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Title: Asiatic Cholera - A treatise on its origin, pathology, treatment, and cure
Author: Whitney, Elijah, Whitney, A. B.
Language: English
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  ASIATIC CHOLERA


  _A TREATISE_
  ON ITS
  _ORIGIN, PATHOLOGY, TREATMENT,
  AND CURE_.


  BY


  E. WHITNEY, M. D.,
  AND
  A. B. WHITNEY, A. M., M. D.,

  LATE PHYSICIAN AND SURGEON

  To Diseases of Women in the North-Western Dispensary,
  Visiting Physician, Etc.



  NEW YORK:
  M. W. DODD, PUBLISHER,
  NO. 506 BROADWAY.
  1866.



  Entered according to Act of Congress, in the year 1866, by

  A. B. WHITNEY, A. M., M. D.,

  In the Clerk's Office of the District Court of the United States,
  for the Southern District of New York.



  E. O. JENKINS, STEREOTYPER AND PRINTER,
  20 NORTH WILLIAM ST., N. Y.



DEDICATION.

TO PROFESSORS POST, VAN BUREN, METCALF, AND BEDFORD.


For those lucid Clinic illustrations and faithful instructions during
a three-years' course in the New York Medical University, particularly
the critical Pathological knowledge there inculcated, and consequent
professional success, the youthful author is indebted.

Knowing they will agree with him, that his appreciation of their valued
services, and his gratitude for the same, can be best acknowledged
in his attempt to benefit suffering humanity, he would here publicly
acknowledge the pleasure and benefit received from their instructions
during his College course, and beg their acceptance of his sincerest
gratitude and affection.

TO THESE ABLE INSTRUCTORS THIS VOLUME IS CORDIALLY DEDICATED BY THE
JUNIOR AUTHOR.

                                              A. B. WHITNEY, M. D.



PREFACE.


The following pages are the result of investigations and the collection
of facts and arguments from a great variety of sources, originally made
and presented in aid of the discussions on the subject during the past
six or eight months.

The most eminent and reliable authorities for nearly half a century,
that is, from 1832 to 1865, including the late reports from India,
have been carefully examined, and such late discoveries, facts, and
arguments collected, as seemed to throw light upon the subject, or in
any degree to indicate or direct to a general principle of practice.

The various experiments instituted for the cure of the disease have
been carefully investigated, and the principle evolved explained
whenever any advantage was derived from the same.

In all these we have diligently searched for the cause of the failure
of "remedial agents," so uniformly admitted, and have endeavored to
present the results clearly and fully in the body of the work.

Our statistics are collected from reliable sources, are very brief,
and introduced in aid of the main object,--the establishment of a
general principle of practice.

The different modes of practice are from the most distinguished authors
of the different Schools of Medicine, and non-professional gentlemen;
condensed and exhibited mainly in their own language, to show their
conformity or non-conformity to the Pathology of the disease.

In all we have kept constantly in view the pathology of the disease,
whose "dictates" have governed us in the exhibition and establishment
of a general principle of rational practice, confirmed by observation
and experience, which, if accepted and carried out by the profession,
we hope and trust will save a very large proportion of those attacked
by "this most acute of acute diseases."

                                                             AUTHORS.



CONTENTS.


    CHAPTER I.

    SEC. I.      ORIGIN AND DEVELOPMENT.                        7

    SEC. II.     PROGRESS AND FATALITY.                        20

    SEC. III.    CAUSES--PROPAGATION.                          34


    CHAPTER II.

    SEC. I.      PATHOLOGY.                                    45

    SEC. II.     PHENOMENA, OR SYMPTOMS.                       55


    CHAPTER III.

    SEC. I.      UNSUCCESSFUL MODES OF TREATMENT.--VENOUS
                 TRANSFUSION EXPLAINED.                        64

    SEC. II.     PHYSIOLOGICAL CONDITION OF THE BLOOD, ITS
                 NON-AERATION, OR NON-OXYDATION.
                 MAXIMS OF RATIONAL PRACTICE SUGGESTED.        91

    SEC. III.    DIFFERENT MODES OF TREATMENT.                130

    SEC. IV.     STATISTICS. PERCENTAGE OF LOSS. VARIABLE
                 RESULTS--THEIR CAUSE.                        166


    CHAPTER IV.

    SEC. I.      GENERAL PRINCIPLE OF RATIONAL PRACTICE,
                 DICTATED BY THE PATHOLOGY OF THE DISEASE,
                 CONFIRMED BY OBSERVATION AND EXPERIENCE.     178

    SEC. II.     REMEDIES, RECIPES, ETC.                      188

    SEC. III.    PROPHYLAXIS, OR MEANS OF PREVENTION.         203

    SEC. IV.     FORMULÆ--PREPARATIONS, ETC.                  213



ASIATIC CHOLERA.



CHAPTER I.

SECTION I.--ORIGIN AND DEVELOPMENT.


Epidemics have occasionally prevailed in all ages. Sometimes they
have been circumscribed in their influence, and limited to particular
localities; while at other periods they have taken a wider range and
extended over larger sections, inflicting the most lamentable results,
and augmenting the bills of mortality to an incredible degree.

The earlier writers have given some account of these diseases, which
have occasionally prevailed as very fatal and devastating epidemics;
surpassing all other diseases in their mysterious origin, in their
rapid extension, and in the duration of their prevalence. In the
East,--in Egypt, and on the eastern border of the Mediterranean,
fearful epidemics have prevailed from time immemorial. They have often
proved very destructive, especially in the Middle Ages, and as late
as the sixteenth and seventeenth centuries. During the prevalence of
the "Pestis," which raged throughout Europe between the years 1347
and 1350, according to computation, a fourth part of the inhabitants
of this part of the globe was carried off. The estimates of the vast
numbers swept away by its repeated occurrence and prevalence appear
quite incredible.

During the time it raged at Marseilles in 1720, it is reported that in
the Charity Hospital there were admitted from October 3d to February
28th, 1,013 patients, of whom 585 died; and during the same period, in
another hospital, there were admitted from October to July 3d, 1,512
patients, of whom 820 died. The population of Marseilles previous to
the occurrence of the disease was estimated at about 90,000, of whom
40,000 died; leaving only about 10,000 of the whole population who had
not been attacked or in any way affected; so that the record shows the
appalling mortality of fifty per cent. of those who were attacked.

The bills of mortality in 1770 and 1771 were as appalling as any
arising from epidemics of a later day. A very extended notice of
the "Pestis" as it raged in Moscow in the year 1771 is given by M.
Gerardin, who, quoting from the published statistics, observes: "In
April, the deaths were 744; May, 851; June, 1,099; July, 1,708; August,
7,268; September, 21,401; October, 17,561; November, 5,235; December,
805"; making a total in nine months of 56,672, which is considerably
less than the estimate given by De Mertens, who thinks the whole
number carried off by this pestilence, from the city alone, cannot
be less than 80,000. These statistics bear a striking resemblance to
those of the Epidemic Cholera, whose fatality is materially varied by
the seasons of the year; the greatest being usually at the close of
Summer or the beginning of Autumn. There are, in short, many points of
resemblance in this and former epidemics to that of the Cholera, which
naturally lead to the supposition that all have had a common origin,
if, indeed, they be in many respects dissimilar.

Their pestilential character, their extended influence, and their great
fatality, rendered their appearance and progress a special terror to
physicians, and melancholy apprehension to the people. They seem to
have been regarded as the manifestation of an invisible power, which
directed and guided "the pestilence that walketh in darkness" and "the
destruction that wasteth at noon-day;" a visitation or chastisement
over which human ingenuity and medical skill had little control. Under
these impressions, the earlier physicians labored and endeavored to
satisfy the great mass of mind that these occasional and special
developments of disease arose from natural causes, and were subject to
certain natural laws. They ascribed their origin to the commingling of
some specific poison in the food, and drink, and air, which, through
these "media," was received into the system.

Subsequently, they seem to have made some advance on this theory, and
considered the extreme Summer heat--especially the intense heat of the
sun in a dry season--the emanations from stagnant waters, and the miasm
exhaled from the soil, and from putrid bodies of animals, as the chief
causes of all epidemics. These views prevailed for a very long period,
and have undergone no very remarkable change from the observations and
discoveries of centuries.

Modern and quite recent writers have advanced nearly the
same doctrines, embracing, however, the principal sources of
insalubrity--the malarious and miasmatic influences; and have assigned
as the cause of epidemics, especially that of Cholera, a peculiar
constitution of the atmosphere, and certain predisposing causes
combining with each other, so that an association or union of these two
independent and individual causes are necessary and essential to the
production of the disease.

Eminent scholars and pathologists have, during the century last past,
patiently searched for its final cause, without arriving at any better,
wiser, or more satisfactory conclusion than the earlier writers, who
regarded it a poison, commingled with the food they ate, the water they
drank, and the air they breathed. The modern writers, according to the
more popular views, almost universally adopt the hypothesis that the
remote or final cause of the Cholera is a specific poison; for at no
period has a person in good health in this or any other country been
known in a few minutes to be shriveled up, his face and extremities to
turn purple, his whole body to become of an icy coldness, and with or
without vomiting a peculiar fluid, like rice-water, to die in a few
hours, except under the influence of poison. That this disease, so
appalling and destructive in its effects, and so mysterious in its
wanderings, should spread over countries in respect to climate, soil,
geological formations, and as to the moral and physical habits of the
population, so utterly opposite to those where it first originated, is
only explicable on the hypothesis of its propagation on the principle
of a specific disease-poison.

How and in what manner it travels has not been satisfactorily
determined. Whether independent of any and all human agency, or
absolutely dependent on ordinary communication and intercourse of
tribes, and peoples, and nations, is as yet unsettled. It is, however,
a matter not of so much consequence as the fact that, in all its
nomadic life, it retains unchanged its youthful disposition, vigor and
energy. It seldom shows any inclination to associate, or coalesce, or
even adopt the milder habits and manners of others.

Perhaps some idea of its character may be obtained from a microscopic
view of its birthplace and its surroundings. Whether the locality
of its irruption in 1629, or that of 1817, whence it spread over the
greater part of the globe, be entitled to the unenviable distinction
of fostering its gestation, concealing and protecting its birth, and
nursing its infancy, is immaterial;--since the similarity of these
localities strikingly illustrates its cause and ultimate development.

On the north side of the island of Java, about 6° S. lat. and 107° E.
long., near the mouth of the river Jacatra, is situated Batavia, in
the midst of swamps and marshes, surrounded by trees and jungle, which
prevent the exhalations from being carried off by a free circulation
of the air, and render the town peculiarly obnoxious to marsh
miasmata. Besides this, all the principal streets are traversed by
canals, planted on each side with rows of trees, over which there are
bridges at the end of almost every street. These canals are the common
receptacles for all the filth of the town. In the dry season their
stagnant and diminished waters emit a most intolerable stench, while
in the wet season they overflow their banks and leave a quantity of
offensive slime. From these united causes, it is not surprising that
Batavia has been considered the most unhealthy spot in the world, and
has been designated the store-house of disease. According to Raynal,
the number of sailors and soldiers alone who died in the hospitals
averaged 1,400 annually for sixty years, and the total amount of deaths
in twenty-two years exceeded a million of souls. The city was inclosed
by a wall of coral rock, with a stream of water on each side within
and without. Few Europeans, however, sleep within the town, as the
night air is considered very baneful. The inhabitants, possibly, as
an antidote against the noxious effluvia arising from the swamps and
canals, continually burn aromatic woods and resins, and scatter about
a profusion of odoriferous flowers, of which there are great abundance
and variety. During the prosperity of the Dutch East India Company,
Batavia obtained the title of Queen of the East, as the resources of
all other districts were sacrificed to its exclusive commerce. Here,
in this noted locality, was the Cholera bred and reared in 1629, under
circumstances of great significance, admirably adapted to convey some
idea of its cause and character.

A learned professor, speaking of the diseases of India, observes:
"CHOLERA is the most acute of acute diseases. It seems to have existed
in Batavia as far back as 1629; and it has been known to prevail as an
occasional epidemic in India at different years and places from 1774
to 1817. Since then it has been endemic, and is a disease whose germs
are essentially maintained in, or upon the soil. It annually recurs at
many of our large stations, commencing generally at the beginning of
the hot season, but sometimes occurring in the rainy and cold season.
Its greatest proclivity to propagation is amongst populations living
in low, damp, crowded, and ill-ventilated situations, especially if
the water supply is impure. Nearly all the diseases fatal in India are
accompanied by profuse discharges, with which the air, water, linen,
bedding, closets, walls of hospitals, and barracks become more or less
infected; so that the 'Materies Morbi' come into contact with all the
inmates of buildings where the disease prevails."

Its origin, or reappearance in 1817, is not in any respect essentially
different from its earlier development on the Jacatra. The River
Ganges, in India, like the Nile in Egypt, flows for a long distance
through a low, level country, which it annually inundates. Dividing its
waters about 200 miles from the sea, the Delta of the Ganges commences
and continues its variegated and checkered surface, till, approaching
the borders of the sea, it presents a peculiar aspect, being composed
of a labyrinth of creeks and rivers, called "The Sunderbunds," with
numerous islands, covered with the profuse and rank vegetation called
"jungle," affording haunts to numerous tigers and other beasts of prey.
This large river, "a Deity of the Hindoo," is subject to an annual
freshet, often rising to the height of 32 feet in the month of July;
when all the lower parts of the country adjoining the Ganges, as
well as the Burrumpooter, are overflowed for a width of one hundred
miles; nothing appearing but villages, trees, and sites of some places
that have been deserted. Here in this vast pest-house, where every
conceivable vegetable and animal substance is left upon the soil by
the retiring inundation, exposed to the heat and dews of a tropical
climate--where, too, noisome and infectious diseases have prevailed for
centuries, the Epidemic Cholera is said to have arisen and acquired its
strength and full development. A fit origin for a fatal and devastating
pestilence.

To this low, insalubrious, and festering locality, this vast
pest-house, where so many noxious and noisome diseases are generated,
and where so many epidemics have arisen and so often swept over the
surrounding regions with most fatal and desolating effects, is ascribed
the birthplace of the Epidemic Cholera of 1817. Here it is said to have
first made its appearance at Jessore--a populous town in the centre of
the Delta of the Ganges; whence attaining its growth and power, it has
extended its influence as from a common centre, and marked its progress
with hecatombs of victims in the direction of almost every point of the
compass.

Here we may remark, that it is not our intention to travel over the
whole ground embraced by the subject under consideration; but, on
the contrary, to present in this treatise only a cursory view of a
few prominent features which may interest and aid in the important
object of deducing from the pathology and the varied phenomena of the
Cholera some general principle of practice. For this, and to this,
our labor and our investigations are directed. Availing ourselves of
every source of information within our reach, and relying in part on
the observations and experience of others, we shall aim to present
such facts and arguments as will shed light upon the subject, and aid
in the accomplishment of this desirable object. However difficult this
may appear, it is nevertheless believed to be within the province of
science and unbiased reason.


SECTION II.--PROGRESS AND FATALITY.

The disease in 1817 appeared on the Delta of the Ganges, and gradually
extending its influence, swept over various countries with terrible
severity. Having here acquired its full development, and manifesting
an indomitable determination to itinerate, it starts upon its lethean
errand, and soon shows a capacity and power to overcome every obstacle
opposed to its progress, and to pursue its course unchecked and even
unretarded by any natural or artificial barrier. It soon traversed
India, and in the succeeding season spread over adjacent countries,
visiting in 1818 the Indian Peninsula, the Burmese Empire, the Kingdom
of Aracan, and the Peninsula of Malacca. In 1819 it reached Sumatra,
Singapore, and various other islands situated along the coast on either
border of this vast peninsula.

During the year 1820, pursuing steadily its progress eastward, it
reached Tonquin, Southern China, Canton, the Philippine, and numerous
other places and islands in that direction. In 1821 it visited
Java--the place of its earlier nativity--Madura, Borneo, and many other
places in the Indian Archipelago. During the years 1822, 1823 and 1824,
it continued to spread over the vast and populous regions of Central
and Northern China and the numerous islands upon the coast, and in 1827
prevailed in Chinese Tartary, leaving few places in all these different
countries on the continent, or even on the islands bordering on the
eastern coast, unscathed by its terrible ravages and depopulating
influence.

During the same period, its progress westward has been uninterrupted,
and attended with results no less remarkable. It has baffled all
attempts to check or even retard its onward course, or mitigate its
appalling effects. In July, 1821, it had reached Muscat in Arabia, and
thence extended its influence to the populous cities and villages along
the Persian Gulf. During the same season it appeared in Persia, and
continued to ravage the principal cities and towns of that empire for
four successive years. At Bassorah and Bagdad it broke out in July,
1821, and thence extended its desolating influence westward to the Red
and Mediterranean Seas, carrying off vast numbers of the inhabitants of
the populous cities of Mesopotamia, Syria, and Judea.

In 1822 it prevailed among the nomadic and Tartar tribes in Central
Asia and in the northern Persian Provinces, and in 1823 broke out on
the Georgian frontiers of Russia, at Orenburg on the River Ural, and
at Astrachan on the Volga. Here its western course was apparently
interrupted. There was, for a short period, an interval of complete
immunity from its presence. Along the border of the Russian Provinces
the disease had entirely disappeared, and seemed inclined to retrace
its course and return to the home of its birth. But the fond
anticipations of Europeans were disappointed; the destroyer was not to
be arrested and turned back in his progress over the earth; his march
was onward, his demands imperative.

Hence, in the month of June, 1830, the disease reappeared in a Persian
province on the southern shore of the Caspian, and again at Astrachan,
on the Volga, in July, where it prevailed with such unwonted violence
that, before the close of August, more than 4,000 persons had died
of it in the city, and 21,270 in the province. From its interval of
repose, it would seem to have recuperated its strength and vigor for
the lethean work awaiting its progress. Ascending the Volga, it reached
Moscow, became prevalent there in September, and continued with great
severity till February, 1831. Here it attacked, in the city, about
9,000 persons, of whom more than one-half died. Continuing its advance,
it reached Riga about the middle of May, and St. Petersburg on the 26th
June.

From Astrachan it also directed its course towards the northern coast
of the Black Sea, and thence along the course of the rivers into
the central parts of Russia. It reached Poland in January, 1831,
accompanied the Russian army in its various marches and encampments
during the subjugation of that country, and proved very destructive
in Warsaw and many other places during April and May. It appeared at
Dantzic in May, and in June at Lemburg, Cracow, and various other
places and sections of country, extending through Gallicia, Hungary,
and reaching Berlin and Hamburg in August and September, and Vienna
about the same time.

Smyrna was visited in September, and Constantinople soon afterwards. It
is reported that the pestilence was conveyed by a caravan from Mecca
to Cairo in August, 1831, some thousands having died on the road;
and, by the middle of September, 10,400 Mohammedans, besides Jews and
Christians, had died of it in this latter city.

Passing from the western coast of the continent, on nearly the same
parallels of latitude, it found its way over the Northern Sea to the
British Isles, and made a lodgment, first, on the northeastern coast
of England, in October, 1831, at Sunderland, situated in latitude
55° north, whence it prevailed and extended its influence over this
section, evincing the same malignant and lethean character it had
manifested in its progress over the continent. Its course thus far has
been marked with unparalleled fatality.

It made its first appearance in Scotland, at Haddington, in December,
1831, and at Edinburgh in January. In these and various other places it
prevailed for some months, and, as warm weather came on, increased in
severity, and carried off a large percentage of those attacked. After
spreading thus over the northern section, and rioting for months in the
more populous cities and towns, it made its appearance in London on
the 14th February, 1832, where it found an abundance of material for
recuperating its strength and multiplying its forces, and soon after
spread over various other places in the United Kingdom, inflicting
the most appalling bills of mortality. In short, its progress over
this country has been attended with the same destructive influence
and the same lamentable consequences as on the continent. No change,
modification, or softening of its disposition or character has arisen
from its passage over the Northern Sea, nor from the refreshing
influences of a purer atmosphere.

It appeared in Calais on the 12th, and at Paris on the 26th of March,
1832, where it continued in these and other cities and villages for
some months with its accustomed severity. During the season it raged
throughout the vast empire, and swept away an immense number of its
inhabitants. During the succeeding years, 1833 and 1834, it traversed
Spain, and proved very destructive in many of its larger cities and
villages.

In the mean time, continuing its course from the British Isles
westward, unchecked by the prevailing western winds and the broad
expanse of the Atlantic Ocean, over which it passes a distance of
nearly three thousand miles, and makes its first appearance on the
American continent at Quebec, Lower Canada, on the 8th June, 1832, and
reaches Montreal on the 10th of the same month. From these cities it
rapidly spread in all directions, prevailing in the towns and villages
on the St. Lawrence and its tributaries, and soon extended along the
chain of lakes, dividing the Provinces from the United States, visiting
the principal ports on either shore. It exhibited in all these places
its peculiar epidemic character, and proved excessively violent and
fatal wherever it appeared.

Its first irruption in New York was on the 24th June, 1832, sixteen
days after its appearance at Quebec, and at Albany, midway between
the two former cities, on the 3d July. From New York it extended its
influence to Flatbush and Gravesend, Long Island, where it appeared on
the 5th July, and on the same day and date at the city of Philadelphia.
It broke out at Rochester on the 12th and at Buffalo--July.

Thus, while it was making its way westward along the great chain of
lakes, towards the arteries of the Great West, it was, at the same
time, steadily pursuing its uninterrupted course along the coast,
visiting the main cities, and spreading from these as from common
centres over the intermediate towns and villages. In its progress it
reached Baltimore on the 22d August, and the City of Washington on the
28th of the same month.

Thence it continued its course to Richmond, Norfolk, Edenton, and
various other cities along the Atlantic and Gulf coast.

It appeared at New Orleans in the Autumn of 1832, during the existence
of a severe epidemic of yellow fever, and apparently subsided on the
disappearance of the fever. Sporadic cases, however, occurred during
the Winter, and in the opening of Spring it broke out with unwonted
vigor and severity, and thence spread, according to its accustomed
laws of itineracy, along the rivers into the interior of the States
bordering upon the Mississippi and the Gulf coast, and raged throughout
Louisiana and Texas with unusual violence and fatality.

In 1832, 1833, and 1834 it prevailed throughout the Mississippi Valley
with great fatality, especially in the principal cities, villages and
towns situated upon its navigable waters. Here, after intervals of
entire immunity from its presence, it occasionally reappeared in some
of the larger cities with renewed vigor and power, and swept off vast
numbers of the inhabitants. In no section of the States have greater
numbers, compared with the whole population, fallen victims to it than
in the fertile and sparsely settled prairies of the South and West.

