ON CHOLERA AND INTERMITTENT EEVER. 

ADDRESSED TO THE 

t MEDICAL PROFIJ^ftW-JIi -MANCHESTER, ÜBEB 27, ASD NOY^MltitS^, 1848. _ .«¦ ¦ {. *J • : 

BY , , 

\ / 

/ 

CHARLES ¥. BELL, M.D., K.L.S., 

PHYSICIAN TO THE MANCHESTER ROYAL INFIRMARY, LATE PHYSICIAN TO H.M. EMBASSY IN PERSIA, ETC. ETC., FORMERLY HOUSE-SURGEON TO THE MIDDLESEX HOSPITAL. 

LONDON: JOHN CHURCHILL, PRINCES-STREET, SOHO. 

MANCHESTER: SIMMS AND DINIIAM. 

MDCCCXLIX. 







PEEEAOIi 

Owing to the variety of forms in which liolera appeared in Persia, in 1842-3, the author was led to entertain peculiar opinions respecting ts nature and treatment. In the course of onversation on the subject, some of his coleagues in the Manchester Royal Infirmary were leased to say that they would gladly hear the iews then advocated by the author, stated at greater length in the form of a lecture. 

The following pages are the result of his endeavours to comply with this desire, and heir delivery was honored by the attendance of many distinguished members of the medical )rofession in Manchester and its neighbourhood, who, in a very flattering manner, expressed a tope that the lectures might be published. In 'enturing now to submit these observations to he profession at large, before the approaching epidemic should have enabled him by further experience more fully to substantiate or to correct his conclusions, he has been moved solely by the hope, that the inquiries here 







assisting investigation of this obscure disease He wishes them to be received solely as sug gestions, and has therefore abstained as muc as possible from detailing the results of his ow experience, desirous of attempting to reaso on the subject rather than to dogmatise. 

Firmly believing in the analogy of cholera with quotidian ague, he has ventured into print ius early, lest by delay the opportunity of onnrming or negativing a point of so much mportance should be lost to others, to whom ircumstances may have been less favorable lan to himself in suggesting the points of their imilarity. 







Gentlemen, — 

Both as students of the science of medicine, and a professors of the healing art, we are all at presen peculiarly interested in investigating the nature o cholera. Thirty-two years have now elapsed since tha Ital disease first became known to our countrymen i idia, and through them to the inhabitants of othe untrics ; but it was long regarded by the nations o urope and America, as belonging rather to anothe jrld, than as ever likely to become personally interes g to themselves. 

It was only on its actual appearance among us i 332 that we became convinced of our mistake, am ere thrown into all the consternation that attends ysterious and unexpected object of terror. At tha me every human attempt made to arrest its progres >roved in vain; and, setting almost every variety o climate at defiance, cholera completed the wide circu of the world. 

No sooner, however, was the danger past, than we relapsed into our false notion of security, until this was again dispelled by appalling accounts of its renewed 



2 

progress through Asia, and of its having again passed he boundary of the Cancasus, invading Kurope by the dentical route which it had followed seventeen years efore, with no other difference than that its front was ow more extended. 

It might reasonably have been expected that, afi le disease had extended itself over nearly the who lobe, and the press of every country had absolute eemed with essays upon the subject, some defini greement would have been arrived at by the profe ion with regard to its essential nature, and to th irinciples upon which its treatment should be con ucted. It is, then, little flattering to our professiona mdc, to be obliged to acknowledge that this expecta on has been disappointed. 

The medical press gives almost daily evidence, that ttle information of importance has been added to hat which had been collected by the earliest observers the disease ; our practice is still almost entirely mpirical, the principles on which it should be conducted c as little determined, and the opinions of the proession as little settled as they were on its first visitation. 

Even the great question of the capability of cholera being communicated by contagion, is still a moot point, and all the evidence collected on the subject is insufficient to convince our legislature that quarantine regulations in regard to it, are only a useless and cruel grievance. Under such circumstances, and after many of the first medical authorities of the past and 



3 

)resent generation have failed to elucidate its nature, s ouly natural that every new attempt to throw ligh pon the subject should be received with distrust, am iat any one who now ventures on the discussion, wi o so at considerable risk to his professional reputation cannot, therefore, but feel much diffidence in doin o, and that much apology is due to you forrequestin our attendance here for that purpose. 

My reason for making the attempt is, simply that I >clieve ihe circumstances under which I have had an >portunity of studying the disease have been peculiar, nd such as to lead to conclusions of great importance, nd that I should be acting little in unison with the pirit of our profession, and be neglecting a great duty, I failed in laying that information which chauce has ccorded me, before its members. I may, it is true, lave overrated the value of my opportunities (this is or you to judge,) but believing, as I do, that what I lave witnessed, if fairly set forth, will lead to the (/termination of a principle, rather than a rule of iractice, T have felt it imperative on me to submit the übject to your consideration, in the same light in Inch it had appeared to myself. 

After becoming acquainted with cholera, under very favourable circumstances, in Edinburgh, in 1832-3, and in London, in 1833-4, it was my lot to be stationed for several years in Persia, a country, situated both geographically, and in point of climate, midway between In lia and Europe, and there I had the opportunity of 



4 

bserving closely the first approaches of the identic holera, which is now sweeping irresistibly towards a 'he disease was there ushered in by a regular successio f epidemics, commencing in a fever apparently con nued, but by and by assuming more the charact f a remittent, and this very gradually changed to a ntermittent of quotidian type ; of this the cold stag radually became prolonged, and assumed all tl ppearances of an attack of cholera, and then came tl tiolera, as it has everywhere been known, without an 'ivious stages or intermission. This again in its tur isappeared, and the epidemic resumed the charact f remittent and continued fever for a time. Thes arious changes occupied a period of eighteen months. 

I Having thus witnessed the disease analysed and ssected as it were, into its component parts, and see continued fever gradually resolve itself into choler and cholera into continued fever, by slow gradation n a manner which does not appear to have ever bee resented with the same perspicuity to any autho laving, too, been obliged to follow each varying typ f that epidemic with appropriate treatment, I hay eon led insensibly to those views of the nature ant reatment of cholera, which I shall endeavour to subm o you, as shortly as may consist with my intention o eading you into the same train of reasoning which myself pursued. 

By considering this fatal disease rather as an exaggerated example of others better known, and 



5 

hose treatment is more familiar to us, than as someling anomalous and unlike every other disease, we mil, I trust, escape the necessity for vainly searching or some principle capable of reconciling modes of reatment so much at variance as hot air-baths and arm stimulant potations on the one hand, and snowaths and iced-drinks on the other. ./"Ether, alcohol, artar emetic, calomel, lead, lunar caustic, croton oil, aphtha, assafoetida, quinine, opium, peppermint, bleedng, blistering, and the actual cautery, are only a few f the remedies that have been proposed for the same age of the same disease, all equally failing— all qually recommended as infallible. 

