverage. 
 The ice frictions were repeated five times in the course of the day; she also 
 took in the same time, four spoonsful of the mixture of mint water, lauda- 
 num, &c. The radial pulsation and action of the surface were excited im- 
 mediately after each of the frictions, but they soon partially subsided ; on 
 the whole, however, reaction was gradually taking place. There was less 
 somnolence — the cramps, purging, and vomiting were less severe. At 
 five p. m. the tongue was still a little cool, but by no means so cold as in 
 the morning. The night was tolerably tranquil, with some vomiting and 
 cramps, much abated however in severity. The diarrhoea was arrested 
 completely by opiate injections. 
 
 May 4th, eight o'clock in the morning. — No vomiting, purging, nor 
 cramps for several hours; the pulse is becoming fuller — the surface warm; 
 in one word, reaction is taking place. To assure this, there was admi- 
 nistered from time to time a tablespoonful of mixture No. II, page 46, to 
 which was added a few drops of laudanum. Mustard poultices were ap- 
 plied to the lower extremities. For a beverage ice lemonade. 
 
 May 5. Reaction considerable — face a little flushed, eye a little inject- 
 ed, and the surface generally is quite warm ; the vomiting, &c. have en- 
 tirely ceased — pulse a little elevated. Applied twelve leeches behind the 
 ears to diminish the mass of blood and prevent the cerebral congestion 
 which is threatened. For a beverage wine and water. 
 
 May 6. Nearly in the same state, with a little amelioration. A broth 
 was given to the patient at her own request. Weak wine and water. Ice 
 applied to the head for four hours. 
 
 May 7. A determination of blood to the head which existed in the 
 morning, was dissipated by the application of ice for four hours.— Beverage 
 weak wine and water. 
 
 May 8. Considerable improvement, no adverse symptoms except the. 
 suspension of the urinary secretion. — Wine and water. Two vermicelli 
 soups. 
 
 May 9. Convalescent.— Two vermicelli soups. Milk. 
 
78 
 
 May 10. Improving rapidly. Urinary secretion completely restored 
 to-day. Wine and water; two vermicelli soups, and a little solid food. 
 
 May 16. Convalescence has terminated in complete recovery, and the 
 patient was discharged cured. 
 
 In this case the cold stage was very severe — that of reaction mild, and 
 convalescence rapid. Youth and a good constitution were much in favor 
 of the patient. The cerebral affection, at no time very severe, yielded 
 promptly to the application of ice and leeches. The urinary secretion was 
 suspended seven days without occasioning thepatient any local uneasiness. 
 Its complete restoration was preceded two or three days by a very scanty 
 secretion. The most important fact in this case however, is the very fa- 
 vorable effect of the ice frictions, which refreshed the patient, and produced 
 considerable temporary action. This temporary excitement did not alto- 
 gether subside, but was gradually augmented into moderate sustained 
 reaction. The vomiting, cramps, and purging ceased with the establish- 
 ment of reaction on the 4th. The constipation persisted till the 10th, 
 without any ill consequence, when she had a healthy discharge without 
 the use of any remedy. 
 
 Case of Cholerine. — April 14, 1832. Marie Louise Balle, aged 17 years, 
 of considerable embonpoint, unmarried, has menstruated but once within 
 the last year; is subject to head-ache and nausea; has been for some time 
 tormented with leucorrhoea till within the last fifteen days, since which 
 time it has disappeared. She has been completely constipated for the pre- 
 ceding eight days. About seven o'clock this morning, while ascending a 
 flight of stairs, she was seized with a sensation of great general weakness, 
 and a few moments after with sickness of the stomach, and retchings to 
 vomit. At that moment she perceived, for the first time, that her abdo- 
 men was painful. About half-an-hour after, she had very severe cramps 
 in the calves of her legs, which continued, with only momentary interrup- 
 tion till her arrival at the hospital about 10 o'clock in the morning. Si- 
 multaneously with the cramps, she had chills, with great coldness of the 
 feet. To the shivering there succeeded about an hour after, considerable 
 warmth, and vascular excitement. She took nothing but some warm 
 coffee. Frictions were made, with some relief of the cramps. 
 
 She was brought into the hospital about 10 o'clock. Frictions, with a 
 stimulating liniment, were made with great briskness, and repeated three 
 times in the course of the day. These procured temporary alleviation, and 
 at length complete cessation of the cramps. Cramps occurred the last time 
 about 4p.m. Except the frictions, nothing was done for her till 5 p.m. 
 She then presented the following state :— surface warm ; pulse full, seventy- 
 six a minute ; face flushed ; head-ache for the past two hours ; thirst con- 
 siderable ; tongue covered with a very little white fur ; abdomen sensible 
 on pressure; no passage for eight days. Venesection twelve ounces; 
 emollient injection. 
 
 April 15. She was much relieved by the bleeding, and by the injection 
 which procured free motions of the bowels. The tenderness of the abdo- 
 
79 
 
 men is nearly dissipated. The other adverse symptoms have all dis- 
 appeared. 
 April 16. She is quite recovered. * 
 
 The case is interesting, as it exhibits a form of the disease of rather 
 rare occurrence, viz. choleric symptoms, accompanied by a constipated 
 state of the bowels. The sudden prostration, sickness of the stomach, 
 and coldness, rendered the debut sufficiently characteristic. These soon 
 disappeared however, and there remained only a single choleric symptom; 
 viz. the cramps, which were very severe. They yielded to very brisk 
 friction, without any other remedy whatever, either internal or external. 
 They had entirely ceased before venesection was performed. 
 