Thus, from the North, and at a later date from the South, extending
its influence along the principal rivers into the interior, it swept
over the States, prevailing in some places in the Valley of the
Mississippi as late as 1836. In short, it reappeared in 1834 in many
cities and places where it had before prevailed, and again spread over
a considerable portion of the country with unprecedented fatality.

In 1833, the disease appeared at Havana and Matanzas, and prevailed on
the island for several months with great fatality, especially among
the colored people. During the same season it appeared in August
at Tampico, Campeachy, Vera Cruz, and the city of Mexico, proving
especially violent and destructive in these and other cities of the
Republic. In Central America it is said to have attacked the army, and
in a very short period to have swept away a very large proportion of
its officers and men.

Thus, it appears that the epidemic or Asiatic Cholera, from its first
irruption on the northern coast, spread over the greater part of the
North American Continent in the space of two years, and has several
times reappeared in different sections in its peculiar malignant
character, spreading on each occasion over a greater or less extent
of territory with the same uniform and destructive influence. Neither
time, nor science, nor professional skill has thus far appeared to
soften its character, or mitigate its severity.

When the disease had fully assumed its epidemic or malignant type in
India, in 1817, its rate of mortality was everywhere in that vast
territory excessively high.

According to the most reliable reports, the cases occurring in the
earlier period of an irruption were generally fatal, few only surviving
the attack; while of those occurring when the disease was on the
decline, a greater proportion recovered. We read of numerous instances
where one-third, one-half, two-thirds, and even nine-tenths of those
seized with Cholera perished, and again of some places where one-fifth,
one-fourth, and in some instances one-third of entire populations were
cut off in a very short period by this disease. But without attempting
to give the statistics of cholera in this part of the world, or even in
Europe or America, we may present a few instances of mortality, going
to show the great percentage of loss by this singular disease during
its ravages from 1817 to 1837.

In Siam, it is said 20,000 persons fell victims to it in twelve days.
The inhabitants are remarkable for their uncleanly habits, and crowded,
ill-ventilated tenements.

In Sicily, 16,000 died of cholera in 1832, at Catania; in Palermo,
40,000. These cities are represented as being filthy in the extreme,
and the personal habits of the people so uncleanly, and the houses so
crowded, that it is a matter of surprise the mortality was not greater.

In Bassorah and Bagdad, situated in low, unhealthy localities, and
exposed to a damp, insalubrious atmosphere, which, in the warmer
season, is often essentially impregnated with miasmata and offensive
exhalations from animal and vegetable decomposition, both within and
without their inclosures, it is affirmed that more than one-third of
their entire populations were carried off in less than one month.

In the Province of Caucasus, out of 16,000 attacked by the disease,
10,000 died. In Russia, out of 54,000 attacked in 1830, it is said more
than 31,000 died.

In Hungary, it is reported that the whole number affected by the
disease was about 400,000, of whom more than one-half died.

It is officially stated that the total number--the military
excepted--of those affected with cholera in France, from its first
appearance at Calais, March 15, 1832, to January 1st, 1833, is 230,000,
and the deaths 95,000.

In England, the whole number of cases of Cholera is reported to be
49,594, and the number of deaths 14,807. In London there were 11,020
cases, of which 5,274 were fatal. In Wales there were 1,436 cases, of
which 498 proved fatal. In Ireland, from its first irruption in 1832
to March, 1833, there had occurred 54,552 cases of cholera, of which
21,171 were fatal.

In Quebec, from June 9th to September 2d, 1832, there had occurred in
that city alone no less than 5,783 cases of cholera, of which 2,218
were fatal. In Montreal, from June 10th to September 21st, there were
4,440 cases, and 1,904 deaths reported.

In New York, from July 4th to August 28th, in 1832, there had occurred
5,814 cases of cholera, and 2,935 deaths by the same disease. In
Philadelphia, from July 4th to August 28th, 1832, there were reported
2,314 cases of cholera, of which 935 were fatal.

In many of our Southern and Western cities and villages the percentage
of loss from the prevalence of cholera is considerably higher than the
general average, compared with the data given above. The mortality
varies materially in different localities, and, indeed, becomes very
much augmented by the prevalence of those influences which particularly
favor the vegetation, and are especially concerned in the production of
zymotic diseases, whether in the lower or higher latitudes.


SECTION III.--CAUSES--PROPAGATION.

The remote or final cause is essentially of miasmatic origin, developed
under certain atmospheric and terrestrial local conditions, not well
defined or fully understood. In its nature and essence, it constitutes
a peculiar disease-poison, which is now generally admitted to be, in
one way or another, absorbed, and infects the blood, inducing a primary
disease of this vital fluid, and directly depressing and deranging
the ganglionic system of nerves. To its general character, and the
circumstances under which it is generated and in which it operates in
producing the disease, we have alluded in speaking of its origin.

The predisposing causes are as numerous as the varied influences
which operate to depress the general health. The insalubrity of the
atmosphere may be regarded as a general, and, perhaps, the most
extensive predisposing cause. In this state, its vital element becomes
diminished or impaired to such an extent as to render it incapable of
sustaining the normal and healthy functions of the system in their
most vigorous condition. Hence, the foul and noisome air of close,
ill-ventilated apartments becomes very depressing and baneful; a direct
and effective element, often, in constant operation in generating and
producing the cholera, typhoid fever, or other deadly maladies. This
is not unfrequently the case on board some of our emigrant ships,
when hundreds of human beings are stowed away between decks without
the means of efficient ventilation, disinfection, or other mode of
expelling the noxious principle. Though the germ of disease may be
ever on board, it does not vegetate and come forth and rapidly acquire
its activity, vigor and power, unless the localizing influence vivify,
foster and nurture its development. This is fully confirmed by the
recent arrival of two steamers with cholera on board.

The _England_, and a few days later the _Virginia_, with crews and
passengers all in perfect health, departing from a healthy port where
no cases of cholera were known to exist, and after being out at sea six
or eight days under the influence of a cool, invigorating atmosphere,
were surprised by the sudden irruption of cholera on board. It breaks
out among the steerage passengers who are crowded and packed together
between decks like sheep for the slaughter, in a confined atmosphere,
daily becoming more noisome, without the means of ventilation or
disinfection. Can any sane man say the disease--the cholera--was not
here, on board these ships, generated and produced?

This is also confirmed by the occurrence of an isolated case on
Ninety-third Street, near Third Avenue, the first case in this city
this season. Though the cholera exists at Quarantine, the patient had
not been in any way exposed to the disease, except to the exhalations
from the overflowing and drainage of a privy and the foul atmosphere
arising from the cellar of her own tenement. On Monday, it is said,
she partook of her dinner, feeling a little indisposed; at 4 P.M. she
called in her physician, and died the next morning, May 1st, at 11
A.M., in a state of collapse.

Take another instance: the second case in this city occurred in one
of the tenement dwellings of the Sixth Ward, No. 117 Mulberry Street.
The patient was a woman about thirty years of age, who had not
been exposed, except to the noisome atmosphere of her own dwelling
and its surroundings, which must be regarded, under the peculiar
circumstances, as a true, genuine cholera atmosphere. In these cases
the evidence is conclusive that the disease was generated and produced
within, and on these premises.

The exhalations from low, moist, and marshy localities, from
the offensive cesspools, water-closets, sinks, sewers, and the
decomposition of animal and vegetable substances, from the refuse or
garbage which so often befouls the sidewalks and gutters of streets,
are all effective, predisposing causes, that directly facilitate the
production of the cholera. Whatever tends to depress the vital powers,
impair normal action, or relax in any degree the tone of the nervous
system, favors the operation of the final cause. So, too, the low,
underground, damp, unventilated apartments, the crowded and uncleanly
tenement houses, in which multitudes of the poorer class live, in a
confined, foul, and noisome atmosphere, not only favor, but actually
invite, the active operation of the infecting agent.

Habits of intemperance, profligacy, impurity, and late hours, have a
powerful influence to depress and prepare the system for an invasion
of the disease in its most malignant form. In a neighborhood of this
description, when the cholera in 1832 was raging in the adjacent city,
from which it was separated by a very small creek, the uncleanly
multitude escaped entirely, not a case occurring there at that time;
but when, after an interval of several weeks, all danger seemed to have
passed, and the people were rejoicing and congratulating themselves
on their good fortune, the fearful disease suddenly appeared in their
midst with greatly intensified effect, and in a very few days swept the
place so clean that few were left to tell the sad story of its ravages.

There are some other predisposing causes of no inconsiderable
influence, which not only favor the operation of the infecting agent in
the production of the disease, but even awaken its latent power, and
stimulate its activity and development in the system, once exposed to
its invasion. Among these, excessive fear of an attack, great anxiety
and depression of mind, constitutional debility, deranged condition
of the digestive organs, accompanied with a relaxed state of the
bowels, exhaustion arising from fatigue or disease, semi-starvation
and unwholesome diet, neglect of personal and domestic cleanliness,
irregular habits, and excesses of every description, are all direct
incentives and stimulating agents in the production of the cholera. Any
one of these may be sufficient to induce an attack; but when a number
unite and act conjointly the danger is vastly greater, as the infecting
agent or disease-poison becomes thereby more intensified.

When the cholera first appeared in Europe and in this country in
its epidemic form, the majority of medical men, as well as the
people, believed it to be contagious, and to be propagated solely
on this principle. But when the disease appeared in 1848 a decided
change of opinion occurred, which led to a full discussion of the
subject, without any definite result; and the great question as to
its contagious character and its mode of propagation remains still
unsettled. The higher authorities, says an eminent author, concurred in
the opinion of the Board of Health, "that the disease was not in any
way contagious, and that no danger was incurred by attendance on the
sick."

A large body of evidence, however, has been exhibited, going to show
that human intercourse has, at least, a share in the propagation of the
disease, and that it, under some circumstances, is the most important,
if not the sole means of effecting its diffusion. On the other hand, it
is affirmed that though it may be communicated, in some cases, by the
agency of human intercourse, it does not follow that the material cause
spreads by true contagion, that is, by reproducing itself in the bodies
of men, and there only.

The disease may be carried by healthy persons in their clothing,
in their ships, and in their caravans. That instances of this kind
have occurred there can be no question, for numerous records present
some undoubted instances of the occasional communication of the
cholera-poison through human intercourse; still it is no less certain
that its general extension over the world cannot be accounted for on
this principle alone. "Its propagation by this means seems to be the
rare exception, its spread over the earth from other causes being the
common rule."

Dr. Hamlin, writing from Constantinople, in reference to the recent
irruption and prevalence of the cholera in that city, observes, "The
idea of contagion should be abandoned. All the missionaries who have
been most with the most malignant cases, day after day, are fully
convinced of the non-contagiousness of the cholera. The incipient
attacks which all have suffered from are to be attributed to great
fatigue, making the constitution liable to an attack."

It is a very singular fact, that the medical profession in India,
the birthplace and home of the cholera, almost universally reject
the doctrine of contagion. If those most observant and familiar
with its history, its prevalence, and its annual recurrence as an
endemic disease, which they are called to treat in all its varied
phases, have discovered no contagious character by which it can be
propagated, it may be safely inferred that it is not contagious in the
common acceptation of the term, and that its extension over the earth
is governed by some other principle, and that the predisposing and
localized causes which are always in operation in India exercise no
small share in its diffusion, in directing its course, aggravating its
severity, increasing or diminishing its fatality, and determining the
duration of its prevalence in particular localities. When its infecting
germs have gained a lodgment in any city, section, or country, they may
be stimulated and become exceedingly active in the production of the
disease through these influences.

As to its introduction into different countries, it is quite evident
that the germ, or latent principle of the cholera-poison, exists in
such a state as to be capable of transportation, and may in this way
be diffused to almost any extent when the localizing influences are
sufficient to develop its energies.

In this, as in all other zymotic diseases, some persons are more
susceptible of an impression and more liable to an attack than others.
Though no class can be considered exempt, yet there are some whose
organization, or innate protective principle, seems to render them
impervious to its influence. The cholera, however, is no respecter of
persons, or rank, or condition. The anæmic and cowardly in all ranks
and conditions are peculiarly liable, and are the most defenceless and
unresisting when invaded. In Europe, the probable numbers attacked in
that part of the world appear from statistics to be, in France, as 1
in 300; Russia, as 1 in 20; Austria, as 1 in 30; Poland, as 1 in 32;
Holland, as 1 in 144; Germany, as 1 in 700. "The circumstance of one
attack by no means protected the individual from a second in the same,
or any subsequent year; still a repetition of the disease in the same
person in the same year was rare."



CHAPTER II.

SECTION I.--PATHOLOGY.


The doctrine now universally accepted and prevailing regarding its
Pathology is, that a poison, virulent, subtle, and unknown, has been
absorbed, and primarily infects the blood, so that, after a longer or
a shorter time, a primary disease of this vital fluid is produced, and
that the poison undergoes an enormous process of multiplication in
the living body of the cholera patient, as the direct result of this
morbific process so established, and that changes are induced in the
function of respiration directly consequent on this alteration of the
blood.

This altered condition and rapid change in the life-sustaining
principle of the blood, the loss of nerve-power, the impaired
circulation and tendency to congestion, are the proper and
distinguishing features of the disease; and the term "Algide," first
used by the French Pathologists, very happily describes one of the
most remarkable and constant symptoms, namely, the diminution of animal
heat. The loss of temperature and its consequent effects upon the
circulation, depressing and prostrating the nervous power, impairing
and paralyzing the respiratory organs, suspending the functions of the
liver and kidneys, enfeebling the action of the heart, and causing
the capillary vessels of the mucous tissues to expand and pour off
the serous fluid from the blood and every muscle and tissue of the
system, with great rapidity, essentially constitute the phenomena of
the Cholera. The constantly increasing augmentation of the poison and
its intensified effects measure the malignity, the violence, and the
rapidity of the disease.

It is this multiplication, and the disturbance which attaches to it,
that in each case constitutes the disease and destroys life. Of this
fact the circumstantial evidence is abundant and conclusive, and may
account in part for the violence of the disease in its first irruption
in any particular locality. The vomiting, purging, and cramps are now
generally considered as secondary and non-essential phenomena, for
numerous cases of cholera have occurred in every section where it has
prevailed in its more violent and malignant form without exhibiting
these symptoms. The poison was so potent, and its progress so rapid,
that life was extinguished in a very short time. In its first irruption
at Muscat, cases are reported in which only ten minutes elapsed from
the first apparent seizure before life was extinct. Dr. Milroy,
speaking of the violence and rapidity of the disease as it occurred in
1817, and again in 1845 and '6, at Kurrachee, observes, that "within
little more than five minutes hale and hearty men were seized, cramped,
collapsed, and dead." Instances of death taking place in two or three
hours are extremely common. When it broke out at Teheran, in May, 1846,
Dr. Milroy observes, that "those who were attacked dropped suddenly
down in a state of lethargy, and at the end of two or three hours
expired, without any convulsions or vomitings, but from a complete
stagnation of the blood." In many places during its prevalence in
1832, and subsequently in 1834, and in 1848 and '9, the rapid fatal
character of the earlier cases was observed and reported as the most
severe and hopeless. In various cities and villages in our own country,
cases of this description were not unfrequent. In all these the
destructive nature and rapid process of the disease was so depressing
and overwhelming as to prevent any effort of the "vis naturæ" to resist
its progress.

Hence, from the autopsy of those who have fallen victims to its baneful
influence in the first stage, or within forty-eight hours of the
attack, no alteration of structure in any organ or tissue has been
discovered. But in those cases where death has occurred at a later
period, some lesions and slight changes in the appearance of some
tissues have been traced. The more important of these, illustrative
of the characteristic effects of the disease, are, in brief, the
following:

The follicular structure of the intestinal canal has been found
slightly swollen, and the intestine partially filled with a
turbid, inodorous, semi-diaphanous fluid, resembling thin starch,
or rice-water, and is supposed to be the remains of that peculiar
secretion which had taken place during life. This fluid is sometimes
acid, and sometimes alkaline. In the small intestines it is found in an
unmixed condition. It consists of two liquids of different consistency;
the one thick, the other thin. The latter constitutes the rice-water
stools, and may be passed off without admixture with the thicker
substance. The colon has been found generally much contracted, and the
mucous membrane and the sub-mucous cellular tissue of the digestive
canal presenting evident marks of congestion, in some cases approaching
to a sub-inflammatory state, generally in spots or patches of various
sizes, the color of these varying from a very dark congestion to a more
roseate hue. The glands of Brunner and Peyer, as well as the solitary
glands, are greatly enlarged. The stomach and bowels are frequently of
a paler color than natural, both in their inner and outer surfaces. The
liver, the spleen, and the kidneys have been found engorged with blood.
The urinary bladder is always contracted, and empty. The gall-ducts
are sometimes contracted, at other times not. The vena porta and all
the other abdominal veins are loaded with black blood, resembling tar
in its color and consistency. The membranes of the brain and cord are
generally found congested, and the substance of the brain more or less
dotted with small points or specks of blood than usual.

"The most common appearances in the lungs," says an eminent
pathologist, "are the presence of blood in the large vessels, chiefly
or solely; the collapse and the deficient crepitation arising from
the more or less complete absence of air and blood, and from the
approximation of the molecular parts of the pulmonary substance.
In other cases there is more blood in the minute structure, a
corresponding dark color of the lung, and a variable amount of frothy
serum. The right side of the heart and the pulmonary arteries were
generally filled, and in some cases distended with blood; the left side
and aorta were generally empty, or contained only a very small quantity
of dark blood; the left side evidently had received little or no blood,
but had continued to contract, in some cases even violently, on the
last drop of blood which had entered it."

Such are some of the prominent appearances which the body has presented
when the patient has died in the first, or pulseless stage of the
disease. But in other cases, where the premonitory stage has been
definitely marked, and attended with diarrhoea or other depressing
disorder affecting the alimentary canal, and where the patient has
continued under the influence of the disease for a longer period, and
has passed through the usual successive stages of it, other additional
appearances have been noticed, which are here omitted, as they are of
a secondary importance, and belong especially to the more protracted
cases.

The _post-mortem_ appearances, the phenomena of the disease, the
Algide, or diminished animal heat, and the loss of nervous power, all
tend to show an obstructed circulation and consequent embarrassment
of respiration resulting in the non-aeration and non-oxydation of the
blood, from which a long train of secondary and non-essential symptoms
arise. For it is affirmed that the mechanical part of respiration
remains in a good degree perfect, and that the heart evidently
continues to beat in many cases till stopped by the want of blood in
the left side and by its accumulation in the right side. Hence, for the
cause of this arrest of the circulation of the blood through the lungs,
we are forced to look to the condition of the blood itself, and the
deranged action of the ganglionic nerves.

Attempts have been made to trace out from analysis the exact chemical
changes in the order of their occurrence which attend the period of
transudation from the blood into the intestinal canal. "The most
prominent phenomena of cholera," says Dr. Aiken, "during this period
of transudation, consists in separation of the water and of the salts
of the intercellular fluid (of the blood) through the mucous membrane
of the intestinal canal, and the retention in the blood of an important
excess of albumen and of blood-cells, with apparently less, but in
reality with great diminution of the salts and fibrin."

"The inorganic constituents," continues the same author, "if compared
to the water, are during the first four hours increased, because at
this time the water is passing off with great rapidity; afterwards, as
the salts pass off, the disproportion is lessened, and after eighteen
hours or so, the proportion of salts is greatly diminished, and, if
compared with the organic constituents, the diminution is enormous.
With respect to the individual salts, there is in the blood a relative
preponderance of phosphates over chlorides, and of potash salts over
soda salts. By the end of eighteen hours or so, the blood-corpuscles
are left in a most abnormal condition; the great loss of water and
of salts, especially of the chloride of potassium--a most important
constituent of the blood-cells--at once leads to the conclusion that
their functions must have been greatly impaired. Accordingly, Dr.
Schmidt found that the amount of oxygen contained in them was lessened
by one-half." Dr. Robertson affirms that the "fibrin of the blood is
usually in large amount and coagulable with great firmness;" while
Dr. Parkes, speaking of the same condition of the blood, and relying
on the accuracy of his analysis, observes, "The presence of fibrin
in the blood was not indicated by any coagulation either in or out
of the body; and whether coagulated or not, the blood has usually a
dark color; but it generally acquired an arterial tint when brought
into contact with the air in thin layers." * * * "When we remember
the great share taken by the blood-globules in the respiratory and
heat-furnishing processes, it is scarcely possible to avoid concluding
that their loss of salts is connected with the characteristic cyanosis
and lowered temperature in cholera." "The diarrhoea coincides with
the first chemical changes in the blood--the transudation of some of
the constituents of the serum." Hence the phenomena of the disease
may thus be traced from this process as the starting-point. All other
chemical changes in the blood, and the most marked symptoms, such as
the abnormal respiratory process, follow as a matter of course. Such
is the theory of the nature of cholera, now advanced and sustained by
the most eminent pathologists, which embraces the doctrine previously
advanced that the blood is the primary seat of the disease, and becomes
contaminated by the absorption of a specific poison.


SECTION II.--PHENOMENA, OR SYMPTOMS.

The attack of this fearful disease is most generally sudden, the
patient being at the time apparently unconscious of any depressing
influence, or derangement of the system. It is not unfrequent, however,
that some slight irregularity of the bowels, loss of animation
and general vigor, or other apparently trifling indisposition,
have preceded it. In some instances there are definite and decided
premonitory symptoms which continue for a longer or shorter time
prior to the attack, commencing usually with a pallor or collapse of
the countenance, depression of spirits, slight pain in the forehead,
noise in the ears, occasional or transient turns of vertigo, slight
nausea, heat and pain in the epigastrium, oppression at the chest,
with frequent sighing, nervous agitation, some loss of muscular power,
general uneasiness, flatulence, with slight diarrhoea, sickness at
the stomach, occasional twinges of the nerves, or cramps in the
extremities, oppressed, small, feeble, and sometimes intermitting
pulse, coldness, clamminess, or humidity of the surface, and general
lethargy. Such are some of the premonitory symptoms which more
frequently occur in the lower latitudes, where the general vigor
becomes depressed by the long-continued and excessive heat of the
climate. Their duration, whenever any of them do occur, varies
materially; sometimes one, two, or three days--sometimes longer but not
often.

According to the observations and descriptions given by those who have
had the best opportunities for becoming familiar with all its various
phases, the symptoms attending its invasion and general course are
too distinctly marked to be ever mistaken for any other disease. In
the minds of many who have been called to witness the developments of
cholera, they undoubtedly exist with such distinctness and vividness
as to render the most labored and accurate description tame. In this
treatise, however, a description of the leading and more prominent
phenomena will be given, and so far as a general principle of practice
is concerned, this might be very appropriately limited to its first or
cold stage.