Still, there is one valuable conclusion to be drawn from the very contrariety of the means employed, viz., that almost all have felt that the more obvious indications (which the well-marked symptoms of cholera would lead us to follow,) are not to be trusted as guides in the treatment of the disease ; that some broader principle is necessary to direct our practice than the fallacious one of opposing the cold of the body by external heat, the collapse and sinking of the vital powers by stimulants, or the purging and muscular spasms by opium. Indeed, the abandonment of this method of treating symptoms, and the loss of faith in heat and stimulants are what chiefly distinguish the more recent works of experienced authors from those of more ancient date, and of less practical acquaintance with the disease. 



6 

In concluding these prefatory observations, I beg o remark, that I have endeavoured to avoid discussing 10 opinions of others, because this is unnecessary to 10 audience I am addressing, who are not only well cquainted with the works of the best authors on the übject, but also possess a large amount of unpublished mowledge of the disease from their own practical xperience. 

The similarity of cholera to the cold stage of ague oo obvious not to have occurred to many, but the ere, unfortunately, two circumstances which contr >uted much to prevent this analogy from being pursue* o its full extent — the first being the want of an tvious stage of reaction, relaxation, or intermission le other, that quinine and arsenic were not founc fectual in the treatment. 

It was observed that recovery from the cold stage of lolera in this country, was not unfrequently followed y a low form of continued — I should rather say emittent-fever, and this, instead of being regarded as ne of the modifications of the disease, induced by imate, or, as a secondary effect of primary disorder, was considered by too many as the hot fit which belonged to the protracted cold stage that had preceded it. 

I shall endeavour to point out that this form of fever not unfrequently precedes and follows cholera as an epidemic, even at long periods, before and after the appearance of the major malady, and sometimes occurs as its substitute ; and that while it prevails in a country, 



7 

the " epidemic constitution" to which it belongs, mor or less influences the course of almost every othe form of disease, by producing a greater than usu tendency to venous congestion, and diminished o irregular action in the capillary circulation ; and th the type of sporadic fever in this country has fo several years approached very nearly to this, especiall in the last few weeks; — as also in Edinburgh Id I SI! in Liverpool in 1844-5, and has been more particular] displayed in those cases of fever that have arisen spon taneously from putrid vegetable matter. 

Finally, I hope to convince you that the alliance o tolera with other diseases, of which quotidian perioc city is a marked characteristic, gives us reason t elieve that even when apparently most destitute o gularly recurring periods, it is not utterly so in realit 'hat it is, in fact, by considering cholera as an aggra ated congestive ague of quotidian type, that we sha ost nearly arrive at just principles on which to con uct its treatment, and that the means by which cur effected in the one, are both theoretically and pract ally those which are most appropriate to the other. 

rSTINCTION BETWEEN MALARIOUS AND CONTAGIODS FEVERS. 

Before we enter on the consideration of those diseases with which cholera is allied, and of which class it may be considered one of the extremes, it will be well to devote a few minutes to consider the broader 



8 

points of distinction between this class and those diseases which are communicable by contagion. 

By active disease, we mean either tha direct effec of toxictil or mechanical injury to some portion of tl system, or the indirect effects produced by the resistanc opposed by the vital powers to the operation of sue causes — or, lastly, the effects of the struggle betwee the noxious influence and the vis medicatrix. 

Fever is the most obvious and most frequent evidence ' the activity of the vital powers to resist a noxious fluence, and of the attempts of the powers of life to pair the effects or remove the cause of injury; but in onsidering fever in general, it is usual to limit the rm from its wider sense to that condition which Hows the absorption of certain poisons into the blood. 'lien, therefore, we find fever to be the consequence of >sorbed poison, it is of the utmost importance to ndeavour at the outset to ascertain, as nearly as we an, upon what part of the system, and in what manner le effect is produced, and what are the actions by hich its influence is resisted. 

That the cause of both contagious and sporadic fever is introduced into the system by the blood, few indeed doubt; but the important question is, does the cause produce its effects directly on the blood itself by essentially changing its constitution, or is it only conveyed by the blood, like digitalis, aconite, opium, &c., and without causing any essential change upon the blood, operate by affecting Ihe nervous system ? 



9 

In an admirable essay on " Spotted Typhus," rea< before the Provincial Medical Association in Augua 1848, Dr. Davies, of Bath, drew a broad distinctio between the two classes of poisons which are known t produce fever, viz., animal poison, and malaria. Ther one kind of poison, he said, which, arising in tb ood, and finding the elements of its reproduction i le blood of another, produces a fever capable of being >ropagated from man to man ; and there is another ass of poisons, which, arising in elements extraneous o the blood, does not find its elements there, and lough it produces fever, cannot reproduce itself, and is not capable of being propagated from one to another. 

The second class is that which is now to occupy our attention, at least, that portion of it which embraces fevers produced by malaria, whose characteristic is periodicity,* and I shall venture to enunciate the proposition with regard to these even more broadly :— That although the first class of poisons— that, namely, which produces the exanthemata,— operates on the blood and changes its constitution, the second operates not on, but through, the blood, and produces its effects by its agency on the sympathetic system. 

* Some malarious poisons do undoubtedly contaminate the blood itself, and require special action for their elimination, as the Egyptian plague by boils ; but these form a distinct genus of contagion, and do not fall under our immediate consideration. Those now to be discussed are all characterized by intermitting action till they reach their 



10 

Both classes no doubt produce effects on the syrup letic, but the first, (the animal poison,) acting by ontinuous irritation, produces a persistent effort of th munctuaries to remove the poison from the blood, o ontinued fever; the second, (malaria,) acting solely b ervous impression on the sympathetic, produces mere struggle between the impression which is oppose( o vitality, and those sensations and actions that a >rovided for the maintenance of animal life. Th ruggle is what we observe to take place in the inte lining and congestive fever, &c. 

If malarious poison actually changed the constituon of the blood, it would be as impossible to cut short a t of ague as an attack of small-pox or scarlatina; nit it is possible to cut short an ague, by means which as we shall see when we consider the treatment of ntermittent,) are not one of them calculated to produce n essential change on the blood itself. There would, 00, in all probability, be some evidence of an eliminaon of the poison by the fit, as by the skin in the xanthemata, which there is not; or some difference n the blood drawn several hours before and after the fit'; but in both cases it is equally incapable of propagating the disease by inoculation. Besides, it appears scarcely possible to account for the leading characteristic of the whole class of these fevers — their periodicity— on any principle but by the law of nervous impressions, — viz., that long-continued impression of 



11 

Ility, but that a change of impression restores it ; as c eye long fixed upon a point becomes insensible to c impression of light, but recovers its sensibility on ling turned to other objects. 