 Case. — Cholera. — April 10. A young woman, named Henriette Pairier, 
 aged 19 years, unmarried, of moderate embonpoint, and good constitution ; 
 after a diarrhoea of three or four days' continuance, was seized about two 
 p. m. to-day with vomiting and cramps, a great increase of the previous 
 diarrhoea simultaneously. She was brought to the hospital about eight 
 p. m. ; that is, about six hours after the invasion. Her face cadaverous; 
 limbs cold and livid ; her voice profoundly altered ; urinary secretion sup- 
 pressed; pulse imperceptible; thirst urgent; epigastrium not sensible. Purg- 
 ing, vomiting, and cramps at short intervals. — Sinapisms to limbs ; fric- 
 tions; warmth externally; opiate injection; mixture .No. I. internally, 
 page 46. 
 
 April 11. Re-action is gradually taking place; the symptoms of yes- 
 terday are somewhat abated in urgency. — Prescription same as yesterday, 
 with the addition of inf. ipecac. ; and for a beverage, lemonade. 
 
 April 12. Re-action is freely declared, but is not excessive ; the purging, 
 vomiting, and cramps have ceased. — Lemonade. 
 
 April 13. Favorable state continues. — Lemonade; gum linctus. 
 
 April 14. Disposition to sleep, with slight stupor ; face flushed ; eyes 
 injected ; pulse full, not hard nor frequent. — Lemonade, ice cold ; twenty 
 leeches behind the ears. 
 
 April 15. The symptoms of yesterday, which were abated after the 
 application of the leeches, have re-appeared in the course of the night. — 
 Iced lemonade ; bladder of ice to the head two hours, and sinapisms to the 
 lower extremities. 
 
 April 16. Amelioration during, and for a time after the application of 
 the ice, with a subsequent return of the drowsiness, &c. — Same prescription. 
 
 April 17, 18, and 19. Same temporary amelioration following the ap- 
 plication of the ice on the head each day. The mouth, however, is be- 
 coming dry, and fuliginous about the lips and teeth. — Same prescription 
 each day. 
 
 April 20. Drowsiness, and other symptoms more considerable, with 
 slight delirium; and sordes of the tongue, lips, and teeth. — Ice lemonade, 
 ice to the head four hours. 
 
 April 21. Very considerable amelioration; mouth moist; sordes disap- 
 pearing; intellect clear. — Blister to the inside of one leg; iced lemonade. 
 
 April 22. The patient is improving. — Lemonade. 
 
80 
 
 April 23. Condition still favorable, except the recurrence of some diar- 
 rhoea this morning. — Injection with ten drops of laudanum ; lemonade. 
 
 April 24. Convalescence appears to be commencing; the mouth is 
 moist; injection of the eye and flushed face have disappeared. — Gum 
 linctus. 
 
 April 25. Convalescent. — Gum linctus ; broth half a pint. 
 
 April 27. Improving. — Two vermicelli soups. She gradually improved ; 
 slowly returning to solid food, and was dismissed cured the eighth of May. 
 
 In this case the vomiting, purging, and cramps yielded to the mixture, 
 to opiate injections, and frictions. From the constipation that existed till 
 convalescence was somewhat advanced, no ill effect was perceived. The 
 return of the diarrhoea for a shoi't time was not critical, for it occurred three 
 days after a decided amelioration. The urinary secretion, however, re- 
 turned about the same time. The ice in this case was of great service; it 
 refreshed the patient, and eventually overcame the cerebral affection, and 
 the symptoms therefrom depending, though they returned with great perti- 
 nacity and increased severity from the fourteenth to the twenty-first. It is 
 very clear that the patient could not have sustained repeated loss of blood, 
 necessary to subdue these symptoms. For it was found in other similar 
 cases, that the affection of the brain, sordes of the mouth, &c. returned as 
 well after being checked by bleeding as after the application of ice. In- 
 deed, after venesection was pushed beyond a certain point, it aggravated 
 instead of alleviating these affections. After the declaration of re-action 
 to the period of convalescence, the pulse was generally full, soft, not fre- 
 quent, but rather below the standard of health. 
 
THE 
 
 CHOLERA SPASMODIC A, 
 
 
 AS OBSERVED 
 
 IN PARIS IN 1832: 
 
 COMPRISING 
 
 ITS SYMPTOMS, PATHOLOGY, AND TREATMENT. 
 
 ILLUSTRATED BY CASES. 
 
 BY ASHBEL SMITH, M. D. 
 
 OF NORTH CAROLINA, 
 Officially attached to the Necker Hospital, during the prevalence of this Epidemic, 
 
 NE W-YORK: 
 
 PUBLISHED BY PETER HILL, 94 BROADWAY. 
 
 SOLD ALSO BY 
 
 J. GALES AND SON, RALEIGH, N.C., AND AT THE OFFICE OF THE WESTERN 
 CAROLINIAN, SALISBURY, N.C. 
 
 1832. 
 
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