The commencement of the disease is often so insidious as to pass
unnoticed till the system is fully prepared for the sudden and violent
attack. The slight, painless diarrhoea, depression of the nervous
power, and occasional vertigo may all pass unheeded, and the patient
be apparently in perfect health. He may retire to rest entirely
unconscious of approaching danger, and after enjoying a sound and
undisturbed sleep for hours, be, on awakening from his slumbers, seized
with a remarkable sickness, perhaps vomiting, accompanied with most
remarkable and profuse discharges from the bowels. These inordinate
evacuations are usually attended with severe pains, extending down the
thighs, and a sense of complete and almost perfect exhaustion. The
physical powers and vital energies are immediately prostrated. The
temperature rapidly sinks below the normal standard--the body becomes
benumbed with an icy coldness--the skin becomes shriveled up, and
almost insensible to hot and stimulating fomentations--the breath,
too, as it comes from the lungs, appears to partake of the same icy
coldness, indicating the rapid elimination of heat, or caloric, from
the body. The patient complains of being greatly oppressed, throws off
his clothing--calls for cold water, which he eagerly and copiously
drinks; though it afford no relief to his insatiate thirst, it ought
not to be withheld. This peculiar icy coldness and loss of temperature
is also further shown by the livid, blue, or purple appearance of
the hands and feet, extending sometimes over the greater part of the
body. The skin becomes, even in a few minutes after the seizure, not
only shriveled up, but often curiously wrinkled, as in extreme old
age. Severe spasms in the fingers, toes, legs, and abdomen, cause the
patient to groan and writhe under their influence, and to call on
his attendants, if fortunate enough to have any around him, for aid
and relief from his agonies. As the disease proceeds, there may be
noticed a peculiar, sharp and contracted state of the features, and
a wild and terrified expression of the countenance, arising from the
impression and fearful apprehension of rapidly approaching dissolution.
These important changes may all take place in a very few minutes. To
these most obvious and singular symptoms there is superadded constant
vomiting--incessant purging--low, feeble pulse, though occasionally
natural and sometimes rapid, yet in some instances, from the very
first moment of attack, cannot be discovered either in the large
superficial arteries or at the wrist. The voice is altered, becomes
low, feeble, unnatural in tone, or sinks even to a whisper. Respiration
becomes quick, irregular, laborious and imperfect. The inspiratory
act being performed with difficulty, and expiration being quick and
convulsive. The flow of bile into the intestines is suspended, the
urinary secretion and micturition entirely suppressed. Almost the
only organ which seems to preserve in any good degree its powers is
the brain--the mental faculties in some cases being retained till
the close of life;--in other cases feeble, weak, and much impaired.
On the accession of the spasms, the vomiting--and the purging--the
disease may be considered as being fully developed, and the crisis at
hand, which, in a few hours, must decide the fate of the patient. Its
progress is now rapid, and must speedily terminate either favorably
or unfavorably. If the result be unfavorable, the patient may die with
all these symptoms distinctly and strongly marked. If the termination,
however, be favorable, these violent symptoms soon yield, and seem
to be materially relieved; yet, though these indications favor the
return of normal power--the weakness, the cessation of the pulse, the
coldness and blueness of the surface, and the sepulchral expression of
the countenance, clearly show that a few hours must close the scene. To
many death thus often comes calmly and quietly, without any struggle to
mark the precise time of this life's departure.

"If the patient," says an eminent author, "should happily survive the
cold stage, the disease may terminate by a rapid recovery, or it may
pass into the second or febrile stage." The former is the more usual
course in India, the latter in Europe. The first symptom of returning
health is shown by the patient falling into a sleep of unusual
soundness, during which the respiration becomes light and easy,
the pulse freer, while a gentle, warm perspiration bedews the whole
body. This grateful pause in the disease appears to be the result of
the returning powers of life, uninfluenced by medicine, for it often
occurs where none has been given. After this balmy slumber the patient
awakes refreshed, and often recovers so rapidly, that in the natives
of India it almost resembles a restoration after syncope. In all the
Presidencies, indeed, and especially in Bengal, the recovery of the
European has, in general, been followed by a stage of reaction, usually
slight, but in some cases assuming the form of the bilious remittent
fever of the country, which has occasionally terminated fatally.
In most cases, however, the reaction is more considerable, and the
patient, in a few hours after the subsidence of the cold stage, labors
under a severe form of fever, resembling the typhoid. During the first
few hours after the febrile reaction commences the tongue is white,
but it quickly becomes brown and dry, while black sordes incrust the
teeth and lips. The eye becomes deeply injected and red, the cheek pale
or flushed, the pulse rapid, and the temperature of the body a little
above the natural standard. The patient, either delirious or comatose,
then lies in a state resembling the last stage of the severest typhoid
fever of this country. This struggle usually lasts from four to eight
days, when the symptoms either gradually yield, or death ensues. In a
few mild cases the fever assumes an intermittent type, or sometimes a
quotidian, sometimes a tertian form: all these cases usually recover.
Such is, in brief, a summary of the more important symptoms of the
Epidemic, or Asiatic Cholera, especially in its earlier or cold stage.
The phenomena, especially developed in, and belonging to, the stage
of reaction, being of minor importance, they have received only a
very brief consideration; sufficient, however, to show the general
character and tendency of the disease in this stage of its progress and
termination.



CHAPTER III.

SECTION I.--UNSUCCESSFUL MODES OF TREATMENT--VENOUS TRANSFUSION
EXPLAINED.


In this discussion we shall avail ourselves of the researches and
investigations of eminent Professors, whose observations, experience,
and position give their views the highest authority. The latest and
most deserving record on this subject is from the pen of Professor
Aiken, of Edinburgh, who observes, "There are few diseases for the cure
of which so many different remedies and modes of treatment have been
employed as in Cholera, and, unfortunately, without our discovering an
antidote to the poison. In Moscow it is said that the mortality was
not greater among the destitute of medical aid than among those who
had every care and attention shown them. It may be fairly inferred,
therefore, that in the severer forms of the disease, the action of
this poison is so potent as to render the constitution insensible to
the influence of our most powerful remedial agents. When, however,
the disease is mild, or on the decline, much may be done by obviating
symptoms to promote the recovery of the patient."

"The heroic remedies that have been employed in Cholera are bleeding,
and calomel and opium, either separately or conjointly. With respect
to bleeding, it may be stated, that in every country the patients
bore bleeding badly in any stage, and that the practice in Europe was
at length limited to a few leeches occasionally to the head. As to
calomel, that medicine was used to the greater part of an ounce in the
twenty-four hours, but with so little success that many patients have
been seized and have died under the full influence of mercury. On the
appearance of cholera in Europe, opium was administered in the doses
recommended by the Indian practitioners to the greater part even of an
ounce of laudanum; but it was soon seen that in the cold stage it was
inefficient in controlling the vomiting or purging; that it did not
allay the spasms, and, moreover, hardly produced any narcotic effect.
The action of the accumulated doses of opium, however, though suspended
during the cold stage, was often fully developed in the last stage,
and occasioned so much affection of the head that most practitioners
either abandoned its use or limited it to a mere fractional dose of
that usually given in India, namely, from three to twelve minims of the
tincture of opium, or half a grain to a grain of solid opium every four
or six hours."

Let us now turn to a paper by the justly celebrated Professor Maclean,
whose observations and experiences have been more extensive than
perhaps those of any other professional gentleman either in Europe or
America. Unlike many of his brethren, he holds on this subject the
safer doctrines of practice, and very frankly and earnestly expresses
the same in the following language: "Opium in cholera should be given
only in the premonitory diarrhoea. At this stage, in combination with
a stimulant, it is of the highest value. If persevered in, particularly
in the strong doses (justly reprobated), it is a dangerous remedy,
inducing fatal narcotism, or, at the least, interfering with the
functions of the kidneys, and so leading directly to uræmic poisoning."

"Urgent thirst is one of the most distressing symptoms in cholera;
there is incessant craving for cold water, doubtless instinctive, to
correct the inspissated condition of the blood, due to the rapid escape
of the liquor sanguinis. It was formerly the practice to withhold
water--a practice as cruel as it is mischievous. Water in abundance,
pure and cold, should be given to the patient, and he should be
encouraged to drink it, even should a large portion of it be rejected
by the stomach; and when the purging has ceased, some may, with much
advantage, be thrown into the bowel from time to time.

In the stage of reaction, the fever may be moderated by cold sponging,
or by the wet sheet; the secretion of urine may be promoted by dry
cupping over the loins by the use of chlorate of potash, and the like.
But suppression of this secretion is most to be dreaded where opium has
been too freely used in the treatment. In men of intemperate habits, we
often see, during the stage of reaction, obstinate vomiting of thick,
tenacious, green, paint-looking matter, probably bile pigment, acted
on by some acid in the stomach or alimentary canal. It is a symptom
of evil omen, and often goes on uncontrolled until the patient dies
exhausted, and this although all other symptoms may promise a favorable
issue. I have known it last for a week, resisting all remedies, and
proving fatal when the urinary secretion had been restored and all
cerebral symptoms had subsided. Alkalies in the effervescing form, free
stimulation of the surface, and chloroform in small doses offer the
best hope of relief. The patient should be nourished more by the bowel
than the stomach when vomiting is present. Ice should be not only to
dissolve in the mouth, but to swallow in pieces of convenient size."

"Another heroic plan," says Dr. Aiken, "peculiar, perhaps, to this
country, which was practiced when the inefficiency of medicines was
generally admitted, was an injection of a solution of half an ounce of
muriate of soda, and four scruples of sesquicarbonate of soda in ten
pints of water, of a temperature varying from 105 to 120 Fah., into the
veins of the suffering patient. The solution was injected slowly; half
an hour being spent in the gradual introduction of the ten pints, and
the immediate effects of this treatment were very striking. The good
effects were rapid in proportion to the heat of the solution, but a
higher temperature than what is stated could not be borne. After the
introduction of a few ounces, the pulse, which had ceased to be felt
at the wrist, became perceptible, and the heat of the body returned.
By the time three or four pints had been injected the pulse was good,
the cramps had ceased, the body, that could not be heated, had become
warm, and instead of cold exudation on the surface, there was a
general moisture; the voice, before hoarse and almost extinct, was now
natural, the hollowness of the eye, the shrunken state of the features,
the leaden hue of the face and body had disappeared, the expression
had become animated, the mind cheerful, the restlessness and uneasy
feelings had vanished, the vertigo and noises of the ear, the sense
of oppression at the precordia had given way to comfortable feelings;
the thirst, however urgent before the operation, was assuaged, and the
secretion of urine restored, though by no means constantly so. But
these promising appearances were not lasting; the vomiting continued,
the evacuations became more profuse, and the patient soon relapsed into
his former state, from which he might again be aroused by a repetition
of the injections; but the amendment was transient, and the fatal
period not long deferred. Of 156 patients thus treated at Drummond
Street Hospital, Edinburgh, under the direction of Dr. Macintosh, only
25 recovered; a lamentably small proportion; and, small as it is, it
seems doubtful if the recoveries were final or complete."

       *       *       *       *       *

But let us turn to another page, whose beauty is especially marred by
unreasonable expedients: "The warm bath," says the writer, "was at
first tried, but discontinued from the uncontrollable nature of the
vomiting and purging, and the oppressive sensation of heat it produced
on the patient's feelings. Mr. Dalton's vapor bath and Turkish baths in
the Hospital at Scutari have been used, but without benefit, and to the
disappointment of the hopes which had been entertained of them."

"Other methods of restoring warmth were had recourse to, such as
frictions with the hand or by the flesh-brush, or rubbing the body with
some strong stimulant embrocation, compounded of garlic, capsicum,
camphor, cantharides, or other powerful irritants. Mustard poultices
also were often applied to the feet and abdomen, blisters with or
without an addition of oil of turpentine, the part having been
previously rubbed with hot sand; and in cases supposed to be urgent,
the mineral acids, and even boiling water, were employed for the
purpose of producing instant vesication."

"And, again, we read of those who tried to stimulate the waning powers
of life by galvanism, acupuncture of the heart, issues, setons, moxas,
actual cautery along the spine, and, lastly, by small pieces of linen
dipped in alcohol distributed over the body and then set fire to!!!"
Such are some of the means which have been used in the treatment and
cure of cholera.

"The failure of such powerful means at length caused most practitioners
to confine themselves to checking the diarrhoea, which so frequently
precedes cholera, and subsequently, to obviating symptoms as they
arose," and for this purpose, returned to and adopted a very simple
stimulating mixture, recommended by the Board of Health:

    Rx. Pulveris Aromat.,               dram iij.
        Tinc. Catechu,                    "    x.
        Tinc. Cardamom, C.,               "   vj.
        Tinc. Opii,                       "    j.
        Mixt. Cretæ Preparat.,          ounce xx.
        M.----S., j ounce, as necessary.

Tinc. Kino, or the decoctum Hæmatoxyli, were sometimes added.

These remedies, it is said, frequently arrested the attack altogether.
If, however, the disease proceeded and the cold stage of cholera
formed, the same remedies were prescribed in an effervescing draught.
"To promote reaction in cholera and diarrhoea, the following formula
has met with most universal approval in this country and in India. So
highly is it valued, indeed, that it is ordered to be always in store,
and in readiness in the _Medical Field Companion_ of the army when on
the march:

    Rx. Ol. Anisi,     }
        Ol. Cajeput,   }       [=a][=a]. dram ss.
        Ol. Juniper,   }
        Æther,                          ounce ss.
        Liquor Acid. Haleri,[I.]         dram ss.
        Tinc. Cinnam.,                  ounce ij.

M.----S.: ten drops every fifteen minutes, in a table-spoonful of water.
An opiate may be given with the first and second dose, but should not
be continued."

The learned author to whom we have referred, after detailing some of
the various expedients employed in the treatment and cure of cholera,
sums up the whole under the common term--failure--and, in effect,
declares the most powerful remedial agents ineffective and useless in
controlling and subduing this disease.

This declaration is made in reference to the general result of the
remedies and the various expedients adopted mainly by one class of
physicians, to which special reference has been made. It is therefore
partial, and confined solely to what is erroneously termed the regular
practice. In declaring all remedial agents a failure, does not the
author himself commit a greater failure in omitting to survey the whole
subject of treatment, and to trace out and to show from the application
of the pathology of the disease the probable cause of such failure?

However formidable this disease may appear, on account of its rapidity
and its firm, unyielding grasp upon the vital powers, the forbidding
and almost hopeless prospect of relief, and the lamentable results
which have attended some modes of treatment, it seems particularly
unfortunate for the profession that there should have been a
disposition on the part of this learned author to abandon all remedial
agents as comparatively useless, without a more thorough investigation
into the cause of failure. On this point no effort or inquiry even is
made. This is the more remarkable and surprising after dwelling at
length on the pathology of the disease. It would seem as if all the
light and science derived from this source for nearly half a century
had been overlooked, or the pathology of the disease, from some cause
not satisfactorily explained, had been deemed unworthy at least in
this instance to dictate the course of treatment. This should govern
in cases of cholera as in all other forms of disease, or else all
our efforts and remedies will prove abortive. Now, had the doctor
carefully investigated the various modes of treatment and compared
the results of each, he might have come to a different conclusion.
But, being confined and limited in his investigations, he is unable
to discover anything reliable or worthy his commendation, except the
formulas above and the recommendation of Dr. Maclean. Among all the
remedies and expedients named, there is only one tending to fulfil,
the indications required, and that one, though prompt and magical in
its effects, has been unequivocally condemned, without looking beyond
the transient result for any light it might shed upon the subject. How
it should have escaped his notice and passed so long unobserved by the
numerous professional gentlemen who had often witnessed the effect, and
were anxiously searching for light and the means of affording relief
to the suffering patient, is a most singular circumstance which can
only be accounted for on the principle that they all were anticipating
some strange phenomenon, or development of cure as mysterious as the
disease itself, which led them to overlook the simple and effective
means of relief so clearly represented and shown in their numerous
experiments for something more heroic and powerful than as yet the
imagination ever conceived.

If we trace the action of calomel, the use of opium, the effect of
cupping, bleeding, blistering, etc., etc., we shall obtain no very
desirable information; nothing valuable tending to indicate a correct
principle of practice. If we go still further, and examine the tendency
and effects of the various baths exhibited at Scutari, the use of the
flesh-brush, the bare hand, the heated sand, the embrocations, the
turpentine and other irritants, the boiling water, or the burning
alcohol, skinning and cooking the patient alive, we shall be shocked
at the enormous cruelty and barbarity that have been pursued, and turn
from the repulsive exhibition, without discovering one ray of light
to guide us in the right direction. Disappointed and baffled in our
inquiries, shall we here abandon our investigations and dismiss the
whole subject, because our course is involved in difficulties? Would
intelligence and reason justify the neglect to improve the means at
command? We think not; but rather induce us to advance in search of
truth if the elements of success are not quite exhausted. Let us be
encouraged and stimulated to untiring perseverance so long as there
remains any experiment untraced and uninvestigated in its bearing upon
the direct action of the disease. Had Dr. Aiken, or those other eminent
surgeons who took part in those numberless experiments, instituted
on the Continent and in England, especially those who initiated the
process of injecting into the veins a solution of soda raised to a
temperature from 105° to 120° Fahr., continued their investigations
patiently and assiduously, they might probably have discovered long ago
the correct theory of practice for the treatment and cure of cholera.

But they failed to see, or, if they saw at all, rejected the feeble
ray of light struck out by the experiments in which they had themselves
participated, and like the celebrated Dr. Hunter, who refused to listen
to the discoveries made by his pupil, the indefatigable Jenner, who
traced the identity of the variola with the common disease affecting
the kine; and thence extracted the vaccine lymph and established a
principle by which that loathsome disease and often recurring epidemic
has been nearly banished from the earth. Though they have thus failed,
they have nevertheless left on record, in unmistakable language,
the result of their bold experiments, which we may investigate, and
appropriate the instruction drawn thence for our own and the advantage
of our fellow-men.

What, then, are these results, regarded as shedding light on this
intricate subject? We refer only to one the most obvious which we have
already cited above. Let us repeat and analyze, and, if practicable,
show the principle evolved. There was, on various occasions, the
solution of soda injected into the veins at the temperature from 105°
to 120° Fahr.: a higher temperature could not be borne. This process
was performed slowly, thirty minutes being occupied in injecting the
ten pints. Now mark the result as the operation proceeds. Says Dr.
Aiken, "After the introduction of a few ounces, the pulse, which had
ceased to be felt at the wrist, became perceptible, and the heat
of the body returned." Mark the language: "only a few ounces" were
required to arrest for the time being, the progress of the disease
and restore warmth to the body; a very remarkable fact, replete with
instruction, as will appear as we proceed. Again says the Dr., "by
the time three or four pints had been injected the pulse was _good_,
the cramps had ceased, the body, that could not be heated, had become
warm, and instead of cold exudation on the surface, there was a general
moisture. The voice, before hoarse and almost extinct, was now natural;
the hollowness of the eye, the shrunken state of the features, the
leaden hue of the face and body had disappeared; the expression
had become animated, the mind cheerful, the restlessness and uneasy
feelings had vanished; the vertigo and noises of the ear, the sense of
oppression at the precordia, had given way to comfortable feelings;
the thirst, however urgent before the operation, was assuaged, and
the secretion of urine restored, though by no means constantly so."
Such is the astonishing result obtained by this experiment, and this,
too, when only three or four ounces had been injected--all the urgent
symptoms mitigated and relieved. What, we ask, could have been more
satisfactory, or better calculated to aid the discovery of an important
truth? Every distinctive and fatal symptom for the time is relieved,
and the normal condition and functions of the system restored; a result
which could only have been obtained by the evolution of a principle of
sufficient promptness and power and diffusibility to arrest and utterly
suspend for a time the force of this disease.

What, then, was the principle evolved in this experiment, which gave
immediate relief? Did it consist in the half ounce of muriate of soda
alone, or in the four scruples of sesquicarbonate of soda alone, or
in the ten pints of water alone, or in the whole combined, or more
especially in the high temperature to which the solution was raised? It
is a well-established fact that, in order to raise the temperature of
cold water to blood heat and above, a large amount of free caloric must
necessarily be absorbed, and exist mechanically in the fluid; and, in
this condition, the solution was introduced into the veins, and there
evolved its vast amount of free caloric, which immediately permeated
every organ of the system, arresting disease, raising the temperature
of the body, and restoring its normal functions. Of this there can be
little doubt. For free caloric is one of the most prompt, effective and
diffusive stimulants known, and was evidently in this case the remedial
agent which produced the result. True, it may be said the effect was
transitory, and passed off as soon as the caloric became eliminated.
This, however, cannot alter the nature, character, or influence of
the principle on which it was produced. It is usually admitted that a
remedy that has power to control disease, will, by its continued action
and influence, restore the normal condition of the system permanently,
or at least aid Nature to repair her own work. By this we would
not be understood as advising a repetition of the experiment under
consideration, even under the most urgent circumstances; far otherwise
would be our advice. We are arguing for the purpose of evolving and
establishing a general principle of practice.

The great question, then, is, Did the principle evolved fulfill the
indications required? and if so, is it available and consistent with
the pathology and the peculiar phenomena, or symptoms of the disease?
To settle this point, we need only turn to the law and the testimony,
the very highest authority on the subject. The doctrine now universally
accepted and prevailing regarding its pathology is, that a poison,
virulent, and subtle, and unknown, has been absorbed and infects the
blood, so that, after a longer or shorter time, a primary disease of
this vital fluid is produced, by which the vital energy is impaired,
and all other morbific changes induced. The term "Algide," first used
by the French Pathologists, very accurately describes one of the most
remarkable and constant symptoms, viz., the diminution of animal heat.
On this depend the altered condition of the blood, the depression of
the nervous power, the impaired functions of the respiratory and all
the vital organs which are essentially involved by the disease. The icy
coldness of the surface, the breath, the extremities and general loss
of temperature, all show the character of the disease and the wants of
the system.

Did, then, the principle evolved accord with the pathology and
phenomena of disease? And did it fulfill the indications required?
If not, we ask by what means was the disease arrested, and all the
urgent symptoms mitigated and relieved, or by what were the good
effects produced, and the normal action for a time restored? Can the
result be reasonably accounted for on any other principle than the one
assigned--the stimulating power of the free caloric? We think not; for
it accords most perfectly with the pathology and the peculiar phenomena
of the disease. It assuaged the more urgent symptoms, answered the
imperious demand of the waning powers, revivified and reinvigorated
the vital energies, and restored for the time the normal tone of
the system. What more could be desired in any single agent than the
result here obtained? That it accomplished all this, there can be no
question, according to the statement of the learned professors who have
repeatedly witnessed and described the results.