So the continued impression of the poison on th sympathetic subdues its sensibility to its appropria (stimuli,— namely, that excitability which resides in th vital organs, whose action the sympathetic governs ant regulates, but its irritability becomes re-excited, and i energies are restored by the new impression caused b change from a natural to a disturbed condition of tl organs, which is the consequence of the withdrawal o the influence that combines and regulates their fun tions. Like the eye, restored to a sensibility to light b change of object, where the energy of the sympathet is thus restored by the new impression, the recovery o its natural sensibilities would be permanent, were itn again submitted to the same influence by which it hen been paralysed at first ; but as the optic nerve will aga become insensible when the gaze is again fixed before, and this sooner or later, as the object is more less illuminated, so does the sympathetic require to 1 again undisturbedly submitted to the noxious impre sion after recovery of its sensibilities before the effe is again produced, and that for a longer or shorter tim according to the power of that impression. 

If we shall see reason to believe that the effects of the malaria under consideration are not caused by actual change operated on the blood, it wilJ be evide n 



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at they can only be produced through the agency le sympathetic, for we shall have frequent exampl ' malaria, affecting at one time the circulation merel in ordinary ague ; at another only the bowels, as b iarrhoea or nervous constipation ; at another tl erebro-spinal system, with convulsion, paralysis, o euralgia ; or, again, we have either two combined, o 1 three, as in cholera; and we know that with th xception of the blood, there is no other element in tl ystem but the sympathetic, which is in such intima outact or connection with the organs of circulatio ' digestion, and with the cerebro-spinal nerves, as t c capable of producing these effects. 

We find, too, that what we should expect from our acquaintance with anatomy, really is the case,— viz., that the capillary circulation is the part of the system which most frequently, most easily, and most completely, submits to the influence of malaria acting through the sympathetic, because almost every other part of the system, — the heart, stomach, lungs, viscera, &c, are all supplied by other nerves, the capillaries alone depending entirely on the agency of the sympathetic, whose branches are distributed to every, (even the minutest,) vessel in which our instruments enable us to trace it. This view is further borne out by considering the change from the healthy functions of this part of the system that are manifested when influenced by the morbid impression. In a state of health we know that certain chemical reactions take place between the 



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blood and the terminal structures of the capillaries, b which perpetual slow absorption and deposition of th tissues, is effected, certain secretions are produced, ant animal heat is evolved, and that while those action go on undisturbed, the blood flows freely and unirapede through the gently distended, but still very minut veins, without exhibiting the least tendency to adher to them, as would be the case in inanimate capillar tubes of equal diameter ; neither does the containei blood exhibit any tendency to coagulate. We kno that this property of preventing capillary adhesion o the blood to the coats of the vessels, and of preservin the fluidity of the blood, is peculiar to the living inne coat, and not to living structures generally, for ex travasated blood, in whatever part of the body, imm diately coagulates. We are also aware that the capillar circulation possesses local excitability, (independent o the heart,) and the power to resist injury or repair i elJ'ects, and that excitability is a reflex action, com mincing in sensibility, therefore that this latter qualit depends upon the nerves of the vessels. 

To prove that all these qualities are bestowed by the sympathetic nerve would lead us too far from our present object ; suffice it to remark, that the first stage of ague and cholera is marked by diminution, or cessation of all these qualities and actions. Of the effect of this on the change of the tissues we have little evidence, but we see secretion stopped and converted into exudation, which physiology teaches is directly the 



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pposite of vital action; the evolution of animal heat eases; the veins contract like those of the dead body ; le blood returns from the terminal structures in a co ition very different from that of health — not coursin reely through the vessels, but slowly, and as if adherin o their coats, and in a half coagulated state; an astly, by the application of stimuli, which would pr uce immediate reaction in the healthy skin, we fine almost impossible to excite these vessels in choler 'he direct conclusion from all this is, that impairei xcitability, nervous energy, and vitality of the capillar rculation, is the first and most essential effect whic c perceive of the impression of ague or cholera, anc lat the change produced upon the blood is more pr ably the secondary effect of the cessation or diminu on of those changes which are produced upon it in ie capillaries of the lungs, and of the system in iealth,than in any way attributable to direct influence ' the poison on the blood. In the whole class of seases now under consideration, we shall find evience of disorder of the sympathetic system in one or ore of its vital functions, displayed either in the apillary circulation, the digestive, or in the cerebrospinal system ; but in not one of them is any conclusive evidence to be found of a poison eliminated from the system by the fit, in any way resembling that which is thrown off from the blood in fevers produced by animal Eisons of the class exanthemata, nor can we conceive v source of constant and universal irritation to the 



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onstitution, such us would result from essentially iseased condition of the blood, to be characterized by ntermissions, or to be capable of cure by means ddressed to the mere interruption of periodicity. In uch a case, on the contrary, we should expect only a ontiuued and persistent action , till the end to be ccomplished by the elimination of the poison is ttained. Moreover, if it be granted that continue! ever is the effect of a constant source of irritation c sting in the blood, it would appear to be a corollary he proposition that intermittent, as opposed to con uued reaction, is direct evidence of the absence of ource of irritation in the blood, and produced b means diametrically opposite, which we have fa rounds for concluding to be the absence of th ritability in the very structures which become excited >y a source of irritation existing in the blood in continued ever, or by their natural stimulant in health, viz., stension by the vis a tergo of the heart* 

On these grounds, considering simple ague as the type of the whole class of diseases which we are about m to study, vt e shall proceed to examine its symptoms and the indications for treatment. 

• The above reflections may serve to suggest tne question to physiologists, — whether the circulation of the blood by successive pulsations of the heart instead of by a continuous action, may not be a wise provision of nature to avoid the exhaustion of nervous sensibility in the capillaries by continued impression, 



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SYMPTOMS AND TREATMENT OF INTERMITTENTS. 

Intermittent fever has been generally described a onsisting of a cold stage, with shivering ; a hot o 'ebrile stage ; and a stage of perspiration and relaxa on, followed by intermission. This description canno lowever, be received as a definition, because of thes ages there is only one that is constant, — viz., per dical return of the cold stage, while the febrile ;u weating stages are only the consequences of subse vent reaction and relaxation, and sometimes they ar altogether absent. But shivering is by no means a essential to the cold stage; on the contrary, in the mo dangerous forms of ague, shivering is often absent, a it is in cholera, because the disturbance of the circula tion in the cold stage is such as to overpower th symptom. 

Shivering may practically be considered not so muc symptom of the impression of cold on the body i iealt.li, or of the cold stage of ague, as an evidence th eaction is taking place in the system, and that th leart possesses the power to overcome the obstiucii< pposed to its action ; it is, in fact, the first step of th ebrile stage, and in the more malignant forms of agu is the surest harbinger of recovery, and the best cv dence of reaction. 

In the medical treatment of ague, little is generally attempted in the cold stage beyond giving a stimulant diaphorotic, or in the febrile beyond cooling diluents. 