The question, however, will arise, Can this principle be rendered
available? Most certainly it can; and though it may not be convenient
to introduce free caloric into the stomach, we can, by combination,
introduce a stimulant of equal potency which shall be equally
as prompt, effective and diffusive in its action, similar in its
influence, and similar in its results. It is the principle--not the
precise element for which we contend.

It is universally admitted that in many instances we may learn much
from observing the manner of death which, in a majority of these cases
of cholera, may be described by the term asthenia--a death similar to
that which occurs in congestive fevers, and in some cases of accidental
poisoning. Perhaps the most striking fact observed in these cases is
the perfect exhaustion attending the last moments of existence, and
the quiet, undisturbed manner in which life terminates. This very
clearly shows the exhausting nature and congestive character of the
disease, and gives us an idea of the course of treatment necessary to
be pursued. If, then, there is anything to be learned from this source
relative to its treatment, it does most certainly corroborate and
strengthen the position we have here taken.

Another feature of the case in aid of our position consists in its
entire accordance with the modes of treatment which have been most
successful in the cure of cholera. The two formulas cited above, and
now most universally adopted in Europe and India, are based on a
similar principle. So in this country 1832,-33 and 34, the successful
modes of treatment consisted in the adoption of a principle essentially
similar. Hence we infer from the teachings of this experiment, and from
all the collateral facts on the subject, that the general principle to
be observed in the treatment of this disease is a prompt and diffusive
stimulant; and hence we deduce the doctrine already apparent, that
every form of treatment, to be successful, must be based on a prompt
and effective stimulant of sufficient power to meet as speedily the
indications required, as did the free caloric in the experiment to
which we have referred.

Here we might pause for a moment and examine the suggestion and
doctrines advanced by the learned Drs. Bell, Johnson, and many
other eminent practitioners in India and Europe. We might further
investigate the principles and trace the practical philosophy of such
eminent surgeons, as Drs. Mackintosh, Thompson, Wallis Maxwell, Massy,
Hill and Brady, all of whom have had opportunity of investigating the
nature and character of the disease and extensive experience in its
treatment.

We might also, in a further examination of the subject, embrace a host
of American authors whose works teem with every shade of doctrine,
and almost every variety and description of practice, some evincing a
degree of skepticism on the subject more wonderful and marvelous than
is becoming the great apostles of medicine. It would seem as if the
guiding light of science and experience had forsaken them in this, the
hour of their need; that facts and arguments had failed to illumine
their minds, or direct their inquiries in the proper course for the
discovery of "the truth." Their conclusions on this subject are,
therefore, marvelously inconsistent and conflicting. Over this mass
of specious and conflicting testimony we might long ponder, without
deriving any very valuable information worthy an elaborate effort, or
making any discovery to aid in the establishment of a general principle
of practice for the cure of cholera. But this investigation must be
deferred to another occasion, when time may permit a more thorough
and critical examination of their doctrines and practice than can be
presented in this brief essay. We would, however, remark in passing,
that in some instances their philosophy, doctrines, and results may
lead us to the same conclusion to which we have arrived from other
sources as above, and from our regard and belief in the progress of
science, feel compelled to advocate the same, as offering the best hope
of success in the treatment of this disease.

In the employment of an anti-miasmatic principle and remedial agent,
we feel ourselves abundantly sustained, by the concurrent testimony,
of those English surgeons connected with the Medical Bureau in the
department of India, whose numerous experiments and carefully detailed
clinic cases occurring in the recent irruption and prevalence of
the disease in that section, exhibit its utility in such a striking
contrast with all former practice, as to leave no doubt as to its
direct and specific action in the cure of cholera. It is in allusion to
these experiments, and in answer to the question, what is deemed the
most successful mode of treatment, that the learned Professor Maclean
unhesitatingly observes, "Alkalies in the effervescing form, free
stimulation of the surface, and chloroform in small doses, offer the
best hope of relief." As this opinion comes from such high authority,
and is compatible with the pathology of the disease, we may, without
fear of controversy, add in conclusion, in any and every form of
medication for the cure of cholera, we must not forget that chloroform
is our sheet-anchor; and must be so combined and administered as to
meet promptly the indications required.


SECTION II.--PHYSIOLOGICAL CONDITION OF THE BLOOD.

ITS NON-AERATION--NON-OXYDATION.

In the preceding section we alluded to the suggestions and doctrines
advanced by the learned Dr. C. W. Bell, Physician to the Manchester
Infirmary, and late Physician to H. M. Embassy in Persia--and also
to Dr. George Johnson, of Kings College, whose views and doctrines,
relative to the Pathology, illustrative of the congestive character
and non-aeration of the blood, coincide with those of Dr. Bell. A
brief examination of their philosophy and doctrines will show very
conclusively the first direct impression of the poison--the gradually
altered condition of the blood, and the corresponding loss of nerve
power--the impeded arterial circulation and the general tendency to
congestion, as well as the altered condition and stagnation of the
blood, especially during the stage of collapse.

The question is asked, "What is the pathological explanation of this
remarkable train of symptoms?" and the answer is given, "The one great
central fact is this, that during the stage of collapse, the passage of
blood through the lungs, from the right to the left side of the heart,
is in a greater or less degree impeded." Very conclusive evidence as to
the existence of impeded pulmonary circulation during life is afforded
by the appearances observed in the heart, blood-vessels, and lungs
after death.

After adducing the evidence of this impediment from _post-mortem_
examinations, and affirming that the blood does not flow freely
through the lungs and pulmonary arteries, which are often filled and
much distended with blood, it is observed--"The most interesting and
conclusive evidence that arrest of blood in the lungs is the true key
to the pathology of choleraic collapse, is to be found in the simple
yet complete explanation which it affords of all the most striking
chemical phenomena of the disease, the imperfect aeration of the
blood, and the suppression of bile and urine."

And again, says the learned author, "It is obvious that the stream of
blood from the pulmonary capillaries to the left side of the heart
is the channel by which the supply of oxygen is introduced into the
system. One necessary consequence, then, of a great diminution in the
volume of blood transmitted to the left side of the heart must be,
that the supply of oxygen is lessened in a corresponding degree. This
position, probably, will not be disputed by any one who will give the
subject a moment's consideration. Nor, again, can it be denied or
doubted that certain results must of necessity follow this limited
supply of oxygen." * * *

"The blood in cholera is black and thick only during the stage of
collapse; in other words, during the stage of pulmonary obstruction and
defective aeration."

Again, in his explanation of the injection of the solution of soda
into the veins of the suffering patient, it is affirmed, "The benefit,
however, is of but short duration, for the primary cause of the
impeded circulation, namely, the poisoned condition of the blood,
being still in operation, * * * the stream of blood through the lungs
will soon again be obstructed, and the patient thus passes into a
state of collapse as profound as, and more hopeless than, before. It
appears, therefore, that the hot saline injection into the veins and
the operation of venesection, when it rapidly relieves, as it often has
done, the symptoms of collapse, have this effect in common, that they
facilitate the passage of the blood through the lungs, and thus lessen
that embarrassment of the pulmonary circulation which is the essential
cause of choleraic collapse. But whereas the _hot injections act_ by
removing the impediment which results from spasmodic contraction of the
arteries; _venesection acts_ by relieving over-distension of the right
cavities of the heart, and thus increasing the contractile power of
their walls."

Such are, in brief, the views of the learned Drs. Johnson and Bell,
whose works are very highly commended by their American editor to
the notice of the profession. These views, coming as they do from
the highest authority, fully sustain the doctrine that the earliest
impression of the disease is made upon the blood, and hence it becomes
altered and changed in its most essential life-sustaining principle;
for its oxygen becomes diminished, its consistency augmented, and its
flow through the lungs impeded. Through this channel the effect of
the poison soon makes an impression on the ganglionic mechanism, and
the nerve-power becomes correspondingly diminished, and the action
of the ganglionic nerves essentially deranged. But this is not all:
they exhibit in the clearest manner the congestive character of the
disease, and show the necessity of prompt and decided means to arrest
this tendency. Hence, they urge, in the strongest terms, the importance
of observing carefully this essential feature, and endeavor to exhibit
fully the condition of this vital fluid at a particular stage of
the disease, when bleeding, as recommended in their practice, is
required, and may be performed to the best advantage for the relief
of the partially congested blood-vessels, and to stimulate and give
freedom to the circulation. The passage of the blood, they affirm, is
impeded, clogged, and partially suspended. To remove this obstruction,
relieve spasm, and secure the prompt aeration of the blood, in hope
of arresting the progress of this disease, is ostensibly the object.
However, they seem studiously to avoid the most logical conclusions of
their explanations, and justify a practice that can give no hope of
permanent relief, while every fact and symptom is ominously suggestive
of the wants of the system, which imperiously demands the aid of
electrified oxygen, ozone, or free caloric, for the oxydation of the
blood.

Says Dr. Reid, "I believe the true explanation of the arrest of blood
in the lungs to be this: The blood contains a poison, whose irritant
action upon the muscular tissue is shown by the painful cramps which it
occasions. The blood thus poisoned excites contraction of the muscular
walls of the minute pulmonary arteries, the effect of which is to
diminish, and, in fatal cases, entirely to arrest the flow of blood
through the lungs."

Says Dr. Wallis, "The phenomena which are exhibited when the
deleterious air has been drawn into the lungs are these: the great
gastro-pulmonary nerve is either wholly or partially paralyzed; the
consequences are the cessation of all its functions, either wholly or
partially. This great nerve is a nerve of function, and performs the
functions of digestion and respiration, and influences all secretions."

Dr. Maxwell, of Calcutta, uses the following language: "The development
of the stages of fever entirely depends on the changes the _leaven
has effected_. If this change has been such that the blood has become
too thick to flow through the lungs, then, as a matter of course,
the collapse stage is developed in excess; in other words, _cholera
asphyxia_ is exhibited. The blood, unable to pass through the middle
passage into the arteries, collects and swells out the veins, giving
that deadly or blue color to the skin. When the vomiting and spasms
come on, this mass of blood in the veins is squeezed with great force,
and hence the clammy moisture that is forced from every part during
these fits. There is no pulse, because there is no blood in the
arteries." "There are also lethargy and languor, and oppression in
breathing, caused by the blood being collected in the veins. These make
up the principal links in the chain of mechanical symptoms."

Dr. Bell, dwelling on this congestive character of the blood, and
endeavoring to point out the best mode of relief, observes, "When this
has reached to such a point as to oppress the action of the heart,
yawning first and then shivering, or a sense of suffocation and pain
in the precordia, are the indications of oppressed circulation, and
of the commencing effort of the heart to overcome the mass of blood
which is stifling it. If, by the application of tourniquets to the
limbs, or by _bleeding_, part of the blood which is rushing from the
extremities to increase this congestion is prevented from reaching the
great veins, the heart, excited to increased action, is enabled, by
this relief, more quickly to overcome the obstruction and restore the
balance of the circulation, and the paroxysm passes off. If not thus
mechanically aided, the heart, after a severe struggle to maintain the
circulation during the period of constriction, is at length relieved
by this nervous disturbance or spasm of the capillary circulation
passing off of itself, and then the heart and arteries, so long excited
by the struggle, maintain for a time their increased action after
the obstruction in the capillaries is removed, and produce apparent
febrile action. Presently this excitement subsides, the vessels become
relaxed, and sweat succeeds. The vessels continue in this state for
a longer or shorter period, according to circumstances, till they at
length recover their ordinary tone and action in the intermission. This
fever, however, is not fever properly so called, but reaction; and the
sweating not critical, or essential, but relaxation. The cold stage
is alone essential, and is the physiological cause of the subsequent
stages."

From the passages we have cited, it is quite evident that Drs. Johnson,
Bell, Parkes, Reid, Wallis, Maxwell, Massy, and many others, admit this
congestive character and impeded circulation of the blood to be the
result, or consequent of a primary affection of the blood, as we have
already observed in a former paper. The _term_ "Algide" is peculiarly
expressive of the diminished animal heat, and, as Dr. Bell represents,
it is the cold stage which is alone essential, and is the physiological
cause of the subsequent stages. It is the specific disease-poison, so
often referred to, that has been inhaled, the leaven that has effected
such obvious changes in the blood. The poison, virulent, and subtle,
and unknown, so marvelously active in its operations, that is exhibited
so prominently in all the works we have perused as the one great,
mysterious, and efficient cause which produces the disease called
cholera, and all the phenomena of its development. To its direct and
specific action, therefore, must be attributed all the phenomena of
the disease as the resulting subsequent consequences.

It is also further evident, from the pathological facts and arguments
adduced in support of this theory of congestion, that the abnormal
condition or state of the blood-vessels is the result and the product
of the activity of the primary or final cause, and must be regarded
in relation to it as cause and effect. On this principle alone, the
thickening of the blood, the contraction of the left ventricle of the
heart, and of the capillary and pulmonary arteries, assigned by some as
the cause of choleraic collapse, must be accounted for. These effects
are not and cannot be from a process independent and outside of the
primary disease action, but are the result of such primary action.

Again, it is evident, from the views and doctrines cited above, that
the disease is decidedly congestive in its tendency and character from
its very commencement. The impeded flow of the blood--the comparative
emptiness of the left ventricle of the heart and arteries--and
the excessive loss of temperature, all indicate a rapid process of
congestion attending the progress of disease. This is one of the
peculiar and prominent features of cholera, and is strikingly exhibited
in the morbid appearances observed in all those instances where death
has occurred within a few minutes from the first indications of attack.

When the attack is violent, the process is rapid; when mild, it is
slow; and even in the collapse stage progresses tardily. In either case
it is the direct resulting consequent of the primary cause. How else
can the violent attacks, suddenly terminating in death, be accounted
for? To what other principle can this altered condition and stagnation
of the blood be attributed? The evidence confirmatory of this position
is abundant and conclusive. Many instances of the apparently rapid
action of the cholera poison are related by Dr. Milroy, in a historical
sketch of the epidemic of 1817; and at Kurrachee in 1855 and 6, it is
said, that within little more than five minutes, hale and hearty men
are seized, cramped, collapsed, and dead!!

When the disease broke out at Teheran, in May, 1846, Dr. Milroy states
that those who were attacked dropped suddenly down in a state of
lethargy, and at the end of two or three hours expired, without any
convulsions or vomitings, but from a complete stagnation of the blood.

In the paper before us, it is stated, that "in a great majority of
cases in which death has occurred during the stage of collapse, the
right side of the heart and the pulmonary arteries are filled, and
sometimes distended with blood; the auricle being partially, and the
ventricle completely and firmly contracted. The tissue of the lungs is,
in most cases, of pale color, dense in texture, and contains less than
the usual amount of blood and air. There is something surprising in
the contrast between the almost constant occurrence of this extremely
anæmic condition of the lung, from which scarcely even a few drops
of blood flow when the tissue is cut, and the hyperæmia of most
of the other viscera." This impeded flow of the blood through the
lungs, resulting, as it must, in a very scanty supply of blood to the
arteries, in connection with the corresponding fact of the increased
expansion of the veins, filled with black, and thick, and stagnant
blood which, by the action of a powerful poison, or malignant disease,
has become disorganized and unfitted for circulation, furnishes
indubitable evidence of one prominent and characteristic feature of
cholera which we term congestion, and to which we alluded in our
remarks when the question under consideration was first introduced;
in this view we are happy to find ourselves, on a more thorough
examination of the subject, ably sustained by eminent pathologists
and authors, who have arisen during the half century last past, and
whose works are said to embrace all that is known and reliable on the
character and treatment of Epidemic Cholera.

It is worthy of notice, before passing from this part of our subject,
that according to Dr. Bell's _views_, the blood is forcibly sent into
the great central veins, and there stopped in its course without any
attempt to account satisfactorily for its singular arrest, at that
point--Dr. Johnson comes to his relief, lifts the veil, and explains
why it is kept there and cannot get any further. If the road, he tells
us, had been clear and uninterrupted through the lungs, the blood would
easily have got round to the left ventricle, and have again gone its
round, but it is stopped by the spasmodic contraction of the minute
branches of the pulmonary artery, which will not even allow the blood
to enter the pulmonary capillaries, as shown by the remarkable anæmia
of the texture of the lungs.

In this connection may be introduced an opinion as to the cause of
the disease and some of its phenomena, which has obtained at least
some celebrity, and attracted the attention, if not the careful
consideration of the profession. It will account, in part, if founded
in fact, for the physiological condition under consideration.

It is said, some have observed a chemical change in the constitution
of the atmosphere, and have attributed the cause of the cholera to
the loss or diminution of its ozone--a principle which is understood
to represent what is very properly termed electrified oxygen. Ozone
is, therefore, the vital element of the air. It is said that oxygen
cannot be assimilated or combined with the blood except when it is
in an electrified state constituting the peculiar property or state
of ozone. In this state it produces vital electricity of the blood,
_which is the life_. The brain is considered and represented as the
reservoir of this vital electricity, and the nerves are the telegraphic
wires or conductors of it. As a necessary consequence, all acts of
material and intellectual life depend upon this double cause. The
absence, then, it is affirmed, of this principle, termed ozone--or
electrified oxygen--from the atmospheric air in certain localities
and the consequent non-aeration or non-oxydation of the blood, may be
considered as an efficient cause which will account for some of the
most striking phenomena of the cholera.

Whether this electrified oxygen, or ozone, is identical with free
caloric, it is unnecessary for our purpose at present to determine. It
will be admitted that oxygen is the source of animal heat, and when
introduced into the system generates its free caloric, which is an
essential life-sustaining principle.

Dr. Massy, after describing a severe and advanced stage of cholera,
observes, "The treatment of this case depends in the first instance
on bleeding, and largely, if the patient's pulse is good, giving at
the same time twenty grains of calomel with one of opium. This, he
thinks, will be found the best practice. After twenty minutes, he gives
ten grains more of calomel and half a grain of opium. He considers,
however, a reliance on opium in this form of cholera most faulty--but
observes, as you draw blood, stimulate, give punch, brandy, or wine
and water, or carbonate of ammonia. Apply friction, with stimulating
and hot liniments to the extremities, warm sand-bags to the feet,
sinapisms to the calves of the legs and pit of the stomach; for, if
you can once raise the pulse, the chances in favor of recovery will be
vastly increased." The practice of bleeding and stimulating at the same
time is deemed of vast importance. Dr. Bell coincides in this view, and
devotes much space to the necessary instruction as to the time when and
under what circumstances to bleed and to what extent, endeavoring to
show the advantages arising from a strict observance of certain rules
in carrying out this practice.

We have thus traced, _in extenso_, the views and doctrines of eminent
surgeons and authors on the changes of the blood, and especially of
the impeded circulation, to show, if practicable, the inconsistency of
the more common and prevailing practice, and its utter inadaptation
to the pathology and phenomena of disease. On the latter there seems
to be little or no discrepancy--on the former there is a great
diversity--as there has been no general principle established and
laid down as the basis of treatment and cure of cholera. It has
often been observed there is no disease on which so many different
modes of practice have prevailed, some purely experimental, others
empirical--and all without discovering an antidote to the poison, or
any efficient mode of relief. The cause, or the poison producing the
disease, still remains undiscovered. The direct mode of suspending
and removing it, or counteracting its power and neutralizing its
effect, and subsequently eliminating _it_ from the system, remains
still in doubt. What course, then, should the epidemic cholera again
prevail in our midst, shall we pursue? Shall we rest satisfied with
the diversified modes of treatment now prevailing? Or guided by the
light of reason, science and experience, endeavor to adopt a general
principle of practice, and exhibit and establish an efficient and
judicious system, consistent with the pathology and the phenomena of
the disease? Does then the practice, the prominent features of which
are given above, accord with the indications required? In short, does
the exhibition of bleeding and calomel and opium, accompanied with
sinapisms, and hot, stimulating applications to the surface, meet
the pathological condition and the phenomena of the disease? We have
seen that the rapid changes in the blood, and the consequent direct
tendency to congestion, are the proper and distinguishing features of
the disease;--and hence the diminution of animal heat and general loss
of temperature and their consequent effect, impeding the circulation,
depressing and prostrating the nervous power--impairing and paralyzing
the respiratory organs--suspending the functions of the liver and
kidneys--enfeebling the action of the heart, and causing the capillary
vessels of the mucous surfaces to pour off the serous fluid from the
blood, and every muscle and tissue of the system with great rapidity,
essentially constitute the phenomena of the cholera;--and that the
constantly increasing augmentation of the poison and its intensified
effects, measure the malignity, the violence, and the rapidity of the
disease. Is there, then, any tendency in bleeding to arrest this rapid
process of disease so disorganizing, depreciating, and enfeebling to
the vital life-sustaining fluid, the blood? Can abstracting a portion
of it, however large, suspend the poison, or its activity, or even
check its progress in its rapid course and fatal termination? Can it
have, under its depressing and depleting process, any tendency or
power to relieve the congestion that is taking place, or change in any
good degree the poisonous principle which is now generally admitted
to exist in the blood, and to be the sole and efficient cause of its
altered character and condition? The poison, once introduced into the
blood, like the leaven hid in three measures of meal, will continue
its activity, increasing its energy, and multiplying its forces, till
the whole circulation becomes affected, and its life-sustaining power
is destroyed and utterly lost, unless, by the exhibition of some
remedial agent, it shall be promptly arrested in its progress, and
suspended and eliminated. Again we ask, Will calomel fulfill any of
the indications required? Has it any influence or power to arrest this
disease, to quiet the nervous system, relieve the cramps, or restore
warmth to the body? Its specific action, so far as known, can have no
tendency whatever to relieve the system in any essential particular,
or stay the progress of disease, or delay its inevitable result, if it
remain unsubdued by the action of other remedies. Its action upon the
liver, however prompt it may be, is only of a secondary importance. The
primary cause must be overcome, its activity and energy suspended and
the system generally relieved, or there is little hope in the case.

Here we may ask, Will opium aid, or give the relief so urgently
demanded? However serviceable as an astringent and anodyne in the
premonitory stage of the disease, it cannot be exhibited in the second
stage to so good an advantage, as its direct influence is to aid and
promote congestion in those cases, where a tendency of this kind is
already in existence. Hence, its continuance in the true or collapse
stage of cholera is now generally considered faulty.

Once more: The auxiliaries employed in aid of the leading remedies
already noticed may be summed up in the language of the celebrated
Dr. Massy, in his instructions and directions on the subject of the
treatment now under consideration. He observes, "But, as you draw
blood, stimulate, give punch, brandy, or wine and water, or carbonate
of ammonia. Apply friction, with stimulating and hot liniments to the
extremities; warm sand-bags to the feet, sinapisms to the calves of the
legs and pit of the stomach; for, if you can once raise the pulse, the
chances in favor of recovery will be vastly increased."

To these directions there can be no special objections, except in the
first instance in which he, indirectly, commends the use of means
tending to deplete and depress the system, already brought by disease
to the very verge of utter exhaustion. Remedies of this tendency
are contra-indicated, and cannot, to say the least, be employed to
advantage.

Depressing remedies generally, instead of checking, or counteracting
the disease, will inevitably aid and hasten its fatal termination.
Stimulants, such as are prompt and diffusive in their character, must
be regarded as essential, and may be employed to great advantage. It
will be found, however, exceedingly difficult in most cases, even
where there is no depletion from bleeding, to keep up the waning
powers, and carry the patient, through this formidable disease, to
a favorable termination. Of the utility of warm applications to the
surface generally, there can be no question; yet, our main reliance is
on internal remedies, as has been already shown: the lost temperature
of the body must be restored, the production and diffusion of heat, or
caloric, must be internal through the administration of remedies, that
will promptly and kindly produce this result.

What are, then, the remedies? We have ventured in this discussion
to recommend the internal use of chloroform, and believe it will be
found in combination with other prompt and diffusive stimulants,
specially adapted to meet this condition. In this recommendation, we
feel ourselves fully sustained by the result of various experiments
heretofore made, and the recent trials of its use, as an internal
remedy in the various stages of the disease.

The earliest record of the use of chloroform in cholera is probably
to be found in the London _Lancet_ for November, 1848, in which Dr.
Hill reports a case of its successful use by inhalation. He placed
the patient in bed, covered with warm blankets, and applied friction,
stimulant liniments, and heated bags of bran to the surface, and kept
the patient under the gentle influence of chloroform, till the more
urgent symptoms entirely subsided. At intervals brandy-and-water, and
thin arrow-root or milk was given. All other medicines were avoided.
Though the urgent symptoms returned at first, as the effects of the
chloroform passed off, they were easily controlled by the repetition
of the inhalation. By persevering in its use, reaction set in, and the
patient became convalescent.

Other cases, afterwards, were treated in the same way, with a similar
result. Some, however, required the gentle use of chloroform by
inhalation, at intervals, for twenty-four hours; after which, none
seems to have been administered. For aught that appears these cases all
recovered.

Another very interesting case is related by Mr. Brady, who observes
that an elderly lady was seized with slight diarrhoea, which, on
the following morning, had become very profuse: excessive vomiting
supervened, accompanied by spasms in the calves of the legs, fingers
and toes. Under these urgent symptoms, the usual remedy, brandy, was
administered without avail; the dejections became incessant, and the
spasms increased in intensity, presenting the features of a decided
case of malignant cholera. In this condition, the physician was called
in haste, as it was believed and affirmed the patient was dying.
In describing this case, the physician observes: "On my arrival, I
found the patient presenting all the symptoms of malignant Asiatic
cholera, in an advanced stage; the features collapsed and ghastly;
extremities and tongue cold; burning sensation in the stomach and
oesophagus; pulse rapid and scarcely perceptible; voice diminished
to a whisper; stomach exceedingly irritable, and the dejections from
the bowels presenting the characteristic rice-water appearance; and
all the voluntary muscles of the body were affected by spasm, so that
the patient actually writhed in agony." Ordered the following: Rx.
Chloroform dram j; Ol. Terebinth. ounce j; aq. Dist. dram iij. M. And
gave immediately a large tea-spoonful, in a wine-glass, of dilute
brandy; and applied sinapisms to the calves of the legs and abdominal
and thoracic surfaces. Thirst was relieved by drinking plentifully of
water nearly cold. Though the stomach was irritable, the chloroform was
retained, as well as the fluid drank after it, and was followed by no
dejection. Half an hour after, two pills were administered, composed
according to the following: Rx. Calomel gr. v; fellis. bov. inspis.
gr. x; Ft. Pil. ij. Half an hour after these were given, vomiting
ensued, but soon subsided; the diarrhoea had apparently ceased; the
cramps had diminished in frequency and severity. A second dose of
chloroform, now one hour after the first, was administered, and soon
after this two more of the pills, both of which were retained, and gave
decided relief. The pulse rose in power and became slower, the spasms
less frequent, and, in an hour after the second dose, the patient was
bathed from head to foot in a warm perspiration, and expressed herself
comparatively free from all uneasy sensations. The attack had been
completely subdued, leaving behind a good deal of pyrexia and debility,
from which she rapidly recovered.

Here it is worthy of notice, that in this case, severe as it was, only
two doses of the chloroform mixture were administered, each containing
about six minims of chloroform and forty of turpentine; the pills
would naturally tend to perpetuate rather than relieve the nausea and
vomiting, and in one hour after the administration of the second dose,
all the urgent symptoms were assuaged.

In another case, the attending physician reports that, after giving
calomel, combined with opium, which was immediately rejected, the
following mixture was ordered: Rx. Chloroform vj minims; brandy dram
iij; water ounce iijss, one-third of which was given immediately,
and was thrown up in half an hour; a second dose was then given, and
was retained. The vomiting and diarrhoea ceased; the spasms became
less severe. In two hours after, gave the remaining third part; and
during the next six hours, administered in two doses six minims more
of the chloroform, with the most decided benefit, and the patient soon
became convalescent. To the extreme tenderness over the region of the
epigastrium flannel soaked in spirits of turpentine was applied; and
as no urine was secreted, I am firmly of the opinion that the usual
remedies would not have met this case. "I candidly confess," says the
physician, "I had no hope of success from its severity; and, but for
a knowledge of Mr. Brady's case, I believe I should have lost my
patient."

Dr. Davies reports a case in which he used chloroform fifteen hours
after the seizure with relief, but not with success, and observes that,
in a number of cases occurring in the hospital, there were 22 cases in
which, as severe symptoms came on, the chief remedy was chloroform,
administered internally, in doses of from seven to ten minims every
hour, half hour, or quarter of an hour, according to the severity of
the symptoms. Of these 22 cases, 8 terminated fatally, and 14 recovered.

Again: "Out of 9 cases of cholera, and 13 of the worst cases of
diarrhoea occurring in my own practice, and treated with chloroform,
_one died_. All these were in the better ranks of life. In some of
them, the warm bath (salt water) was used as an auxiliary, and the
diet consisted of nothing but cold milk and water, with some carbonate
of soda, _ad libitum_. The fatal case was that of a drunkard, who,
probably, did not take the remedy. These cases varied in severity,
from sickness and diarrhoea, and mild collapse, to sickness,
diarrhoea, severe cramps, and great collapse, with almost clear watery
evacuations, passing away involuntarily * * * Of 14 cases of cholera
treated by Mr. Towers, Medical Resident of the Infirmary, many of
them under my own observation, _one died_. The fatal case was that
of a woman aged 63, who was previously suffering great depression,
consequent on extreme destitution."

Again, says Dr. Davies, "It will probably be remembered that, in my
second report, I expressed a very favorable opinion of chloroform in
this deadly malady. I considered I had strong grounds for so doing,
after observing the large proportion of cases which recovered under
its administration. From the history of this last visitation in the
county prison, however, the fact turns out, that, under some uncertain
circumstances, the use of chloroform will not prevent the proportion of
deaths being considerable. I have reason to believe that it was, from
over-anxiety, given in too frequent doses in some cases, and that it
thus rather added to the coma, which is one of the characteristics of
the malady.

At the commencement of the outbreak, the doses were repeated every
hour, or every two hours, and it is to be noted that the first seven
cases _recovered_.

As the cases multiplied, the remedy was given every half hour, and, in
some instances, every quarter of an hour; the result was that the next
six cases died. Whether these cases had anything in them inherently
more fatal, it is difficult to tell. The symptoms at first were about
equal, and the differences did not show themselves until towards the
end. There was next a recovery of seven cases in succession; in these
the remedy was administered less frequently, but subsequently two
deaths occurred under the less frequent administration.

The chloroform was administered also by inhalation, in some of the
more severe cases of cramps, with the effect of affording relief in
every instance. The inhalation was not carried so far as to produce
insensibility. Although I am still of the opinion that chloroform
properly regulated is the remedy of all others hitherto tried to be
depended on, yet it cannot be considered a specific for cholera."

Mr. Steadman reports a very interesting case treated by chloroform.
He observes, "The spasms were universal and extremely violent, as if
knots were being tied in the bowels, countenance livid and cold, voice
feeble, and all medicines rejected. In this condition gave chloroform
combined with 'aquæ vitæ' and distilled water. The first dose had
a partial but most satisfactory effect. In two hours after, as the
symptoms manifested a disposition to return, gave a second dose, which
entirely controlled all spasms, vomiting and purging. The patient was
ordered cold rice and mucilaginous drinks, and had the chalk mixture
with nitric ether prescribed. A dose of oxgall (gr. x) was given in
course of the day, which produced the desired effect. In two days the
patient was declared convalescent." The daughter, who had nursed the
mother in this case, was seized soon after in a similar manner, except
the dejections were more abundant and frequent. The mother having some
of the chloroform mixture left, gave it to the daughter without advice
or hesitancy, and obtained the same magic results. The first dose was
only partial in its effect, but the second completely subdued the
disease.

Such are the results of some of the experiments which have been made
by the administration of chloroform; and, so far as appears, the first
cases treated by inhalation were severe malignant cholera in the
advanced stage, all of which recovered. So, also, those treated by the
remedy used internally, combined with a prompt and decided stimulant
like the spirits of turpentine, or aquæ vitæ and brandy, recovered.
In all these cases the remedy appeared to meet the urgent demand, to
remove the impediment to the circulation, to relieve the nausea and
vomiting, and purging and cramps, and restore, in a very short time,
the general action and normal tone of the system. Still we must admit,
that some cases, treated by its internal administration, and also by
inhalation, proved, on some accounts not satisfactorily explained,
unsuccessful. Were these cases given in detail, it would be much easier
to detect the cause of failure, or its questionable use in such cases;
but we have only the bare fact that they were thus treated, without the
manner or character of the combination, if any were made, being given.

Hence Dr. Davies, under whose direction these cases occurred,
remarks, in view of this result, "that _no reliance_ could be placed
on chloroform alone." The correctness of this opinion cannot be
questioned, for the experiments we have cited all show the necessity
of a prompt and diffusive stimulant in aid of its action, to render it
sufficiently prompt and powerful to meet and overcome the disease in
the more rapid and severe cases. Chloroform, properly combined, offers
the best hope of relief, and is, without doubt, the most perfectly
adapted of any remedy known to the pathology and phenomena of the
disease. There is no remedy, when properly combined, so capable of
meeting all the indications required as this, and none that can be
administered with more certainty of success.

In conclusion, we may, with much propriety, refer again to the
pathology suggested by the authors cited above, and inquire whether
the action of chloroform as a remedy in these cases be consistent? and
whether as such it has that curative influence, or direct controlling
power, to arrest, suspend, and cure the disease, so imperiously
demanded? We have seen that, according to the opinion generally
prevailing, the first impression of the poison is made upon the
blood, and through it upon the nerves, especially those which, from
their anatomical position, bear the most intimate relation to the
blood-vessels. Through this channel the first invasion appears to be
made on the ganglionic, the nerves of circulation. These nerves are
distributed chiefly to the viscera and blood-vessels, and are at least
very early involved and essentially disturbed, for their healthful
action depends in no small degree on the aeration or oxydation of
the blood. Says an eminent author, "The action of every ganglionic
mechanism depends on the existence of certain physical conditions,
among which the most prominent and important is the due supply of
arterialized blood. If this be stopped but for a moment the nerve
mechanism loses its power, or, if diminished, the display of its
characteristic phenomena correspondingly declines." Hence the loss
of power in these nerves, and their deranged action, the contraction
of the capillary and pulmonary arteries, the impaired and impeded
circulation and all the phenomena arising therefrom.

Again, the great pneumogastric nerve, which is composed of both motor
and sensitive filaments, has a very extensive distribution in the
upper part of the abdominal cavity. It supplies the organs of voice
and respiration with motor and sensitive fibres, and the pharynx,
oesophagus, stomach and heart with motor influence. This very important
nerve, through the primary action and deteriorating process of the
cholera poison, becomes early involved, and its functions greatly, and,
in fatal cases, permanently deranged. The evidence of this disturbance
and loss of nerve-power is too obvious to be overlooked or disregarded
in the treatment of this disease.

In confirmation of this, we may, with great propriety, adduce the
testimony of Dr. Wallis on the loss of nerve-power, and the process
through which the result is produced, who observes, that "the phenomena
which are exhibited when the deleterious air has been drawn into the
lungs are these: the great gastro-pulmonary nerve is either wholly or
partially paralyzed, the consequences are the cessation of all its
functions either wholly or partially. This great nerve is a nerve of
function, and performs the functions of digestion and respiration, and
influences all secretions."

Hence it appears the nervous power generally, as before observed, is
very early and essentially impaired, and to such an extent that there
can be no rational hope of relief, unless some remedial agent can be
found that will exercise such a controlling influence and power, as
shall be adequate to restore the tone of the nervous system.

Hence, we are forced to the conclusion that the prominent, leading,
and most urgent symptoms requiring special attention, are "the Algide"
or loss of temperature, the loss of nerve-power in the ganglionic and
pneumogastric nerves and their branches, the altered or disorganized
condition of the blood, the impaired or obstructed circulation, and
the early and direct tendency to congestion. These are the prominent
and essential features to be observed in the treatment. They are too
intimate, dependent and inseparable, to warrant any attempt to mark the
precise order of their development. They are the essential phenomena,
proceeding equally and directly together from the primary cause and
disease action, and strictly constitute the complex character of the
cholera, and exhibit its main, distinguishing features, which must
necessarily govern and dictate the maxims of rational practice in
the treatment of this disease. The object, then, of first importance
is to restore the lost temperature, the caloric already eliminated,
and prevent its further depression; to restore, at the same time,
the lost nerve-power to the nerves again; to arrest the process of
disorganization of the blood, and equalize the circulation; to relieve
and suspend the congestion; and then, according to all the experiments
which have been made, the consequent and dependent phenomena of the
cramps and the vomiting and the purging will disappear.


SECTION III.--DIFFERENT MODES OF TREATMENT.

After speaking of the various expedients resorted to for the cure of
cholera, says Dr. Watson: "I believe that each, in some cases, did
good, or _seemed_ to do so; but I cannot doubt that some of them did
sometimes do harm. I had not more than six severe cases under my
own charge, and I congratulated myself that the mortality among them
was not greater than the average mortality. Three died, and three,
I will not say were cured, but recovered, * * * under large and
repeated doses of calomel. Yet, as I said before, I do not venture
to affirm that the calomel cured them." It seems that Dr. Latham
commenced the treatment and Dr. Watson followed it up, repeating the
half-drachm doses of calomel many times, as the patients seemed to
rally after its administration. Again, he observes: "It was remarked
of those who recovered, that some got well rapidly and at once, while
others fell into a state of continued fever, which frequently proved
fatal, some time after the violent and peculiar symptoms ceased.
Some, after the vomiting and purging and cramps had departed, died
comatose--_over-drugged_--sometimes, it is to be feared, by opium. The
rude discipline to which they were subjected might account for some
of the cases of fever." * * * "Never, certainly, was the artillery
of medicine more vigorously plied, never were her troops, regular and
volunteer, more meritoriously active. To many patients, no doubt, this
busy interference made all the difference between life and death. But
if the balance could be fairly struck and the exact truth ascertained,
I question whether we should find that the aggregate mortality from
cholera in this country was any way disturbed by our craft."

In a report by the acting physician to the Bellevue Hospital, made to
then "Special Medical Council," August 2d, 1832, while the Epidemic
Cholera was still prevailing there and in the city, the physician
says: "The treatment I have divided into two kinds--the pathological
and the mixed. The first having been determined on, after the careful
examination of twenty-three persons dead of cholera; since then, ten
more have been examined, which serve to confirm the conclusions first
formed.

PATHOLOGICAL TREATMENT--_First Stage._--This consisted in the
administration of blue pill and opium with absolute diet. If pain was
present, leeches to the epigastrium and arms, and when these could not
be procured, cups to the epigastrium. This plan never failed to arrest
the disease in the hands of those who diligently pursued it, where
the mucous membrane of the gastrointestinal canal was not previously
diseased.

_Second Stage._--First, Blood-letting; second, diligent frictions
with the ointment alluded to above, when persons could be procured to
perform the duty; third, ice to allay the thirst; fourth, small doses
of brandy and laudanum, if the vomiting continues; fifth, cups to the
epigastrium, if there was pain and the brandy omitted.

_Third Stage._--First, ice to allay the thirst, which is now, indeed,
unquenchable; second, external heat; third, a continuation of the
frictions; fourth, no opium, and, frequently, no brandy, especially
among the children.

MIXED TREATMENT--_First Stage._--Besides the above treatment, calomel
and Dover's powders was a very frequent prescription; also scruple
doses of calomel, and calomel and opium in small doses, and all with
success. Nevertheless, I believe they occasionally did harm.

_Second Stage._--First, blood-letting less frequent than above; second,
calomel and Dover's powders continued; third, calomel and opium;
fourth, calomel, capsicum and opium; fifth, soda powders; sixth,
scruple doses of calomel every half hour; seventh, ice.

_Third Stage._--Calomel and Dover's powder; calomel and opium; calomel,
capsicum and opium; carbonate of ammonia and capsicum; scruple doses
of calomel every half hour. External heat in various ways; ice, etc.
Severe shocks of electricity along the course of the muscles to allay
the cramps; also, the burning of alcohol on the skin. The first was the
practice of Dr. Devan, the second, that of Dr. Gardner, and both lay
claims to having been the first to use these means."

The ointment alluded to above is composed of mercurial ointment, one
pound, camphor finely pulverized, seven ounces, and the same quantity
of capsicum. With this, the patient was rubbed briskly from head to
foot and repeated at short intervals. The result was, that mercury
generally showed its specific effects upon the gums in from five to ten
hours from the commencement of reaction. The success of this external
application of mercury, conjoined with its internal administration and
frequent blood-letting, may be learned from the cholera statistics of
this and other institutions.

Dr. Pereira employed sixty-grain doses of calomel, it is said, with
success, and Dr. Barton of New Orleans, in 1849, gave in ten cases from
120 to 150 and even to 180 grains of calomel at a dose, and, in one
case, gave 220 grains, intending, it is said, to have weight sufficient
to keep it down. This brave and heroic practice did not afford relief
in a single instance; the cramps, and vomiting, and purging continued,
and a few hours closed the scene--all died.

The treatment recommended in the American Practice of Medicine, by
Dr. W. Beach, which was fully tested by the author himself while in
discharge of his official duties as physician of the Tenth Ward, city
of New York, during the prevalence of cholera in 1832, is worthy of
consideration on account of its simplicity, its great efficiency and
wonderful success. "Among all the medicines," says the author, "ever
given or proposed in the incipient or premonitory stage, none will
be found so efficacious as our neutralizing mixture, made of genuine
materials and given very strong. Occasionally, it may be proper to add
fifteen or twenty drops of laudanum; this, however, is very seldom
necessary. A vast number of medicines are recommended in this stage
of cholera, but there are none, I am convinced, so efficacious as the
above."

In the second, or confirmed stage, the same medicine was continued in
larger and more frequent doses, with hot fomentations to the abdomen,
stimulating lotions, sinapisms and injections. The cholera drops were
also administered, composed according to the following formula:

    Rx. Tincture of Capsicum,
        Tincture of Opium,
        Spirits of Camphor,
        Essence of Peppermint.
                      Equal parts--mix.

Give a tea-spoonful every hour or half hour, according to the severity
of the symptoms.

In the third, or collapsed stage, he directed a tea-spoonful of
pulverized black pepper to be mixed and given in a tumblerful of hot
gin-sling; also, the same to be prepared and applied hot to the bowels
and extremities. Also, to two tea-spoonfuls of either pulverized red
or black pepper, pour on a sufficient quantity of hot water, let it
stand till nearly cold; strain and inject the whole up the bowel. This
would often arouse the patient in the collapsed stage when there was
little or no hope of recovery. Such are in brief the remedies which
were used so successfully in the Tenth Ward of this city, in 1832. Here
it will be noticed that the general principal evolved in this treatment
consists in its prompt and diffusive stimulant, its antispasmodic and
corrective power so combined as to act gently and kindly, yet promptly
and successfully, as the records show, to which we shall refer in the
sequel.

Another mode worthy of a passing notice is one analogous to this,
adopted and recommended by the eminent Dr. G. S. Hawthorne, of
Liverpool, England, who observes: "Of the medicinal remedies, the chief
is opium. This, I have explained, should be given in combination with
medicines of a cordial, stimulating and antispasmodic character, of
which the most efficient are camphor, capsicum, ether and aromatic
spirits of ammonia. The following formulæ present the combination of
the medicines which I would prefer:"

    Rx. Powdered Opium,                  gr. xij.
        Camphor,                         gr. xxx.
        Capsicum,                         gr. ix.

Spirits of wine and conserve of roses Q. S.--mix--divide into twelve
pills. Each of these pills, it will be observed, contains one grain of
powdered opium. These are accompanied with the following:

    Rx. Chloric Æther,
        Aromatic Spirits Ammonia,
        Camphorated Spirits,
        Tincture of Capsicum.
                       Of each, one drachm.
        Cinnamon water, two ounces--mix.