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t is customary to trust entirely to the means of pro onging and confirming the intermission by the use o ntiperiodic medicines. But this routine method o eatment is not applicable in all agues, for these diffe aterially in the urgency of their symptoms, accordin o their various types, and the duration of their perio< f intermission. 

Thus, both in quartan and in tertian ague, febrile action generally runs so high as to cause this stage be most dreaded by the patient, and the congestive ago is of comparatively little moment, being accom mnied with shivering almost from the first ; but i uotidian the case is very different, the fever, where xists, being slight and of short duration, and both th nd the sweating stages often absent or iinperceptibl nd the interval between the fits is sometimes so sho s to be insufficient to restore natural irritability to th rstuin by repose. The congestive or cold stage is, o le other hand, extremely severe, and such as to ndanger the vital organs, and even to give rise to the read that the attack may prove fatal before it reaches he stage of reaction. In such a case, then, — and such t will appear is cholera, — not fever, but tho opposite ondition, is to be feared, and all our efforts must be irected to obviate or relieve congestion. 

There cannot be a doubt that this is the most essential part of cholera, and the great source of danger in congestive ague; we shall, therefore, devote the remaining portion of this lecture to the consideration of the 

¦ 



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ongestive stage in its cause, course, symptoms, and Sects, and to the mechanical means of relieving and uring it, whether natural or artificial, reserving what we have to say on the medicinal part of the treatment or a future lecture. 

It is customary to date the commencement of a fit f ague from the commencement of shivering, and of holera from the first purging, but this is an important rror, for long before this symptom comes on, a certain brivelled appearance of the skin may be observed ; le expression of the eyes changes; there is a feeling f malaise and confusion in the head ; the nails look >lue and bloodless, and are marked with a red and hite streak, and there is a tendency to yawn, and a eeling of oppression about the heart, accompanied ith sighing. 

I The essential part of ague has begun, perhaps, as uch as two hours before the shivering occurs ; the ood is gradually forsaking the extremities, and is iven in upon the heart more quickly than it can b nt through tho pulmonary circulation, whose capilla ss also resist the free transmission of blood; it therefor accumulates in the great veins, so that a great part o that fluid which a shod time before was circulating in the extremities, being now rejected by the capillaries is forced to find room in the venous reservoirs, and great vascular organs of ihe cheat and abdomen, while the arterial system is left comparatively empty. 

The consequence of this congested condition of the 



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fmt veins is the disturbance of the circulation in th >racio and abduminal viscera, and oppression of th lion of the heart. This disturbance of function pro ces an excitement in the organs themselves (that i on and through the sympathetic nerves,) to resi pression, by increased efforts to preserve life, or wha called reaction. When this effect is felt, the who ame partakes of the influence, and manifests it b onvulsive shivering. The struggle of the powers o fe against the disturbed or oppressed action of thos rgaus whose office it is to sustain life continues, till . length the highly-excited powers of the heart and rteries overcome the inertia of the capillary circulaon, and the blood once more courses freely through ie veins. But this excess of action does not imineately cease with its victory, a period of fever succeed LI at length, exhausted, the capillary circulatio >ecomes relaxed, perspiration bursts from every por le excitement of the heart subsides, and the circulatio eturns to its natural condition for a time. This perioc of repose is not, however, permanent; by and by th capillaries again succumb to the eflects of renewec impression, the same effects are produced as befor and the same struggle ensues. Tho duration of th cold fit depends upon the susceptibility of the sympa thetic, to be sooner or later roused to perception of the disturbance of the vital functions which is taking place, and on its ability to excite the organs of circulation lo more healthy action, for according to this will the 



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ruggle be more or less severe and protracted, and i Ice manner the severity of the congestion and abridge ent of the period of intermission will be in proportio o the power of the impression to produce the paralyt ondition of the capillary vessels by its agency on the erves, till the climax is reached in cholera wher ntermission is either wanting, and consequently fata r very imperfect. 

If, then, the cold stage commences in disturbei apillary action, and contraction of the veins of tl \ Demi ties, by which the blood is forced into the interi nuses of the chest and abdomen, distending th >leen, oppressing the heart's action, and disturbin le circulation and functions of all the viscera, it vident that to prevent or remove this disorder apillary action before it produces the above effec ill be to prevent or cut short the fit. 

If again capillary disturbance have taken place, ut blood from the extremities be prevented from caching the interior in great excess, and from proucing more than mere disturbance in the circulation nd action of the vital organs, the symptoms of congestion, or the fit, will be prevented, or so far mitigated lat reaction will take place with comparative ease. 

Or, thirdly, congestion and oppression to the heart having taken place so severely as to prevent reaction from being evinced by shivering, the removal of some part of the blood which is producing it will enable reaction to take place, and this last is the use of 



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Kding in cholera, as well as in the cold stage of j. In the cure of ague, therefore, the three inten-3 we have to fulfil by treatment are — 

11st. To prevent disturbance of, or restore natural tion to, the capillary circulation. 

12nd. To prevent excessive congestion, by anticipa>n. 

3rd. To relieve this if it have taken place. 

The first has been accomplished sometimes by pr ucing a sudden general impression on the nervou 'stem, — as for example, by unexpectedly plunging th iliont into cold water; but the more usual method o give those medicines which possess a peculiar pow n preventing periodicity, such as arsenic, and quinin r if we consider their modus operandi, we might sa lose which possess a peculiar tonic effect upon tl apillary circulation, or upon the sympathetic nerv n that part of its functions, and which, by producing n effect directly opposed to that of malarious poison, ct as antidotes to it, in the same manner as diffusible imulants will oppose the depressing effect of digitalis r aconite on the action of the heart. 

The first, then, is chiefly the medicinal part of the treatment, which shall be considered hereafter; the second and third rather mechanical than medicinal, for the second intention is attempted to be fulfilled by the application of tourniquets to the limbs in such a manner as to retain as large a quantity of venous blood in the extremities as possible, but is still better effected by 



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!e early use of venesection before the more prominent idences of congestion have been manifested. The ird is, after the congestion has taken place, to draw ood rapidlj from both arms, in order to relieve the ngestion. 

The mechanical treatment of ague by bleeding, lerefore resolves itself into this, that if we can bleed fter disordered action in the capillaries has commenced, nd as yet has only disturbed but not oppressed the ction of the heart, but before the great struggle of the ystem which ensues on established congestion has >egun, the abstraction of blood is easy, safe, and ffectual in preventing congestion and producing immediate cure; but after shivering has begun bleeding s unnecessary and may be injurious, because it will ion disturb the healthy reaction of which this is an ndication: If practised after the commencement of livering, the first effect of bleeding will be to bring ack tho congestive stage with tendency to collapse, and afterwards to relieve it ; but this is done at unnecessary expense of blood, and although generally successful in cutting short the ague, is practically neither sc safe nor so effectual as bleeding just before slii voring begins, and therefore it is better to delay till the next antecedent period. 