"Cholera," observes Dr. H., "presents itself in four distinct degrees
of malignity. All the modifications of the disease require to be
treated on the same principles, the only difference being that, in the
detail, the milder forms require less powerful doses of the medicines.
The mode of treating the most malignant form of the disease, will
serve as a model on which all the others are to be treated. This most
malignant form has, by all writers on the subject hitherto, been
pronounced incurable. They say it never was cured in a single instance,
and never can be cured by the power of medicine. I shall, however,
point out a mode of treating it which will prove itself infallibly
successful where my directions are followed with sufficient promptness,
boldness and skill." In detailing the mode of procedure, the doctor
observes: "Place the patient immediately in the horizontal posture in
bed, and give him on the instant, as this is an extreme case, ten of
the antispasmodic pills, and two ounces of the antispasmodic mixture,
and wash the whole down with a glass of undiluted brandy or whisky,
flavored strongly with cloves, essence of ginger, or some such warm
aromatic spice. In the mean time, have him covered with an additional
blanket, and let the usual means of communicating heat, such as jars
or bottles of hot water, bags of hot salt or sand, hot bricks, or
whatever can be most readily procured, be applied without delay to the
feet and different parts of the body, so as to restore the temperature
and produce perspiration as quickly as possible. As soon as the
perspiration has begun to flow freely, superadded to the medicines and
cordials already administered, a glass of brandy-punch should be given,
the punch to be made strong and to be swallowed hot as possible. After
this, no drink should be given until the perspiration has flowed freely
for a few minutes. The stomach will then retain it, and the patient
should be indulged freely with copious draughts of rennet whey, warm
toast-water, flavored with some agreeable spice, mint, or balm-tea,
or any such mild beverage. The necessity of attending to this is most
important. When the discharges from the bowels cease, and when the
pulse becomes full and bounding, the body is covered with a copious,
warm perspiration, which will not fail to be the case under such
treatment; the danger is over. The perspiration, if the patient can
bear it, should be kept up for twelve hours, and may, with advantage,
be continued moderately even longer. Its duration, however, must be
regulated according to the strength of the patient and the state of the
pulse. After the first four or six hours, more heat need not be applied
than is perfectly agreeable to the feelings of the patient. It is
remarkable how suddenly the precordial oppression, etc., are relieved
on the breaking out of a free perspiration, and, what is of greater
importance still, the vomiting, where it exists, immediately ceases."
In short, all the urgent symptoms soon subside, and the patient becomes
convalescent.

Such is Dr. Hawthorne's treatment, which is affirmed to have been
invariably successful. It is based on the same general principle as the
preceding--a prompt and diffusive stimulant. Here we might ask, What
constitutes the chief reliance in the formulæ? Was it the opium that so
promptly met and arrested the disease? or the combination of the other
powerful stimulants with which it was united? Dr. H. places his main
reliance on this drug, and yet affirms that it produced no narcotism or
other sensible effect whatever, except as a diaphoretic, and even in
this its influence may be questioned. The prognosis becomes favorable
from the fact of a sudden rise in the temperature of the body, for
the icy-coldness disappeared, the heat of the surface returned, the
circulation was equalized and a profuse perspiration set in, and,
as these conditions appeared, the urgent symptoms subsided. Not the
excessive doses of opium, but the remedies in combination as a whole,
produced by its prompt stimulating power these results, and the patient
was thus relieved.

Mr. Forward, while superintending some of the public works in the State
of Kentucky, in 1832, had in his employ more than two hundred laborers,
among whom the Cholera Epidemic of that year appeared about a week
before its irruption in Louisville. The first case was that of a young,
sober, industrious white laborer, who was at the time vigorous and
apparently healthy. It was a sudden and severe case and occurred about
eleven o'clock at night. The physicians who usually attended these men
were at a distance, and could not be obtained without considerable
delay. Under these circumstances, Mr. Forward, after visiting the
patient, becoming acquainted with the symptoms, and believing it a
genuine case of cholera, commenced treatment at once, fearing, as he
states, the patient could not live till a physician could be obtained.
It was, indeed, a desperate case; violent spasms, with constant
vomiting and severe purging, attended with that livid appearance and
peculiar coldness so characteristic of the disease. "Of the treatment,"
says Mr. Forward, "I gave him first a quick, stimulating emetic
prepared from the lobelia seed, which checked the vomiting and purging,
but had little effect upon the spasms. I then applied the steam bath,
having his feet and legs at the same time immersed in water as warm as
he could bear, which was made strong with salt and wood ashes. I then
sweetened a tumbler of warm water and put into it a tea-spoonful of
"number six," and about the fourth part of a tea-spoonful of Cayenne
pepper, and gave him one-third of it when I commenced sweating him, and
the balance at intervals while he was sweating. By the time he had been
sweated ten minutes, he was free from spasms and pain, but I continued
the sweating ten or fifteen minutes longer, then wiped dry, after which
the patient laid down and went to sleep--being thus relieved and cured."

Another case of a colored man who was strictly temperate and healthful
occurred an hour or two later the same night. His attack, too, was
sudden, and still more severe; cramps very violent, vomiting and
purging equally as severe, though he had not been awakened from his
slumbers more than fifteen minutes. This case was treated the same
as the former, with the emetic, sweating, and when the sweating had
subsided, administered a table-spoonful of spirits of turpentine, which
relieved him entirely, and he soon went to sleep. The next morning
both were comfortable, and went to work and remained well. During the
prevalence of cholera at that time, Mr. Forward had thirteen cases in
his own family, and, on one day when the epidemic was at its height,
seven cases among the laborers. All these and many others that occurred
were treated in the same manner, with the same undeviating success.
Not a single instance of death from cholera in his own family, or
among the hands on the road. When the epidemic cholera reappeared in
1835, the same course of treatment was pursued, with the same uniform
success. Such results, considering the malignant character of the
disease, are truly astonishing. Whatever may be said of the general
principle of practice in these cases, its success must be admitted
as equaling, if not surpassing, the treatment of any equal number of
cases on record. Though conducted by an unpretending and unprofessional
gentleman, yet, out of the whole number attacked during the continuance
of the epidemic, not a single case was lost.

In a report of a case of cholera treated successfully by rectified oil
of turpentine, administered internally as a specific, by Richard Brown,
Esq., Surgeon, Cobham, Surrey, November, 1848, it is stated that the
patient, "aged fourteen, having suffered from severe bowel complaint,
presented all the symptoms of cholera in the stage of collapse. The
bowels acted incessantly, and anything taken into the stomach was
immediately rejected; the pain around the umbilicus was intense,
attended with severe cramps of the legs; the pulse exceedingly small,
and scarcely perceptible; tongue coated in the centre, and flabby; the
surface of the body much below the natural standard; the countenance
of a blue cast, and expressive of the greatest anxiety. So decided,
indeed, was the symptom that the case was considered almost without
hope." "But I had determined," says the physician "to treat the first
case of cholera that occurred in my practice with rectified oil of
turpentine, given internally, the active principle of which, camphogen,
possesses stimulating, diuretic, diaphoretic, sedative, antispasmodic,
antiputrescent properties. I administered immediately one drachm of it
combined with mucilage and aromatics, directing it to be repeated every
two hours, the patient to be kept warm and to take meal broth with
excess of salt."

Now mark the result of this simple, uncombined remedy. In the evening
of the same day all the urgent symptoms were assuaged, the purging and
vomiting had ceased, the pulse was raised, the surface of the body had
become warm and moist with perspiration, the pain around the umbilicus
diminished, and the cramps less violent, but the countenance still bore
the appearance of great anxiety. Such were the immediate results of
the administration of this remedy, which appear, from the subsequent
history of the case, to have been permanent and unattended with any
constitutional derangement, or other serious and unpleasant effect. On
the morning of the next day the patient was steadily improving; much of
the anxiety of countenance had vanished, but the pain in the belly and
cramps of the legs still remained, though much relieved. On the second
morning after the attack the patient was very much better; no pain in
the belly, and does not feel sick from the turpentine. On the third
morning the patient was up, and, though exceedingly weak, there was no
trace of any alarming symptom remaining. The bowels had moved from
the effects of a previous dose of calomel (two grains) given the next
morning after the attack, and the evacuation was much more healthful. A
mild tonic and alterative plan of treatment was all that was necessary
to restore the patient to her usual health, and she is now well. The
remedy was given at first every two hours, then every four, and lastly
every six hours. This treatment commenced on the 26th and terminated
on the morning of the 29th. Its duration about sixty hours, when the
patient is declared convalescent and comparatively well. Here we might
ask, What experiment with any single remedy has been more important
and satisfactory in indicating and directly pointing out a general
principle of practice for the successful treatment and cure of this
formidable disease? We say single remedy, for it is doubtful whether
the two grains of calomel exercised any curative influence whatever,
or in any way varied the result. It is, therefore, to the use of the
rectified oil of turpentine that the favorable termination and cure of
the disease is to be attributed.

There is another mode of practice which has been exhibited to some
extent in almost every part of the world, claiming to be more
efficacious and successful than any other in the cure of epidemic
cholera. It is the general principle which is the great and important
consideration with which we are concerned in presenting it among the
various modes adopted for the cure of this disease. This is found
clearly defined and ably presented by Dr. Joslin in his lecture on
cholera, in which, after exhibiting the views and doctrines governing
the practice, and contrasting its results with those of other modes,
he observes, in relation to the treatment of cholera in its early
stages, that "whatever may be the form of attack, give one drop of the
tincture of camphor dropped on a lump of sugar, and then dissolved in
a table-spoonful of cold water. Repeat this every five minutes until
there is a decided mitigation of the symptoms. This will usually be
after five or six doses. If the disease be taken in time, ten or
twelve doses are ordinarily sufficient. There is abundant testimony
of the efficacy of this camphor treatment from all parts of Europe."
Again, speaking of the first variety, in which the most prominent
symptom is diarrhoea, the Dr. observes, "If camphor does not soon give
relief, we are to resort to phosphorus, or to phosphoric acid. Dr.
Quinn has employed both with equal success. Phosphoric acid is to be
preferred when there is a gluey matter on the tongue. In some cases,
veratrum, chamomilla, mercurius, or secale may be indicated. However,
phosphorus and phosphoric acid rarely fail to cure; and some high
authorities are in favor of giving one of them at first, in preference
to the administration of camphor in this form of cholera."

Again, in the second variety, cholera gastrica, Dr. Joslin observes,
that "the remedies are generally ipecacuanha or veratrum, sometimes nux
vomica. Camphor is to be given at the outset. Put two or three globules
of the third of ipecac. in a little sugar of milk and place them on
the tongue. This may be repeated, if necessary, in half an hour, an
hour, or an hour and a half. But if the disease is not checked, give
veratrum or other medicines according to the different indications."
Again, in the third variety, cholera spasmodica, "the remedies are
camphor, cuprum metallicum, and veratrum. If camphor has not relieved,
give cuprum, and repeat it many times, at intervals of half an hour or
an hour, if its salutary effect is not manifested. If necessary, then
give veratrum in repeated doses, or other medicines, according to the
different indications." In the fourth variety, cholera sicca, "there
is no diarrhoea or vomiting; there is sudden prostration of the vital
powers," etc. "The first remedy, as in other varieties, is camphor.
If the patient is cold, blue, pulseless, that is, collapsed, carbo
vegetabilis; some recommend hydrocyanic acid." In the fifth variety,
cholera acuta, veratrum is named as the main remedy.

Such is, in brief, the treatment so highly extolled and recommended
by some in the cure of cholera. It is, in substance, the same as
was originally suggested when the disease first appeared in Europe,
nearly half a century ago, and will probably continue unchanged for
generations to come. Of its general principle and its adaptation to the
pathology of the disease we shall speak more at length in the sequel.

After referring to the pathology of the epidemic cholera, showing its
strong analogy to congestive fever, from the fact that in both diseases
the blood recedes from the surface, and collects upon the internal
organs, inducing a state of congestion, and showing the necessity of
adopting prompt and efficient means to promote reaction, Dr. Massie
observes, "I am not so bigoted, or so wedded to any system of medicine,
as to be its champion to the exclusion of others. I consider I have a
perfect right to investigate all of the different systems, and avail
myself of any information which I may deem important and true, and I
will premise by saying that the treatment I now adopt for cholera
has been attended with more success than when I treated it under a
different system."

"If I am called at an early period of the disease, even when there is
nausea, vomiting, and diarrhoea, I commence the treatment by giving
equal parts of rhubarb root pulverized, saleratus, and peppermint plant
powdered; one pint of boiling water being added to half an ounce of
this compound. After simmering it for half an hour, sweeten with loaf
sugar and strain, and, when nearly cold, two or three table-spoonsful
of good French brandy should be added. Give two table-spoonsful of
this, taken warm, in connection with the following preparation, viz.:
Rx. Pulverized cinnamon, cloves, and gum guaiacum, each one ounce, good
brandy one quart, given in two tea-spoonsful to a table-spoonful every
fifteen or twenty minutes to an adult."

"The patient should be well covered with warm clothing, and bottles of
hot water, bricks and stones placed around his body. This course is
almost sure to be followed by a moderate moisture of the skin, which
should be kept up for eight or ten hours; to do which, I give ptisans
of catnip or spearmint, and apply hot tincture of Cayenne by flannel
cloths over the abdomen; if this fails to keep up the perspiration,
I administer the following: Rx. Camphor, grs. x.; Ipecac., grs. v.;
Opium, grs. ijss; Supercarbonate of soda, scruple ij. Mix, and divide
into two, three, or more powders; give one every hour, or oftener."

"In very urgent cases, I have used tincture of camphor, ounce iv;
essence of peppermint, ounce iv; syrup of ginger, ounce ss; tincture of
Cayenne, dram j. A table-spoonful, from one to four in an hour. I have
given the saturated tincture of prickly ash, with the compound tincture
of guaiacum, with good effect, in doses from a tea-spoonful to a
table-spoonful every fifteen or twenty minutes. When there is excessive
irritability of the stomach, the following injection should be given
after every discharge: Rx. Saturated tincture of prickly ash, ounce
ss; water, ounce j; tincture opii, dram ss. Mix." Such are the views
of Dr. Massie, as presented in his Treatise on the Eclectic Southern
Practice of Medicine. They are confirmatory of the observations and
experience of many other eminent practitioners, and strictly accord
with his views of the pathology and essential phenomena of the disease.

We find in a very valuable work, entitled the Eclectic Practice of
Medicine, published at Cincinnati by Professors Powel and Newton, a
full account of the mode of practice generally adopted and pursued by
the great body of physicians in the West, the substance of which we
are induced here to present, preserving, as far as practicable, the
language of the authors. For our inquiries are, What are the modes of
practice? and what modes, if any, are consistent with the pathology and
the essential phenomena of the disease? Each mode, however prominent or
however obscure, is entitled to a fair representation in our inquiries,
and should be held responsible for its deviations from the strict and
generally received principles of science, and the consequences arising
from any such deviations, or departure therefrom.

"When called upon," say these eminent professors, "to treat a patient
in the early stage of the disease, he should at once be placed in a
recumbent position, and everything should be avoided which will have a
tendency to disturb the mind, as well as the stomach and bowels. In the
greater part of cases in this early stage, the administration of the
compound pills of camphor, made according to the following formula, is
sufficient to prevent a further development of the disease:

    Rx. Camphor,        }
        Opium,          }       [=a][=a]., gr. xxxv.
        Kino,           }
        Capsicum,                             gr. v.
        Conserve of roses, Q. S.--Mix.

Divide into thirty pills, and give one after each discharge from
the bowels, or oftener, if the urgency of the case requires it.
Occasionally, however, there may be applied a large sinapism over the
whole abdomen with advantage. Greenhow's aromatized brandy,[II.] the
aromatic tincture of guaiacum,[III.] may sometimes be beneficially
alternated with this pill. Should there be an overloaded condition of
the alimentary canal, the fluid extract of rhubarb and potassa,[IV.]
three parts, with saturated tincture of prickly-ash berries, one
part, may be administered in table-spoonful doses every hour, and
continued until the bowels are properly evacuated, after which the
above astringents may be given; but where the diarrhoea is excessive,
it would be imprudent to wait for catharsis, as the discharge should be
checked as speedily as possible.

In the second stage, when nausea, vomiting, and cramps are present,
more active means should be pursued. To overcome the nausea or
vomiting, the preparation of Dr. O. E. Newton, termed in the American
Dispensatory compound mixture of camphor,[V.] may be used with
excellent effect; it is prepared as follows:

    Rx. Camphor water,     }
        Peppermint water,  }   [=a][=a]., f ounce j.
        Spearmint water,   }
        Paregoric,                        f dram ij.
                                                Mix.

From a tea-spoonful to a table-spoonful may be given every five or ten
minutes; and in cases where this does not act sufficiently prompt, the
following may be administered:

    Rx. Common salt,                      dram j.
        Black pepper,                     dram j.
        Vinegar,                        f dram v.
        Hot water,                    f ounce iv.
                                             Mix.

Of this a table-spoonful may be given every ten or twenty minutes, and
continued until the nausea ceases.

To remove the cramps, hot bricks, or bottles of hot water, etc., should
be kept applied to the feet, legs and arms, and cloths wet in water
as hot as can be borne, must be applied over the abdomen and changed
every few minutes; this should be perseveringly pursued until relief
is obtained. Sometimes advantage will ensue from stimulant applications
along the whole length of the spine. Cramps of the muscles of the limbs
may be overcome by bathing with the compound cajeput mixture,[VI.]
either alone or in combination with chloroform, and applying friction
at the same time. This course usually checks the further progress of
the disease, and the patient is saved; however, should it fail and
the stage of collapse come on, in addition to the above treatment
energetically pursued, the patient should be enveloped in blankets, wet
with water as hot as can be borne, which should be renewed every ten
or twenty minutes, and stimulants may likewise be given; the saturated
tincture of prickly-ash berries will here be found beneficial, both by
mouth and enema."

Dr. Morrow observes, that "to fulfill the most prominent indication,
the production of an equilibrium in the circulation, and excitability,
the compound tincture of guaiac[VII.] may be given." This is prepared
by adding gum guaiacum, cinnamon and cloves--each, one ounce to a quart
of best brandy, and is administered in tea-spoonful doses in hot,
sweetened water and brandy, every fifteen or twenty minutes till relief
is obtained. As a general remedy, its exhibition is most salutary.
In some cases where excessive nausea is the most prominent symptom,
it may be advisable to administer an emetic to relieve the gastric
irritability, to equalize the circulation and check the spasms. For
this purpose, the acetous tincture of lobelia and sanguinaria,[VIII.]
with the addition of one-third spirituous tincture of aralia
spinosa,[IX.] is preferred. This is given in doses from a tea-spoonful
to a table-spoonful every ten minutes in warm catnip-tea, sweetened.
In very urgent cases, it may be given in larger doses and frequently
repeated.

In most cases, the saturated tincture of xanthoxylum fraxinifolium
bac. may be used with great advantage. It is a reliable, excellent and
prompt remedy. When given in the early stages, it will frequently
relieve in from ten to twenty minutes. In combination with the fluid
extract of rhubarb and potassa,[X.] it has generally proved very prompt
and efficient. In cases of partial collapse, when the patient is
suffering from severe cramps, Hunn's Antispasmodic Mixture[XI.] is an
excellent remedy. In cases of violent spasms, it has been administered
every ten minutes in doses of from one to two tea-spoonsful in hot
brandy-and-water sweetened, with great advantage, and it is peculiarly
applicable in such cases where there is not too great irritability of
the stomach. In many cases, camphor is very beneficially prepared, by
adding one drachm of camphorated spirits to a half-pint of cold water
and the mixture given in tea-spoonful doses every three or four minutes.

Dr. King states that in the early stage he has used very extensively
the following preparation:

    Rx. Ox Gall,                         ounce j.
        Capsicum,      }
        Gum Guaiac,    }  [=a][=a].,  scruple iv.
        Leptandrin,                dram iv.--Mix.

This was given in doses of one grain, and repeated two or three times
a day. He had also succeeded in some cases with a mixture composed as
follows:

    Rx. Sulphur Sub.,                    grs. iv.
        Gum Guaiac,                      grs. ij.
        Charcoal,                        grs. ij.
        Camphor,                           gr. j.
        Opium,                     grs. ss.--Mix.

Dose, one to ten grains, repeated every ten minutes until relief is
obtained. In some cases, however, this compound did not appear to
exercise any beneficial influence. In cases of excessive irritability
of the stomach, oat-meal cake coffee was given, for the purpose of
allaying its irritability, with admirable effect. The saturated
tincture of prickly-ash berries,[XII.] combined with tincture of opium,
was used in some cases as an injection, with very good effect.

Dr. R. S. Newton observes that he had also used a preparation composed
of equal parts tannin, capsicum, camphor and kino, with considerable
success, to be given in doses of four grains, and repeated at short
intervals until the discharges were checked.

He considered the saturated tincture of xanthoxylum fraxinifolium
bac.[XIII.] the most valuable of all the remedies for the cholera which
he had tested. When the stomach would not retain it, he gave it as an
injection. It had a peculiar influence on the system, and having taken
the remedy, he could speak from experience of its effects. When given
as an injection, the effect produced was almost instantaneous; the
sensation was as if he had received an electric shock; its use was very
soon followed by a copious perspiration. He had more confidence in this
than any other one remedy with which he was acquainted.

Dr. Wright observes that he had also used the neutralizing extract,
saturated tinc. xanthox. fraxi. bac., and the compound tincture of
guaiac.[XIV.] He had succeeded best with a mixture of equal parts
tincture of prickly-ash berries and neutralizing extract.[XV.]

He had always found it necessary to attend strictly to the surface. The
best external application he found was equal parts of capsicum, salt
and mustard.

Dr. Chase states that, "in the early period of the disease, he had
used the leptandrin, combined with neutralizing extract,[XVI.] very
successfully. He thinks opium can be dispensed with in the treatment of
cholera altogether. In typhoid cases, he pursued an entirely different
course, and remarked that many cholera cases presented symptoms similar
to those described in Wood's Practice, as belonging to pernicious
fever, which must be treated according to their peculiar character."

Such, it is said, is the more general and successful practice in the
Mississippi Valley, where the disease has several times prevailed in
its most malignant form. For its curative efficiency much is claimed.
Its utility, however, must be measured, as in all other cases, by the
unerring rule, the actual results sustained by incontrovertible facts.
The nearer any mode of practice accords with the general principle
of pathology, the greater must necessarily be its success, for it is
not in this disease, or in any other, that the bold, energetic and
heroic practice, which is inconsistent and incompatible with this
principle, cures, however extensively adopted and rigidly pursued. For
this principle must direct and govern the practice, or else it becomes
necessarily experimental or empirical, and must be inevitably attended
with the most lamentable results.


SECTION IV.--STATISTICS--PERCENTAGE OF LOSS--VARIABLE RESULTS--THEIR
CAUSE.