When, however, the evidences of extreme congestion exist without shivering, shewing that it is becoming dangerous, and that due reaction is prevented by the mechanical obstruction offered to the heart by excess of 



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blood, bleeding from the veins cannot be had recourse to too promptly, in order to relieve it and the other organs from the pressure. But although in an early stage these are perfectly good and intelligible reasons for bleeding where congestion is severe, the practice is not to be recommended after it has existed for a long time, and the reason is this, — 

Experience has proved, that often in cholera, where scarcely any external evidence is given of reaction, or restoration to a more natural condition of the circulation, such restorative action is nevertheless really taking place, and if the powers of life can only support the oppression without utterly failing, for certain period, thedisturbed circulation of the capillari will by and by cease, the heart be freed from obstru tiuii, and the general circulation be more or less r stored. Practically, therefore, it is better and safer n to use the lancet if congestion have existed for sever hours, lest by bleeding we disturb the natural tendenc to recover, so far as to reach a second period of reli at least, if not of reaction; and lest instead of relievin oppression, we should thereby produce syncope. Unde such circumstances it is more advisable to trust medicine and to nature, until the 18th or 20th hou in quotidian disease, or till an hour or two before tl next anticipated fit in other forms, shall afford us a safer and more advantageous opportunity of pursuing the same practice with a view to arrest the congestion in its renewed accession. The case, however, is very 



24 

different when early called to a patient in whom this condition has existed but a short time, and when there is reason to believe the heart to be in full possession of its energies and only in want of mechanical relief to enable it to resume its powers. In such circumstances there is not only no danger from bleeding, but its effect is little short of miraculous, and in the course of a few minutes, the patient arises from a bed of death and torture, to the full enjoyment of life and health. 

In a case like this, no mistake is so fatal as delay, which is unfortunately the most general one, for here the timid practitioner fears to bleed when he can hardly feel the pulse ; he hesitates and waits until he observes it rise a little, and then acting on the rule, rather than on the reason of the practice, he opens a vein, cuts short the feeble attempt at reaction, and kills his patient in the attempt to cure him. Some have even carried culpable ignorance of the intention of bleeding in cholera so far, as failing to obtain blood from a vein, o open an artery, little thinking how much reduced is le quantity of properly arterialized blood that amid le disorder reaches the left side of the heart, and that pon the capability of that little to sustain life through 10 struggle depends the life itself. By taking arterial Btie takes the life of his patient, produces syncope, aving removed the feeble resistance to death still existed, his patient sinks at once and ibly into complete collapse. Of this fact there Tant of examples on record. Be assured that 



25 

the rising of the pulse after it had been lower, in cholera, as in congestive ague, is positive reason against bleeding, and the best evidence that the constitution possesses the power to carry the patient over that days' attack, to enable him to reach a second, if only let alone, and not worried to death with over-treatment. 

When, however, we decline to bleed after the patient has been labouring under severe congestion for five or six hours, we must search for the practical reasons against doing so, in the effects produced by bleeding in the hot stage of intermittent. This is a subject on which I can speak from sad experience, and one on which unintentional evidence is borne by many cases reported in various works on cholera, where bleeding has been practised in a late, but yet too early, period of the attack. 

In ague, when the period of congestion is over, and the febrile stage marks the progress towards a return to natural action, but where the impression which produced the cold stage is as yet only partially recovered from, it is evident, if the theory be correct, that the effect will as readily be renewed as that of light upon the half-dazed eye, which, having been fixed on an object till insensibility is produced, and only half restored to its sensation by removal, is again subjected to the impression, without sufficient interval fully to regain its powers, it becomes almost immediately reaffected as before, and insensibility is nearly instanyncope 



26 

and return of the congestion are the immediate onsequence; or in loss severe cases, or later in the hot t, the intermittent is in danger of heing converted it" remittent fever of a low, irritative, and dangerous haracter. Much more might be urged on this subject o show that, independently of the above considerations, iiit period which immediately succeeds to a long and xhausting struggle of the heart and arteries is not the most favourable time to expect a greatly increased ffort, but that on the contrary, when the tone of the xhausted vessels, now long accustomed to an overharge of blood, has become impaired, syncope should c a more probable consequence of venesection than elief and reaction. 

If then we have reason to believe that there is a atural tendency to recover from this condition, and o dread and expect its renewal at a certain future >eriod, we must be exceedingly careful not to run into he dangers we have indicated by mistimed bleeding, ut rather trust for a time to medicine alone, and wait that more favourable period, which, with proper are, will arrive with certainty in by far the greater proirtion of cases of congestive ague, and also, I feel ssured, from my own observation, in cholera. 

We shall have occasion again to return to this subject, but were I called on to give a rule for bleeding in the congestive stage, it would be to bleed early and boldly in the first, or even the second, hour, but no later, till the eighteenth or twentieth, after its first 



27 

manifestation, when the same rule will again apply after the twenty-fourth. 

I The above remarks have been addressed chiefly to c consideration of the cold stage of intermittent ver, and their application to cholera has been only cidental ; nevertheless I have stated, that I believe lolera to partake also of this character, — viz., a ndency to intermission, however slight and imperfect, am unwilling to state a fact of this importance on my m observation only, and prefer to rest the argument n the near relation of cholera to quotidian ague, and n its connection with diseases of an intermitting haracter, with which it was associated in its first onset Persia, in 1842-3. This will form the next part of ur enquiry. For the present I shall content myself ith stating that the perusal of cases by a great variety authors, has not tended to change this opinion ; and conceive, that if read in the same spirit with which perused them, this will also become your opinion of c disease, both as it has appeared elsewhere, and as it will probably appear here. In the usual form of cholera, I must allow that the symptoms of this condition are very slight indeed, and I cannot expect them to be conclusive with most, because only to be recognized, if recognized at all, on being sought for with the desire to find them, which undoubtedly is not good evidence. The obvious and external signs of its existence, merely amount to this, — that in most cases of cholera, not rapidly fatal, if visited about the eighteenth 



28 

twentieth hours after the commencement, the patient 11 be found lying in a sort of lethargic condition, parently more sunk and more resigned than he bad en for several hours before; but on examining the tion of the heart with the stethoscope, you find it ore natural, and less excited ; — you find the warmth little more extended on the chest, and the patient ther sulky than insensible. If, finding him in this ndition, you sit down by him, and watch what takes ace, you observe this apparent lethargy cease, he ;aiu becomes agitated, throws off the bed-clothes tha te had latterly permitted to remain upon him, th tion of the heart again becomes tumultuous, and th evious signs of suffering are increased. This cer inly is but small evidence of intermission, neverthe ess it is some, and considering it as such, the efficacy bleeding in this stage of repose, or just as the agitaon is beginning, has been such in my own practice, as my mind, to corroborate the opinion ; whereas the suit of the practice of bleeding, as the pulse begins rise very slightly previous to the period when this nd of repose might be expected, (as I have seen pracsed by others, and which you will find recorded in any published cases,) is very much the reverse. I n only endeavour to reason on this subject, which must be left to the general experience of others to decide. I am satisfied, however, that as far as my own has gone, the rule I would attempt to impress, with regard to the most favourable times for bleeding, is correct. 



29 

There are, however, other objections to this belief, as, for instance : — Why should not a man recovered from cholera be subject to continued daily accessions ? This 1 confess myself unable to explain, but such is the case with many other diseases, such as ague cured by bleeding ; and it is not always the case in cholera, though the character of the accession may differ. It would be too much to attempt to explain everything of what is confessedly so obscure, that even the smallest contribution to its history is looked for with anxiety ; but while upon this subject, I may merely mention one point of observation, which, if more extended experience tend to confirm it, may aid in explaining the natural mode of cure in cholera. This is, that in all forms of quotidian ague with which I am acquainted, there appears a marked tendency to run a course of three days ; and you will find many recorded cases of cholera which will bear this interpretation, where, after three accessions, or, if you please, three days' continuance, of the symptoms of cholera, the coldness and purging cease. Thus, a man has purging one day and gets better; next day he is attacked with algide cholera, he struggles through this, and there is imperfect attempt at reaction, but the purging, cramps, and coldness again become severe on the third ; if this day's accession be not fatal, he goes on into the stage of consecutive fever on the fourth day. Many cases appear to confirm this view, and many to oppose it, as may very naturally be 



30 

fects of the very active treatment pursued, from those a very active disease. 

In treating of cholera, one of the greatest difficulties arises from its unfortunate and most inappropriate name, which would seem to point to the diarrhoea and disturbance of the bowels as the essential part of the disease ; and if we look merely to popular opinion, an to that countenanced by documents issued by authority it would appear as if no room were left for doubt upo this subject, and that the great matter to be attendee td in the cure, is the arrest of diarrhoea, as if that were a iuvariable symptom, and the most imminent source o danger. It is undoubtedly very right in popula treatises and directions, to fix public attention upo this symptom, because in the epidemics best known this has been one of the most frequent early effects and it is well that it should be looked upon as mos dangerous, and as a good reason for applying fo medical aid before worse follows ; but it does not becom the professors of medicine, as a science, to adopt sue an opinion without examination. We have endeavourec to shew, that, according to particular circumstances, o which we are ignorant, a very considerable derangement of a part may exist without that general disturbnace of the whole capillary system, which we observe in the cold stage of ague or a confirmed attack of cholera,— that exudation may at one time take place from the bowels ; at another into the cellular texture of the body generally or locally ; at another, that this 



31 

peculiar condition may chiefly affect the cerehral system, with extremely little or no evidence of the capillary circulation of the extremities partaking of the influence, — that in fact, the force of the disease may at one time be directed on one class of organs, at another on another, just as we witness the fever of one year to be attended with ulceralion of the ileum, — of nother in the colon, — of another with pneumonia,— nd yet, another with cerebral affection, &c. S len we come to consider the different modes in whic c system may be and is affected by the impression of loleric influence, we shall find it producing the sam Feet on the general capillary circulation, and the sam nsequent congestion of the interior organs; but \\ mil observe that this oppression does not always see c same mode of relief, although the end attained is ill the same — viz., diminished quantity of the venous ood; and that it does not uniformly expend its force y exudation into the intestines, which is the form we c most familiar with, but that in like manner exudaon will take place into the serous tissues and from le skin. These are my reasons for not insisting so much as is usual on the diarrhoea of cholera. Even those authors who lay most stress on this symptom, constantly inform us that the most malignant cases are those in which there is neither vomiting nor purging. such, for instance, as those extreme cases which almost always occur on the first arrival of cholera in a district, 



32 

>igastriutn and expires in a few minutes, with the nrd " water" on his lips, but without either vomiting purging, — that is to say, without the more ordiary means of relief to the congestion having come the aid of the vital powers. Thus, Mr. Parkes, 10 is one of our most recent authorities in cholera, >ut whose views are very different from those now Ivocated, says, — " There is no one who has seen uch of cholera who does not know that, exclusive of c mildest forms of the disease, a case with little omiling and purging is more malignant and more pidly fatal than one in which these are prominent mptoms;" in other words, this might be expressed, lat where natural relief to the congestion does not ke place, the congestion proves more fatal. Premising en, that we do not look upon purging as essential to lolera, but only as the most common mode of relief the circulation, and that it takes place earlier or ater in the stage of congestion, according to the peculiar ndency of the epidemic and condition of the individual tacked, we shall trace the ordinary course of the first age of cholera up to this point, passing over those (•asi's of diarrhoea in which it would appear that the relaxed condition of the enteric vessels proceeds so pari passu with the general tendency to congestion, as to prevent any serious amount of internal congestion from occurring, such as is very frequent in the first day's attack of cholera, and from which many recover without passing into the algide stage. 



33 

When a man is attacked with cholera there is some ling in his appearance which another, who has ha( xperience, may recognize, even before the patien limself is aware of it; there is a sunken clay-colourec ast in his features; he looks stupid; perhaps ha ight dimness of vision, or dulness of hearing; h lands look shrivelled, the nails blue, and the veins o le back of the hand are dark and contracted, lik ines traced with ink upon the skin ; it is cold an amp to the touch ; if you look at the tongue you fine clean, pale, and watery, as if macerated till deprive< ' blood, and the conjunctiva is bloodless. He terhaps, now feels a sudden but slight pain da ccasionally through the left breast and arm, and i 'ou press upon the epigastrium, especially over th tleen, he complains of pain ; he has then sudde all to stool, perhaps vomiting, or according to th laracter or type of the disease, there may be intens >am and sense of burning in the stomach, &c. Let uffice for the present to trace the course of thes mptoms up to this point. 

The shrunken condition of the skin indicates the state of the peripheral capillary circulation, and when the minute vessels reject their blood, it accumulates in the vena cava, overcharges the right auricle and ventricle, and interferes with their action ; it distends the spleen to its utmost capacity as the reservoir provided by nature to relieve the circulation when -oppressed by too great accumulation of venous 



34 

ood. Hence pain referable to the heart, an nit produced by pressure on the spleen; the pu onary capillaries partake of the inaction, and resis c passage of blood through them, the accumu ation of blood continues from the exterior, and th ferior cava is so distended that it is impossible fo ood to enter it by the renal veins ; the circulation o le kidneys being thus suspended, their secretion nested, hence suppression of urine. Still blood accu ulates which cannot revert through the well-valvei ems of the extremities, and it must go somewher 'he portal circulation already oppressed, so as to pr vent the secretion of bile, now yields still further, an< the blood is forced back in a retrograde course along le niosenteric veius till their minutest terminations on he villous coat of the intestines are injected as with a fringe, and their natural action is at an end ; a little ore blood suffices to make the watery particles filter irough the membrane, carrying with it the mucous >ithelium, which gives that peculiar character to the lolera evacuation that has been so aptly described as le rice-water purging. No sooner, however, has a large evacuation of this kind been produced, than immediate relief is, in the great majority of cases, experienced by the heart, which had been struggling with the load of blood that oppressed it ; the same effect is produced directly, which we endeavour to produce indirectly by opening the external veins, and the heart is thereby enabled to overcome the resistance of the 