The results of the different modes of practice which we have briefly
noticed will aid materially our effort to discover and establish some
general principle for the successful treatment and cure of cholera.
For all modes, whatever be their merits or demerits, are supposed to
be founded on the pathology of the disease. To treat any disease
successfully, its pathology must be observed, and so applied in the
arrangement and adoption of a mode of practice as to secure not only
entire harmony, but a complete and perfect adaptation of the treatment
to its pathological character. The nearer any mode approaches to an
exact conformity to this principle the greater will be its success.
The neglect to conform, in the treatment of the epidemic cholera, to
this acknowledged and universal law, has, no doubt, been the prolific
cause of the sacrifice of thousands of valuable lives. For this
principle is the key to unlock the mystery of disease, unfold the
process of diseased action, and, as an unfailing and definite rule,
must govern all correct theories as well as all rational practice of
medicine, under whatever name it may be conducted. All practice, then,
deviating from, opposed, or contrary to, this principle must be purely
empirical, and unworthy the confidence of an intelligent community.
Hence we may refer to statistics rather than argument on the subject,
to ascertain how far and to what extent each of the different modes of
practice conform to the general principle; and on the other hand, to
show what modes may be at fault, being deficient in the application
of science, opposed to the established laws of practice, and contrary
to observation and experience, and therefore utterly and hopelessly
empirical.

The statistics collected from the most reliable sources, and here
presented, may be regarded as a fair representation of the general
average of loss by the different modes of practice. In a report now
before us, it is stated, "The average proportion of deaths in Paris
from cholera, treated under the allopathic practice, was 49 per cent.;
while that under the homoeopathic was only 7-1/4 per cent." "In
Vienna, (Aus.,) under the former, the deaths are reported at 31 per
cent.; while under the latter it was only 8 per cent. In Bordeaux,
death occurred under allopathic treatment at the rate of 67 per cent.,
and under homoeopathic, 17 per cent. only. The general average in
the places last mentioned will stand thus: Allopathic, 49 per cent.;
homoeopathic, 10-1/4 per cent." The record of mortality in twenty-one
hospitals in Europe shows the average deaths under allopathic treatment
to be 65-1/8 per cent., while in ten hospitals where the cholera
patients were under homoeopathic treatment, the average deaths from
that disease was 11-3/4 only. In a report "published by the authorities
of Pischnowitz (in Prussia), it will be seen that 680 cases were
treated as follows: 278 treated homoeopathically, of which 27 died; 381
treated allopathically, of which 102 died."

In St. Louis, during the prevalence of cholera in 1849, the number
treated by three homoeopathic doctors, to July 13th, was 1,567, of
which 51 died--a loss of 3-1/4 per cent.

In Cincinnati, during the month of May, there were treated by the
eclectic physicians 330 cases of cholera and 198 cases of cholerine, of
which only five died.

In the same city, during the same time, there were treated by the
allopathic physicians 432 cases of cholera, of which 116 died.

Again, during the month of June there were treated by the eclectic
physicians, when the disease had reached its maximum intensity, and
many of the patients being reached by the physicians only in the
collapsed stage, 764 cases of cholera, with a large number of choleroid
diseases not fully reported. During this month, the mortality with all
physicians was necessarily greater than either in the preceding or
subsequent month. Including then the month of May, the aggregate to
July 1st is 1,094 cases, with a loss of only 36, which is considerably
less than four per cent. (being 3.28); while the mortality of the old
school cholera practice being 26 per cent. in May, must have risen to
at least 50 per cent. in June, when the ratio of mortality was more
than doubled with all physicians. The _Western Lancet_ for July, 1849,
issued while the cholera was still raging, and speaking in behalf
of the allopathic physicians, observes, "that of the cases of true
cholera, with rice-water discharges, at least one-half the cases in
this city, as everywhere else, proved fatal." This confession of the
_Lancet_, edited by a thoroughgoing allopathic physician, advocating
the interests of that school, must be regarded below rather than above
the actual allopathic loss. Now, admitting the _Lancet's_ correctness,
and taking into account the aggregate loss of only 36 by the eclectic
physicians in treating 1,094 cases of "true cholera," we ask what
must have been the loss by the allopathic school of practice to have
brought the average percentage of all schools up to 50 per cent., as
affirmed by the _Western Lancet_? If the cholera hospitals be included
in exhibiting the results of the different modes of practice, it will
appear from the reports that the total number of deaths, compared to
the admissions, was, under the eclectic treatment, 23-1/3 per cent.;
under the allopathic treatment, 60 per cent. This percentage is
confined exclusively to the three cholera hospitals reported.

In the report of 1832, by Dr. Atkins, it appears "that the total number
of cases" of cholera in this city, New York, "including those in the
hospitals, as well as those reported to the Board of Health, had been
5,835 on the 1st of September. The total number of deaths by cholera to
September 1st was 2,996." More than one-half died. "Dr. Buell reports
the success," says Professor Clark, "of sixty-grain doses of calomel
in one of the New York hospitals, as 93 deaths in 100 cases;" very
remarkable success! the largest mortality in the city.

As like causes produce like effects, we need not be surprised at
this high rate of mortality, for, says Professor Aikin, "taking
the whole number attacked, it is said that the number of deaths in
Astrakan were _as one to three_; in that of Nizhni Novgorod, _as one
to two_; in Moscow and Kazan, _as three to five_; and in Penza, in
the country of the Don Cossacks, _as two to three_. In the summer
of 1831 the mortality at Riga, St. Petersburg, Mittan, Limburg, and
Brody, according to the _Berlin Gazette_, was _about one-half_,
while at Dantzic, Elbing, and Posen it was _about two-thirds_ of the
whole number attacked. The period of the epidemic, however, greatly
influenced the mortality; for on the first onset, _nine-tenths_ of
all those attacked perished, then _seven-eighths_; and the proportion
of deaths forms a gradually decreasing series of _five-sixths_,
_three-fourths_, _one-half_, _one-third_, till, towards the close, a
large proportion of those attacked recovered. The uniformity of this
law in every country affected with cholera, whether Europe, America,
India, or China, is extremely remarkable." This high rate of mortality
is truly and peculiarly illustrative of the inadaptation of the general
mode of the so-called regular practice to the pathology of the disease.
This, no doubt, is the main cause of its failure, and justly exposes it
to the unenviable distinction of being empirical.

The practice of Dr. Beach, the physician of the Tenth Ward of this
city, during the prevalence of the cholera in 1832, embraced about
one thousand cases, of which only a small percentage was lost. One of
his associates, Dr. Hopkins, reported 157 cases, of which only 6 died,
being less than 4 per cent., which probably is not much below the
general average of the other districts in that ward at that time.

Mr. Forward, an unprofessional gentleman of Kentucky, treated a large
number of cases, during the prevalence of the disease among his
employees, numbering over two hundred, without the occurrence of a
single death. Another instance similar in principle is that of Dr.
Browne, who reports a case treated by rectified oil of turpentine,
with the most satisfactory and happy result. So, too, the late Dr.
Sharp, of Paris, Ky., adopted a similar principle of practice, and
became, thereby, eminently distinguished for the cure of cholera; his
percentage of loss being very small indeed.

We might extend these statistics and references, and quote from the
reports of many other distinguished physicians who have been very
successful in the treatment of this disease; but these are sufficient
for the purpose of directing our inquiries as to the utility and
success of different modes of practice. It is immensely important to
ascertain, if practicable, the general principle which has been most
successful in the treatment of this disease, before it shall again make
its appearance among us as a prevailing and fatal epidemic; especially
when we realize and duly appreciate its vast mortality, as represented
in the report now before us, that prior to its recent irruption and
prevalence in India and Europe, nearly fifty millions of the earth's
inhabitants have been swept away by this terrible scourge alone.

This estimate may, however, appear excessive and unworthy belief.
Yet the general average for the forty-three years included is only a
little over one million per annum, truly a vast number to be carried
off by the prevalence of one disease alone. But, if we reduce this
estimate within more reasonable limits, and take only two-fifths of
it, or twenty millions, as an approximation to the truth, it would
still be appalling, and imperatively demand, on account of the vast
interests involved, the most rigid and thorough investigation as to
both the direct and indirect cause of this vast sacrifice. It will
also furnish us a sufficient apology for attempting a brief review
and critical examination of the principles involved in the different
modes of practice noticed above, in order to ascertain any failures or
errors that may have, in some degree, operated as the indirect cause,
in procuring this immense loss of life. All must admit that there are,
in respect to the treatment of the cholera, great and palpable failures
and errors which, though they have continued for nearly half a century,
and have been sanctioned by high authority, as well as by long usage,
ought nevertheless to be fully shown and exposed, so that they may
henceforth be avoided. In our examination, there is but one rule to be
observed, and one criterion of ultimate appeal by which to try each
and every principle on which any mode of practice may be conducted.
This universal and acknowledged rule is Pathology, the science which
unfolds and exhibits the nature and character of disease, and "dictates
the maxims of rational practice." It is the foundation and only base of
rational medicine, which proceeds on the assumption that the nature and
character of disease is fully known and appreciated. This knowledge is
not only rational, but indispensable, in order to understand and apply
the principles which ought to govern in the medication and cure of
disease.



CHAPTER IV.

SECTION I.--GENERAL PRINCIPLE OF RATIONAL PRACTICE--DICTATED BY THE
PATHOLOGY OF THE DISEASE--CONFIRMED BY OBSERVATION AND EXPERIENCE.


It has been observed that the essential characteristic, the leading
and most prominent indications requiring special attention and
permanent relief, are the "Algide," or loss of temperature; the loss
of nerve-power in the ganglionic and pneumogastric nerves and their
branches; the altered or disorganized condition of the blood; the
impaired or obstructed circulation, and the early and direct tendency
to congestion; and that these prominent and essential features are
correspondingly developed, and in their relation to each other are
too intimate and dependent to admit the idea of priority and regular
order of succession. The primary impression being on the blood, these
proceeding, _pari passu_, together constitute the complex character of
the disease, and suggest the general principle of rational practice.
If our pathology be correct, it must be regarded as the foundation
and only base for a successful mode of treatment, and must be allowed
to dictate the maxims of rational practice in the prevention and cure
of this singular disease. The neglect to apply to the treatment of
the cholera the science of its peculiar and established pathology
and phenomena, or to give heed to its teachings, has no doubt led to
the errors and failures in practice, which, from their too general
occurrence, induced the learned and celebrated Dr. Velpeau to declare,
before the Academy of Medicine in Paris, that "we know nothing more of
the treatment of cholera now, than on its first appearance in 1832. All
our remedies and modes of practice have failed."

By observing the fundamental principles of the science of medicine,
and adopting a mode of practice suggested by the pathology and
phenomena of the cholera, these errors and failures, which have justly
brought odium upon the so-called regular profession, will probably
result in saving nine-tenths of those attacked, instead of losing that
appalling proportion, as has been the case in some instances in years
past.

What, then, is the principle which, for nearly half a century, has
been strangely overlooked, and utterly disregarded by the so-called
regular profession, so far as the maxims of rational practice are
concerned in the treatment of this disease? We unhesitatingly affirm
the principle suggested by the pathology of the disease is, and
must be, one that will reproduce and resupply the lost caloric, or
restore warmth to the body; one that will restore promptly the lost
nerve-power to the ganglionic nerves especially; one that will arrest
and remove the tendency to congestion, equalize the circulation and
relieve the oppressed respiration, and thus mitigate the long train of
dependent symptoms. For this purpose, a prompt and diffusive stimulant
is required of sufficient power to meet these urgent demands, and
suspend promptly any further depressing influence or action of the
cholera poison. A stimulant, essentially different from alcohol in any
of its forms, is required. Alcohol, except so far as it necessarily
enters into the composition of medicines, is inadmissible. So, too,
are all those stimulants whose action is violent, or tends to induce
constitutional derangement, or impairs in any way the subsequent
health of the patient. It must be one prompt, kind and diffusive in
its nature, and peculiarly adapted to meet and relieve the essential
urgent symptoms on which the whole train of _non-essential symptoms_
depend. In short, it must be one possessing the singular properties of
a stimulant, sedative and astringent, especially an arterial stimulant
and antispasmodic.

In confirmation of this doctrine, we may refer to the general principle
exhibited in the most successful modes of practice. During the
prevalence of the cholera in 1832, the physician having charge of the
Tenth Ward in this city, in which more than a thousand cases occurred,
adopted as the principle of general practice in that ward a prompt and
diffusive stimulant, which was, at that early day, regarded by him as
based on the pathology of the disease. This principle was strictly
observed and fully carried out in practice by all his assistants.
The result, embracing the different stages of the disease, and some
of the most malignant cases, was the curing and saving of more than
nine-tenths of those attacked.

Another instance directly in point is the course pursued by Mr.
Forward, an unprofessional gentleman, who had over two hundred laborers
in his employ, among whom the cholera prevailed in 1832 with its
accustomed severity. On its first appearance, Mr. Forward, unadvised,
and depending on ordinary domestic remedies, adopted as the base of
practice in the emergency a prompt and diffusive stimulant, which
proved perfectly successful. Being advised to continue the same
course, should any more cases occur, the result was, in treating a
large number of cases, including thirteen in his own family, that all
were cured. Again, on the reappearance of the cholera in 1835, the
same practice was pursued, with the same uniform success. Can anything
be more satisfactory or more conclusive as to the adaptation of a
principle of practice to the pathology of the disease, or furnish
better evidence of the correctness of the doctrine we have advanced?

Richard Brown, Esq., surgeon, Cobham, Surrey, November, 1848, reports
a case treated successfully by rectified oil of turpentine, the
therapeutic character of which is unquestionable.

Dr. Massie, of Texas, adopted a similar principle of practice, and
highly commended the same to his professional brethren, as the safest,
best, and most efficient in the treatment of the cholera. He affirms,
that of all the modes devised for the prevention and cure of this
disease, none is so simple and efficacious as the one exhibited in his
practice.

The homoeopathic treatment, which claims to be a complete and perfect
system, arranged and adopted by its originator and all his disciples,
confirms the correctness of the doctrine we have advanced. Its
curative principle in the treatment of cholera is based on a prompt
and diffusive stimulant, peculiarly adapted, so far as it has any
power, to meet and relieve the essential symptoms of this disease.
Hence its success and favorable results, which show a saving of nearly
nine-tenths of all the cases treated.

Again, the eclectic physicians, who now, including all of the reform
school, constitute a majority of the practitioners of medicine in
this country, adopted a principle essentially similar, which has
governed their practice in the treatment of this disease from its
first appearance in 1832. Their system seems to have been more
strictly conformed to the pathology of the cholera than that of any
other school. Hence, their unparalleled success furnishes the most
substantial and conclusive evidence, sustaining the correctness of
the doctrine we have adduced, and the general principle of rational
practice suggested and imperatively demanded by the pathology of
the disease. Their treatment, directed mainly to the relief of the
essential symptoms, has been based on a prompt and diffusive stimulant,
which, fulfilling to some extent the indications required, has enabled
them to meet the disease on each occasion of its reappearance with some
assurance of success, and more generally to arrest its progress or
subdue its power as exhibited in its several stages, and even in many
instances to restore the patient and save life in the last stage of the
almost hopeless collapse. This is clearly shown in the actual results
which fully exhibit the incomparable fact that in private practice
considerably more than nine-tenths of the cases of "true cholera"
are cured, and the constitution and health of their patients saved
unimpaired.

Again, this doctrine is substantially confirmed by the results of
the experiments made by Drs. Hill and Davies, in the exhibition of
chloroform, either alone or combined with other stimulants. In the
carefully detailed account of its exhibition in the various stages of
the disease, it is clearly shown that its direct action tends to arrest
and suspend the depressing influence of the primary cause, and when
properly combined with other stimulants, affords very prompt relief.
The favorable results thus obtained encourage the hope that it may
prove a successful remedy and lead to the adoption of a more consistent
mode of practice in the treatment of epidemic cholera. In India, in
Europe, and in America, it is now regarded as a very important remedy,
and especially indicated in this disease. As an antidote to miasmatic
poison, and as a prompt and diffusive stimulant when properly combined,
it is admirably calculated to meet and suspend the most urgent
symptoms. In short, it may be considered, in relation to this disease,
an excellent therapeutic agent, and well calculated to form the base
of the principle for which we contend.

But again, our doctrine is confirmed by the experiment usually
termed "venous transfusion." The solution of soda, when raised to
a temperature from 105° to 120° Fahr., and injected into the veins
of the suffering patient, gave _temporarily_ prompt and immediate
relief; but, when injected at a lower temperature, failed. In this
experiment, the sole and only agent contributing to the result was,
as before explained, the free caloric which immediately permeated
every tissue, supplied warmth to the body, relieved the depressed
nerve-power, equalized the circulation, and restored generally the
normal action of the system. Of this result, and of the diffusive and
prompt stimulating power of free caloric, there can be no question.
The principle here evolved, which answered so perfectly the imperious
demand and so immediately suspended the power of the disease, is the
very principle dictated by its pathology. Stronger and better evidence
of the utility of a prompt and diffusive stimulant, permanent in its
character and influence, cannot be furnished; one that will act kindly,
without violence and without any disturbance to any organ or tissue, to
injure or delay the return of immediate and perfect health after the
disease is subdued. Such we affirm to be the principle demanded in the
successful treatment of the epidemic cholera.


SECTION II.--REMEDIES, RECIPES, ETC.

Considering the general principle of treatment, and the nature of the
remedy so clearly suggested by the pathology of the disease to be fully
established, it now remains for us to point out some of those curative
agents which may be employed to advantage. It may be here observed,
that among the few that can be confidently recommended, there is no
single remedy yet discovered which seems to possess all the properties
necessary to meet the complex condition presented in a malignant
case of cholera. Yet it is believed we have simple remedies, which,
when properly combined, will prove successful. Among the number that
seem best adapted to meet and fulfill the indications, may be named
chloroform, as the leading remedy on which we may reasonably hope for
success. This may be united with spirits of camphor, the tincture of
xanthoxyli fraxinifolii bacca, the compound fluid extract of rhubarb
and potassa,[XVII.] and the oil of monarda punctata, and a very
valuable and reliable remedy obtained. The following formula exhibits
the mode of combination, which may be varied and adapted to suit any
emergency:

   Rx. Chloroform, (sq.,)                dram ij.
       Spirits Camph.,                    dram j.
       Ol. Monarda,                      gtts. x.
       M. et adde--
       Tinc. Xanthox. Frax. Bac.,       ounce ij.
       Fluid Ext. Rhei et Potas.,       ounce iv.

M.--S.--From dram j. to ounce ss. every half-hour, hour or two hours,
according to the urgency of the symptoms and the stage of the disease.
As soon as relief is obtained, it should be given in minimum doses and
less frequently. This is admirably adapted to the cold stage, and will
give prompt relief in a great majority of cases.

In the premonitory stage, it can be administered to good advantage
in small and less frequent doses. In some instances, an additional
astringent may be necessary. The deceptive and painless diarrhoea
should receive prompt attention, and be regarded and treated as the
incipient form of the disease. According to the best authorities, the
diarrhoea commences with the first chemical change or alteration of
the blood, and proceeds gradually, in most cases, for some hours, and
even in some instances, though rarely, for days. It is not sufficient
to check the diarrhoea merely; the cause must be removed, which is
essentially of miasmatic origin. When the cholera is prevailing, and
the diarrhoea is essentially choleraic, or the result of a depressing
miasmatic influence, it should be treated with chloroform, aided, if
required, by appropriate astringents.

In the fully developed stage, and even in the stage of collapse,
perhaps no combination is better adapted to meet promptly all the
necessities and wants of the system, and suspend the action of the
cholera-poison, than the one named above. It is a simple, prompt and
diffusive stimulant, approximating the principle indicated. This
peculiar remedy is essentially required, and should be continued
through all the stages of the disease till relief be obtained, varying
its administration according to the urgency of the symptoms. When the
stomach is too irritable to retain medicine, it should be given by
the bowel. Take of the above mixture, one-half ounce, of the tincture
of prickly-ash berries one-half ounce, of the tincture of opium ten
drops, of warm water one ounce and a half--mix and inject. This may
be repeated after every evacuation three or four times, unless relief
be obtained earlier. Thus, it should be administered perseveringly by
stomach and by bowel, aided by due employment of all necessary external
means for furnishing warmth and giving relief. Opium, however, should
be omitted after two or three injections. Its continued use to check
the movement of the bowels is decidedly injurious.

The vomiting and irritability of the stomach may often be allayed by a
strong decoction of spearmint and horse-peppermint (monarda punctata),
equal parts, alternated with camphor water in small repeated doses
every five minutes. This will often succeed when all other means fail.

The compound cajeput mixture[XVIII.] is a very excellent and prompt
stimulant, and may be alternated with other remedies with good effect.
It is particularly useful in allaying violent cramps, and restoring
warmth to the body, and may be given in doses of one tea-spoonful every
ten or twenty minutes in mucilage, simple syrup, or, better still, in
hot brandy-and-water sweetened.

The aromatic tincture of guaiac[XIX.] will be found very useful in some
cases, and may be united with chloroform according to the following:

    Rx. Chloroform, (sq.)                dram ij.
        Spirits Camphor,                  dram j.
        Ol. Monarda,                      gts. v.
        M. et adde--
        Tinc. Guaiac. Arom.,            ounce iv.
        M.

S.--From one-half to one tea-spoonful every half hour, or, if
necessary, in violent cases every twenty minutes, in a little sweetened
water. This may be alternated with some other remedy to great advantage.

Chloric ether has been with some a very favorite remedy, and, in
combination with other diffusive stimulants, may serve a good
purpose. So, too, the spirits of turpentine, and the rectified oil of
turpentine, have proved very beneficial, the former in combination,
the latter administered alone. These agents, however, can be rendered
more prompt and effective by combination. It is the promptness, the
instantaneous or electric action like that of oxygen, ozone, and
caloric that gives value to the combination, and renders it peculiarly
efficacious when it possesses the other peculiar properties required.

In the early stage, sulphuric acid, in the form of elixir vitriol, has
given very prompt relief, and is very highly recommended as a curative
agent in the treatment of this disease. The following formula presents
the mode of its exhibition:

    Rx. Elixir Vitriol,                  ounce j.
        Tinc. Xanthox. Frax. Bac.       ounce ij.
        Ess. Lemon,                       dram j.

M.--S.--Tea-spoonful in a gill of sweetened cold water every two or
three hours.

This recipe was used in the incipient stage quite extensively in the
epidemic of 1849, with decided advantage. It generally removed the
symptoms speedily, without any other treatment. In the more advanced
stage it was thought not so reliable as other means named above.

Dr. Fuller, of this city, advocates the use of sulphuric acid as
a prompt and efficient remedy, and affirms that according to his
experience, a great majority of cases may be cured by this mode of
treatment.

Dr. Cox, of England, has also spoken in its favor, and recommended
its use as an infallible remedy. The eclectic physicians are entitled
to the credit of its first introduction as a curative agent in the
treatment of the Asiatic cholera, combined with the tincture of
prickly-ash berries and the essence of lemon, as noticed above. In our
estimation it may be rendered more effective, combined according to the
following:

    Rx. Elixir Vitriol, }
        Chloric Ether,  }      [=a][=a]., ounce j.
        Tinc. Xanthox. Frax. Bac.        ounce ij.
        Ess. Lemon,                        dram j.
        M.