35 

pillaries, (already as I think disposed to relax,) thus natural cure is often effected which the well-timed ministration of a stimulant may hasten and confirm, f, however, this first evacuation of the fluid particles the blood does not suffice to give relief, the same ? ect of increased congestion and attempted relief by mrging takes place again and again, till the power of action ceases, and the patient dies in the stage of llapse. Perhaps, however, he is more fortunate, and ough ineffectual to produce complete relief, and store the power of the circulation, these frequent rainings of the interior veins may suffice so far to lieve him, that the congestion does not destroy lif and there may yet be sufficient blood pass through tl pulmonary capillaries to maintain life through th mergency, and so far to restore more natural action, a permit of something approaching to repose to th latient from his sufferings, and partial return of th gans to their natural functions. This would doubt ss proceed gradually to reaction, and sometimes doe ien there is no fresh accession of capillary disturb nee to renew the congestion, and tbo consequence 1 le low form of fever alluded to ; but unfortunately ther appears to be a tendency to relapse, which my observa lion leads me to believe occurs just twenty-four hour after the first commencement of capillary disturbance, the weakened powers now more readily yield to the oppression, and about the twenty-sixth or twenty-eighth hour is one of the most frequent periods of death in 



36 

Eose who have escaped during the first eight hours. fter this the period of death must be uncertain. I id that Mr. Parkes gives the average period of death forty-one cases as twenty-seven and a half hours :>m the commencement. 

Having now considered the subject of congestion a ;reat length,— first, in its probable origin ; secondly n the effects on the peripheral circulation ; thirdly, : le effects and symptoms of the distension of th horacic and abdominal veins and viscera; andfourthl le artificial and natural means of mechanical reli nd cure, we have now, I think, only to consider th ymptoms of recovery and of death in cholera, and o le post-mortem appearances, before we proceed to th medical part of the treatment. 

The symptoms of the disease, if traced in their natural order of succession, are as follow, and those of recovery these reversed :—: — 

11st. Constriction and bloodlessness of the capilies—of the skin first, and afterwards of other »ans, with coldness of surface. 

12nd. Oppression of the heart and pain in the epigasum. 

3rd. Suppression of urine. 

4th. Suppression of bile. 

oth. Vomiting and purging — one or both, or neither. 

6th. Muscular spasms in connection with spasmodically contracted colon, and with the state of the bowels. 

7th. Especially where the purging has been absent 



37 

[scanty, tetanic convulsion of the whole body, from c influence which at first was confined to the circuliug system, proceeding onwards to attack the nervous stem, as the circulation of arterial blood ceases. 

JBth. Death by mere cessation of action of the heart, i., or by affection of the nervous system in tetanus, both combined. 

9th. Returning warmth to the skin after death, which in life had been icy cold. This, as far as my own experience goes, is always the case, commencing in the extremities, but, perhaps, does not occur so remarkably when purging has been very long continued, and the disease much prolonged. Of this I cannot speak with certainty. Partial return of warmth to an isolated part of the body is mentioned by several authors as a sign of extreme malignancy in the attack, and a certain forerunner of death. In all the cases where I have witnessed death from a rapid attack of cholera, whether in this country or in Persia, where there was either no purging, or where it had soon ceased, I observed the feet begin to get warm some minutes before death, and sometimes the warmth spread even above the knee, while the thighs and body remained cold, and the patient yet lived. This I look upon as a sign of death, beginning in the extremities, and I have invariably observed, that after the occurrence of this symptom, the least interference was apt to induce tetanic convulsion. I have twice attempted to draw blood under these circumstances, but am now convinced that this 



38 

ymptom always is a sign of death, whether the patient ppear to live or not, and I feel much inclined to conider that hope still exists, so long as this symptom is bsent. We shall again allude to the subject in speakng of the treatment by heat and cold. 

Post-mortem spasms in the muscles not unfrequent ccur, even some hours after death. These do n ppear to be the mere effect of relaxation of spasmod ally contracted muscles, but rather resemble th erking spasms produced by galvanism on an anim ecently killed, and are probably intimately connectec ilh the cause of warmth returning to the corps nicli in life had felt icy cold, and afford some reaso o believe that the condition of the capillaries produce< n life by cholera is not a mere cessation of vitalit a them, as we have considered it; for the cold, here purging is scanty, exceeds that of any dead tody, insomuch as to suggest a question, whether the lemical or electrical actions in the capillaries which elong to health may not be not only impaired, but dually reversed in the disease, and heat absorbed istead of being evolved. 

On opening the body after death, the appearances are exactly such as we should expect from the symptoms. The right side of the heart is found gorged and dilated, the dilatation and softness of the coats being greater as the case has been more protracted. The superior and inferior cavoe, and all their larger branches are loaded with dark, tarry, half-coagulated blood. 



39 

Ie minute vessels of the lungs are empty, and th arenchvma often shrivelled and contracted, bein >alo on the surface, while the pulmonary artery i uite full of blood. The left side of the heart is con acted, and either empty or contains firm congula ndicating a greater amount of life in the arterial tha enous blood, which forms no solid coagulum ; and th ntraction of its auricle and ventricle a less annum exhaustion of the muscular fibre in the left than on ie right side of the heart, which is flabby and distendec 'he amount of congestion of the portal circulation, &c. s always considerable in the large vessels, but thesmalle nes are more pale and bloodless incases in which ther las been much exudation. The gall-bladder generall ontains bile. Tbe spleen is commonly congested, bu ometimes found empty, which is, probably, a post orient effect of its peculiarly elastic structure ; whe eath takes place from consecutive fever, however, it i ft and friable, an almost invariable condition in deat rom malarious poisoning by tropical fever, Sec. Th U'siines present a peculiar appearance, the colo uch contracted and empty, the small intestines con ining fluid similar to that passed in life, mixed with denser material, probably the fibrin and albumen in >eculiar chemical combination from which the more fluid part of the blood had been drained off, the sub-mucous coat is distended in different places with the same material, sometimes mixed with broken down red globules. Tbe kidney is nearly normal, and the bladder contracted ; 



40 

appearances require no comment beyond that which has preceded their description in relation to the symptoms. 

It would appear, then, that congestion and oppressio o the circulation is always the cause of death, and tha ongestion is a consequence of disordered capillary cir ulation. We have sufficiently discussed the mode >oth natural and artificial, of relieving this congestion >ut as yet we have left the means of removing its caus n the capillary circulation altogether unconsiderei though it is perfectly evident that this must be th am object of medical treatment. The patient is cole othing can be more natural than to try to warm him id the circulation being nearly at a stand, what i ore natural than to rouse it with a stimulant? But the le is cold only to our sensations, not to his own; he i )urning and suffocating, and cannot bear even clothing uch less external heat; he is craving for ice and col( ater, and the hot stimulant draught which we force upo iiin is torture; he is vomiting, yet anxious to drink. 