S.--A tea-spoonful in a gill of sweetened cold water every two or three
hours. Thus combined, it forms a very prompt and diffusive stimulant,
and is well adapted to meet the indications in the earlier stage of
the disease. In the last stage perhaps no remedy will be found so
prompt and decided in its action as the injection named above, with the
internal use of chloroform as combined in the recipe on page 189.

In cases of excessive irritability of the stomach, the following
combination was administered with good effect, and was especially
beneficial in cases attended with stupor from the commencement of the
disease:

    Rx. Common Salt,                      dram j.
        Black Pepper,                     dram j.
        Vinegar,                       f. dram v.
        Hot Water,                   f. ounce iv.
        M.

Of this, when settled, or strained, a table-spoonful may be given every
ten or twenty minutes. It seldom failed to quiet the stomach and check
the motion of the bowels. In this condition the injection should be
also administered, and repeated as occasion may require.

Some advocate the use of the spirits of ammonia and tincture of
capsicum, properly combined with other diffusive stimulants, as a very
efficient and successful remedy. The following is, perhaps, the most
desirable formula:

    Rx. Chloroform, (sq.)       }
        Spts. Camph.,           } [=a][=a].,  dram iij.
        Spts. Ammonia Aromat.,  }
        Tinc. Capsicum,         }
        Elix. Opii (McMunn's),                 dram ss.
        Syr. Zingiberis,                      ounce ij.

M.--S.--Tea-spoonful in water every thirty minutes till relieved. Then
less frequently, according to circumstances. This is said to give
very prompt relief in the earlier stage of the disease. With some
practitioners the following has been quite a favorite remedy:

    Rx. Æther Chloric.,                  ounce j.
        Tinc. Cardamom.,                ounce ij.
        Spts. Camph.,                   ounce ss.
        Elix. Opii (McMunn's),           dram ss.
        Syr. Zingib.,                   ounce ij.
        M.

S.--Two tea-spoonsful in water every 10 or 30 minutes till relieved,
then continued less frequently and in less doses every one, two, three,
or four hours, according to circumstances.

For the purpose of promoting reaction in cholera and diarrhoea, the
following formula has been extensively used and most universally
approved. It is, indeed, so highly valued in England and in India, that
it is ordered to be always in store and in readiness in the Medical
Field Companion of the army when on the march:

    Rx. Ol. Anisi,     }
        Ol. Cajeput,   }      [=a][=a]., dram ss.
        Ol. Juniper,   }
        Æther Chloric,                  ounce ss.
        Liquor Acid. Haleri,[XX.]        dram ss.
        Tinc. Cinnamon,                 ounce ij.
        M.

S.--Ten drops every fifteen minutes, in a table-spoonful of water. An
opiate may be given with the first and second dose, but should not be
continued.

Another recipe which has been used with some success in private
practice, illustrative of the use of chloroform as a diffusive
stimulant and sedative, is the following:

    Rx. Chloroform (sq.)  }
        Spts. Camph.,     }
        Tinc. Capsicum,   }   [=a][=a]., dram ij.
        Tinc. Zingib.,    }
        Tinc. Cardamom.,  }
        Syr. Simplex,                   ounce ij.
        M.

S.--Tea-spoonful in a little water every half hour, hour, or two hours,
according to circumstances. An opiate may be given with the first and
second dose, but should not be continued. Should the first dose be
ejected, give another immediately after the vomiting.

In collapse, which is simply a more advanced stage of the disease,
indicating the gradual failing of all the powers of life, our main
reliance is on enemata, as noticed above, often repeated, and continued
as occasion may require.

Rev. Dr. Hamlin, of Constantinople, observes, "It is difficult to say
when a cure has become hopeless. The blue color, the cold extremities,
the deeply sunken eye, the vanishing pulse, are no signs that the
case is hopeless. Scores of such cases in the recent epidemic have
recovered."

Here it may be proper to add, that a cure, even with the most efficient
remedies, cannot be easily effected without placing the patient at
the commencement in a recumbent position. This appears indispensable.
The patient should be placed in bed and kept there in the horizontal
position, comfortably covered with blankets, and with warm applications
to the feet. Every necessary convenience should be at once provided to
prevent, if possible, the patient from rising to, or standing upon,
his feet, for the erect posture, before relief is fully obtained,
will inevitably hasten the unfavorable termination of the disease. On
this direction, therefore, the physician must insist if he would save
his patient. Says an eminent physician, perfectly familiar with the
disease, "This direction faithfully observed, and good nursing, will
save very many patients even without medicine."

Of the auxiliary aids, consisting of various external applications, we
cannot speak in very flattering terms. To the mind of the practitioner
the more important are readily suggested, and are promptly employed by
nurses in the earlier stages of the disease. It is impossible for any
person to attend on a case of true cholera without being instinctively
moved to apply heat friction, and warm stimulants to the surface for
the relief of the suffering patient. Any attempt to prevent these kind
offices and apparently beneficial appliances would be unwise, and most
certainly, in private practice, unavailing. It becomes, therefore,
necessary to direct the use of those which are most agreeable to the
patient and tend to preserve and sustain the recuperative power; those
which tend to weaken and depress the system are the most objectionable.
Among the number that seem to do good, we may mention bottles of hot
water to the feet and calves of the legs, hot bricks dipped in water
and wrapped in flannel and applied to different parts of the body;
blankets wet in water as hot as can be borne, and wrung out so as
not to drip, and applied to the whole surface, and changed at short
intervals, so as to keep up a steady and permanent temperature of
the surface; flannels moistened with spirits of turpentine, or other
stimulant embrocation, and laid over the stomach and bowels, may be
employed, as these all, in some instances, seemed to be beneficial.
Their necessity and use, however, must be governed by circumstances.
As we have before said, our main reliance is on a prompt and diffusive
stimulant internally; other means, at best, are very uncertain.

Such are some of the remedies evidently suggested by the pathology
and phenomena of the disease, and adapted to meet and remove the more
urgent, essential symptoms. They are not entirely new. They have been
employed to some extent in former epidemics of cholera, and have
sustained a good reputation as useful and curative agents in the
treatment of this disease. The combinations here suggested are the
result of observation and experience, and are intended to present the
form in which these remedies can be exhibited to the best advantage.
They are simple, prompt, and reliable, such as will leave the system,
when the disease is subdued, in its ordinary condition, without any
injury whatever to prevent its immediate return to its normal state
of health. Let them be employed, and their utility thoroughly tested.
They will bear the strictest scrutiny, and sustain their reputation
untarnished under the most trying circumstances. Should the cholera
appear again in our midst in its epidemic form, and these remedies be
generally employed and properly administered, we venture to predict
their efficacy will be abundantly proved in the successful result of
saving more than nine-tenths of those attacked.


SECTION III.--PROPHYLAXIS--OR MEANS OF PREVENTION.

In presenting a course of preventive treatment consistent with the
origin and general character of the disease, we are necessarily limited
to the means of sustaining the _normal_ action of the system, and
suppressing the operation of those causes which, by reducing the
general health, tend to generate, foster, and develop the cholera. Of
the former so much has been written and published, inculcating the
general principles of hygiene, that it seems quite unnecessary to dwell
on a subject so familiar to the great mass of community; yet, there
are occasions when the most familiar truths have to be impressed upon
the mind, by constant repetition, to prevent threatened dangers, and
obviate the most serious consequences. In no instance is this more
important than in time of prevailing epidemics; for it is an undeniable
fact, that multitudes _will_ neglect the most obvious principles of
hygiene, and tolerate, with utter indifference, the most offensive
nuisance, in and around their dwellings, and if attacked by disease,
will often wonder why _they_, more than _others_, should be visited by
a malignant disease, or become the victims of a prevailing epidemic.
Hence the necessity of urging the observance of some of the most
obvious principles of hygiene, in the preventive treatment of Asiatic
cholera.

Pure air, pure water, and a frugal nutritious diet are Nature's
great preventives for the thousand ills of life. These are the great
essentials in sustaining the healthful and normal condition of the
system, always of primary importance in preserving its tone and energy,
and rendering it impervious to any miasmatic or epidemic influences.
Therefore, the tone of the system should, more especially when
epidemics are prevailing, be kept fully up to its normal standard.
This cannot be accomplished without pure air,--whether our dwellings
be located in the city or in the country; free ventilation of all
apartments is of the first importance. Kitchens, sitting-rooms,
dressing-rooms, and especially sleeping-rooms, should be kept
constantly and thoroughly ventilated; cellars and vaults, too, should
receive attention, and be kept free from a deteriorated or foul
atmosphere. Everything within and without our dwellings, tending to
impregnate the atmosphere with noxious effluvia, should be removed, and
the foul air promptly purified by the use of appropriate disinfectants.

Pure water for drinking and culinary purposes is another preventive
remedy, whose employment cannot be safely omitted. It is a well-known
fact that, in various localities, wells only a few feet deep, which are
mainly supplied by drainage or surface water, have proved a fruitful
source, and in some instances a direct and efficient cause of epidemic
cholera.

The water from rivers flowing past large cities and villages is often
so impure as to render its use decidedly deleterious, if not an actual
source of disease. In some cases they have been literally so filled
with portions of fish, and other animal matter, that all city supplies
were made endurable only by long-continued filtration. The waters of
many of our Southern and Western rivers are rendered impure from the
lime and surface drainage with which they are so highly impregnated
that they often become a direct source of diarrhoea and cholera. Pure
water, free from the impregnation of vegetable, animal and mineral
substances, should be sought and obtained for domestic use.

A good nutritious diet is an indispensable requisite in the prevention
of disease. The system in comparative health requires, and should
regularly receive, its proper aliment. Its daily recurring demands
should be judiciously met with pure and wholesome food, in such
quantity as can be readily digested, assimilated and duly appropriated
for the supply of its wants. Due regard, however, must be had to the
existing and peculiar condition of the digestive organs, on which
mainly depends the process of supporting and perpetuating the general
health.

It is not the profuse variety and the incongruous mass composed of
baked, roasted, boiled and fried meats, fish and fowl, oyster, lobster,
frog and turtle, with puddings, tarts, jellies, cakes and creams from
the pastry room--fruits and salads, native and foreign, rich and
rare--alcoholic stimulants, and cooling ices, but the simple, plain
and frugal diet, properly cooked and particularly nutritious, that
conduces to the most vigorous health.

Regular, temperate habits in all things, are especially commended;
excesses of all kinds are reprehensible. Great and sudden changes in
the habits of living are always deleterious, and must be particularly
so, when an appalling and fatal epidemic is prevailing. Temperance,
sobriety and cheerfulness, regular hours for meals, for rest and for
business, repeated ablutions and perfect cleanliness, moderate exercise
and avoidance of irregularities, persevering self-government and duly
subjected passions, all contribute to health, to happiness, and the
prevention of disease.

Exposure to the extremes of heat and cold should be avoided, and
the clothing properly adapted to the climate--to the season and its
variable temperature. Constant vigilance is necessary to guard against
the numberless causes tending to produce an abnormal condition,
resulting in the derangement of the stomach and bowels, or in
depressing the nervous power, thus enfeebling and prostrating the
general health. The neglect of these hygienic principles and essential
preventives of cholera may induce the condition which temptingly
invites the disease. Some are vastly more susceptible than others, and
may not be able, with all their watchfulness and care, to avoid an
attack, should the disease extensively prevail among us.

The premonitory symptoms requiring special attention, when the epidemic
cholera is prevailing, are definitely presented in Chap. II., Sec.
2, page 56, to which special reference is made. Whenever any of
these do occur, though generally supposed to present no particular
characteristic of the cholera, they should, however, receive prompt
attention. The loss of animation, the depression of nerve-power, the
pain in the forehead and slight vertigo, the nervous agitation and
oppression at the chest, with slight nausea, may in most instances be
promptly removed. They should be at once patiently and perseveringly
treated by the use of camphor water, prepared as follows: Take spirits
of camphor, one tea-spoonful, and put it into a half-pint of cold
water, and give of the mixture two tea-spoonfuls every half-hour, hour,
or two hours, according to the severity of the symptoms. A strong
decoction, or tea of horsemint (monarda punctata), is an excellent
remedy even in this early stage. The essence of monarda, or horsemint,
in doses of eight or ten drops in a little water, and repeated every
hour or two, will often give prompt relief. Where the horsemint
cannot be obtained, the spearmint, and the peppermint also, may prove
serviceable.

Keith's concentrated Tincture of Veratrum Viride is also an excellent
remedy in these premonitory symptoms. Put three or four drops into a
tumblerful of cold water, and give of the mixture a tea-spoonful every
hour or two hours, as occasion may require. This may be alternated with
the essence, or tea of horsemint.

But another more general symptom, which may be properly termed the
incipient stage of the disease, is the slight diarrhoea, usually
termed painless, though it is by no means always so, but frequently
the very reverse, severe and painful. This at first may be slight, but
gradually increasing, soon becomes obstinate, painful, and exceedingly
difficult to control. It therefore should receive attention at its
very commencement, for it is in reality the stealthy invasion of
the citadel--it is the cholera. The loss of life becomes imminent;
treatment becomes indispensable; send at once for your physician. And,
in the meantime, continue the camphor mixture, the horsemint tea, and
give of the fluid extract of rhubarb and potassa, prepared according
to the formula in the American Dispensatory, one or two tea-spoonfuls
every hour, and, if necessary, add four or five drops of laudanum, or
its equivalent in paregoric, to each dose, till relieved. In this early
stage, opium in small doses may be given four or five times, but should
not be continued. These remedies, properly administered, will control
the great majority of cases.

If, however, the diarrhoea be uncontrolled and vomiting ensue, the
recipe on page 189 will be found very efficient, and should be
perseveringly administered till relief is obtained. It is prepared
as follows: Chloroform, two drachms; spirits of camphor, one
drachm; essence of monarda (or horsemint), three drachms; tincture
of prickly-ash berries, two ounces; fluid extract of rhubarb and
potassa, four ounces--mix. Give from one-half to one table-spoonful
every half-hour, hour, or two hours, according to the urgency of the
symptoms and the stage of the disease. This remedy is well adapted to
every stage, and may be used in collapse as an injection, combined as
follows: Take of the above mixture _two table-spoonfuls_, and add to
it tincture of prickly-ash berries, _two table-spoonfuls_; laudanum
_ten drops_; warm water, _six table-spoonfuls_--mix, _and inject up the
bowel_. This injection should be repeated as often as required. In some
desperate cases it has been repeated many times and the patients saved.

Wherever the disease prevails, all discharges from cholera patients
should be promptly disinfected and disposed of. Bedding, linen,
water-closets, cesspools, etc., should be thoroughly disinfected and
renovated, so that no germ may remain to propagate the disease.



FORMULÆ

FOR SOME OF THE PREPARATIONS USED IN THE ABOVE RECIPES.


  GREENHOW'S AROMATIC TINCTURE OF GUAIACUM.--Take of guaiacum, cloves
  and cinnamon, each, in powder, _one ounce_; best brandy, _two pints_.
  Macerate for fourteen days and filter.

  Dose.--From a tea-spoonful to a table-spoonful, in sweetened water,
  every fifteen or twenty minutes.--_Am. Dis._


  COMPOUND CAJEPUT MIXTURE--HUNN'S DROPS.--Take of oils of cajeput,
  cloves, peppermint, and anise, each, _one fluid ounce_; rectified
  alcohol, _four ounces_. Dissolve the oils in the alcohol.

  The ordinary dose is from ten drops to half a tea-spoonful; to be
  given in simple syrup, mucilage of slippery-elm, or in hot brandy and
  water _sweetened_.--_Am. Dis._


  FLUID EXTRACT OF RHUBARB AND POTASSA.--Take of the root of the best
  India rhubarb, in powder, and bicarbonate of potassa, of each, _one
  ounce_; cassia or cinnamon, and golden seal, in powder, of each,
  _half an ounce_; boiling water, one-half pint. Macerate the roots and
  seeds for an hour; strain and dissolve the potassa in the strained
  liquor when nearly cold, and add one gill best brandy; essence of
  peppermint, one tea-spoonful, and refined sugar, _two ounces_.

  Dose.--From one to two tea-spoonfuls as often as necessary.--_Am.
  Dis_.


  TINC. XANTHOXYLI, or Tincture of Prickly-ash Berries.--Take of
  prickly-ash berries _eight ounces_; diluted alcohol, _two pints_.
  Form into a tincture by maceration, or displacement, and make two
  pints of tincture.

  The ordinary dose is twenty or thirty drops. In cholera, from
  a tea-spoonful to one or two table-spoonfuls, according to
  circumstances.--_Am. Dis._


  TINCTURE OF OIL OF MONARDA--Essence of Monarda, or Horsemint.--Take
  of oil of horsemint _one fluid ounce_; alcohol, _nine fluid ounces_,
  Imp. Meas. Mix with agitation.

  Dose.--From ten to twenty drops on sugar, or in sweetened
  water.--_Am. Dis._


  ELIXIR OF OPIUM, prepared on the base of Dupuy's formula is less
  objectionable as an ingredient in recipes for an advanced stage of
  cholera than other preparations of that drug.



FOOTNOTES:


[I.] Sulphuric acid, one part; Rectified Spirit, three parts.

[II.] See American Dispensatory.

[III.] See American Dispensatory.

[IV.] See American Dispensatory.

[V.] See American Dispensatory.

[VI.] See American Dispensatory.

[VII.] See American Dispensatory.

[VIII.] See American Dispensatory.

[IX.] See American Dispensatory.

[X.] See American Dispensatory.

[XI.] See American Dispensatory.

[XII.] See American Dispensatory.

[XIII.] See American Dispensatory.

[XIV.] See American Dispensatory.

[XV.] See American Dispensatory.

[XVI.] See American Dispensatory.

[XVII.] See American Dispensatory.

[XVIII.] See American Dispensatory.

[XIX.] See American Dispensatory.

[XX.] Sulphuric acid, one part; rectified spirit, three parts.



Transcriber's Notes:


Passages in italics are indicated by _underscore_.

The tables have been equalized as good as possible.

Rx. is used for Prescription.

There are diacritical marks in the text, they are marked as [=a] which
represents a marcron (straight line) above the a.

Fractions are displayed as follows: 1/4 correlates with one-fourth, 1/2
correlates with on-half, 1-1/2 correlates with one and a half....

The following words have been retained in both versions:

  formula (pages 73, 136, 157, 189, 194, 196, 198, 211 and 214),
  formulas (pages 76 and 87) and formulæ (pages 8, 138, 142 and 213)

  ether (pages 123, 138, 193 and 195) and æther (pages 73, 139, 197 and
  199)

  spoonful and spoonsful (various occurrences in the text)

Other than the corrections listed below, printer's inconsistencies
in spelling, punctuation, hyphenation, and ligature usage have been
retained.

The following misprints have been corrected:

  changed "December, 805; making a total in"
     into "December, 805"; making a total in"
    (page 9)

  changed "principle of a specific disease--poison."
     into "principle of a specific disease-poison."
    (page 13)

  changed "violent and fatal whereever it appeared."
     into "violent and fatal wherever it appeared."
    (page 27)

  changed "cholera in 1832, at Cataria; in Palermo, 40,000."
     into "cholera in 1832, at Catania; in Palermo, 40,000."
    (page 32)

  changed "In Bassorah and Bagdad, situate in low, unhealthy"
     into "In Bassorah and Bagdad, situated in low, unhealthy"
    (page 32)

  changed "In the Province of Caucassus, out of"
     into "In the Province of Caucassus, out of"
    (page 32)

  changed "phenomena, for numorous cases of"
     into "phenomena, for numerous cases of"
    (page 47)

  changed "The slight, painless diarrhoeea, depression of"
     into "The slight, painless diarrhoea, depression of"
    (page 57)

  changed "be withheld. This pecnliar icy coldness"
     into "be withheld. This peculiar icy coldness"
    (page 59)

  changed "urinary secretion and micturation entirely"
     into "urinary secretion and micturition entirely"
    (page 60)

  changed "the second or febrile stage. The former is"
     into "the second or febrile stage." The former is"
    (page 61)

  changed "spent in the gradual introducion of the"
     into "spent in the gradual introduction of the"
    (page 69)

  changed "Other methods of restoring warmth were had"
     into ""Other methods of restoring warmth were had"
    (page 71)

  changed "when on the march:""
     into "when on the march:"
    (page 73)

  changed "philosophy of such eminent surgeon, as"
     into "philosophy of such eminent surgeons, as"
    (page 88)

  changed "Medical Bureau in the departmnet of India, whose"
     into "Medical Bureau in the department of India, whose"
    (page 89)

  changed "opium, accompanied with sinipisms, and hot, stimulating"
     into "opium, accompanied with sinapisms, and hot, stimulating"
    (page 110)

  changed "if it remainun subdued by"
     into "if it remain unsubdued by"
    (page 112)

  changed "PATHOLOGICAL TREATMENT--_First Stage_: This consisted"
     into "PATHOLOGICAL TREATMENT--_First Stage._--This consisted"
    (page 132)

  changed "the medicines which I would prefer:"
     into "the medicines which I would prefer:""
    (page 138)

  changed "Aromatic Spirits Amomnia,"
     into "Aromatic Spirits Ammonia,"
    (page 139)

  changed "It was a sudden and severe, case and"
     into "It was a sudden and severe case and"
    (page 143)

  changed "are camphor, cuprum metalicum, and veratrum."
     into "are camphor, cuprum metallicum, and veratrum."
    (page 152)

  changed "may be given. This is prepared"
     into "may be given." This is prepared"
    (page 161)

  changed "administered in tea-spoonful does in hot, sweetened"
     into "administered in tea-spoonful doses in hot, sweetened"
    (page 161)

  changed "unfold the process of d seased action, and, as"
     into "unfold the process of diseased action, and, as"
    (page 167)

  changed "in that of Mishni Novogorod,"
     into "in that of Nizhni Novgorod,"
    (page 172)

  changed "in Moscow and Kasan,"
     into "in Moscow and Kazan,"
    (page 172)

  changed "During the prevalence of the cholora in 1832, the physician"
     into "During the prevalence of the cholera in 1832, the physician"
    (page 182)

  changed "Rx Chloroform, (sq.,)"
     into "Rx. Chloroform, (sq.,)"
    (page 189)

  changed "M. S.--From dram j. to ounce ss. every half-hour,"
     into "M.--S.--From dram j. to ounce ss. every half-hour,"
    (page 189)





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