(Are we then to treat him according to our sensation to his? — to torture him, or indulge cravings tha pear to us so opposite to what his condition requires or are we to disregard alike his sensations and ou m impressions, and seek for the means of removin c cause of this anomalous condition? 

These are questions which must be considered in a future lecture. 



LECTURE 11. 

Gentlemen, — 

The object of my former lecture was to show tha cholera is not adisease sui generis, butoneof a large clas produced by malaria ; — that, operating on the mdi vidua either by some agency with which we are unacquainted or by a poison carried by the blood, its cause doe not directly affect the blood itself, and is not capable o reproducing itself in the blood by the elaboration of fres poison in the system, like that of contagious fevers ; — that no poison is extricated from the blood by specia emunctuary action, like that of small-pox and scarlatina which is capable of giving rise to the same disease i another by inoculation or by infection; — but that dis eases of this class are all incommunicable from man t man, and as there is no remedial object accomplished by the morbid action, and no noxious poison removed from the system, there is necessarily no crisis and no natural termination ; and so far from disease of this class conferring immunity from subsequent attacks, one of its chiefest characteristics is a tendency to 

i. 



42 

ess, amenable to the influence of the same impressio or the future. Not being like that of exanthematou ever, (a poison which produces disease in the blooc tself,) the cause of this class of disease does not opera s a source of continued irritation to the whole system o as to produce continued fever, but on the contrar cting in a manner directly opposite, it induces dimin shed irritability of the system, instead of irritatio auses depression, instead of excited action of th ital powers, and when fever succeeds, it is that of mer eaction against an impression opposed to vitality, not struggle to rid the system of a source of irritation which proceeds unintermittingly towards the accom>lishment of an end. When, in continued fever, the igestive and cerebro-spinal functions become disrdered, they do so in consequence of an all-pervading ource of irritation, and in conjunction with excited lrculation ; but in the class of diseases under conderation, we observe the effects displayed in the igestive, the cerebro-spinal, or the respiro-circulatory unctions, separately, or in either two combined, in injunction with depressed circulation. 

In continued fever, death occurs either in consequence of organic disease and change of structure in some vital organ, or from the effects of poisoned blood upon the brain ; but in the class of intermiltents, the brain is the last to die, death taking place in consequence of mere disordered function of the vital organs, without organic change of structure. 



43 

These wide distinctions between the effects which w mow to be produced by the circulation of disease< lood in contagious fevers, and those which follow th mpression of the unknown cause of epidemic disease ed us to the conclusion that the phenomena displayec n the latter class, were inconsistent with the belief tha ctual change in the constitution of the blood couU >OBsibly be their cause; and if not on the blood, it uite evident that whatever produces these effects, mus aerate on the sympathetic system of nerves, for onl le sympathetic and the blood are distributed co-ex ensively with the effects observed. 

We showed reason to believe, that in every disease o his class, the first effect of the unknown cause is a mpression on the sympathetic, which impairs its powe f exciting, regulating, or combining the functions o lose vital organs whose unity of action is necessar o life ; and that this impaired vitality or disturbe< unction of the sympathetic, is variously evinced b erangement of the functions, in whole, or part of th rculating, digestive, and cerebro-spinal systems, eithe eparately or combined. 

It was argued that, great as the changes are that take place in the appearance and quality of the blood, during a fit of cholera, this does not at all militate against the above conclusions, for these changes are not primary effects of poison on the blood, but secondary effects of functional derangement in the pulmonary and systemic capillaries, by which the blood is prevented 



44 

from undergoing the processes necessary t its healthy condition, and to the maintenance of ii vitality. It is only in consequence) of cessation of sue changes that the blood in these diseases loses its ilori colour, its fluidity, and its vital property of forming firm coagulum as it dies, for it has been observed tha El drawn during an attack of cholera, as well a taken from the body after death, shows all ih ed disposition of healthy blood to absorb oxyge the air; and when we practise bleeding succes fully in a severe case of cholera, and thereby restor the patient to immediate health, we find that the bloo which at the first was dark, tarry, and adherent to th wound, and made to flow with the greatest difficult presently runs more and more freely, and before w bind up the arm we see it acquire all the characteristic in colour, fluidity, and free uncontrolled motion throng the vessels, which belong to healthy blood. It is obv ously impossible, that by simple removal of a portio of the blood, all the dread poison on which so man authors of repute insist, can be removed from the who mass of the blood, along with this small quantity; o the contrary, this is rather an experimentum crucis, show that restoration of the functions of the minu circulation in the lungs, and throughout the system, is the cause of the immediate restoration of the blood to its natural condition, which had been altered only by the cessation of these functions. 

Having thus endeavoured to prove that the disorder 



45 

therefore that the primary cause must be morbid im ¦ )ression on the sympathetic nerves, we proceeded t nsider the great characteristic of this whole clas disease, — viz., periodicity of attack, and attempte< explain periodicity by the law of nervous impres on, — viz., that long continued impression on a nerv sense subdues its sensibility, and that change o mpression restores it, endeavouring to show that when isorder is induced by morbid impression in one par the circle of vital actions, the derangement of action iich results in other associated organs produces ew impression on the nervous system, calculated to unteract the first, and restore to the nerve the power being excited by its natural sensibilities in all its aried functions. 

Having then shown that the first stage of disease i alike in ague ami in cholera, it was argued that the are alike subject to the same effects or law,— viz periodicity of action. Such was the theory of th disease then offered to you. Practically it was shown that in ague and in cholera, the morbid impression always evinces itself first in apparent cessation of vital action in the capillary circulation, more or less general, and more or less complete, by a greater or less approach in the condition of these vessels to that of inanimate tubes or dead structure ; that the vital changes on the blood in the terminal capillaries then cease, animal heat is not evolved, the blood instead of coursing 



46 

reely through the minute veins, adheres to their coat and instead of remaining fluid, assumes a half-coagu ated condition, as if the interior coats of the vesse iad lost a portion of their known power to maintai ts fluidity; thai the veins, instead of being gentl istended, contract, as in death, and reject the ontents. Such was considered the first condition o he cold stage. 

It was then shown that the direct effect of this firs ondition, and of the continued rejection of the blooc rom the capillary circulation, is its accumulation tie great sinuses and venous organs of the chest am bdomen, oppressing the action of the right side of tl leart, deranging the circulation, and impeding tl unctions of the principal vital organs, and diminishin tie quantity of arterial blood distributed to every pa f the body ; therefore, as upon this the life of tl whole body depends, destroying vital action, am ausing collapse and death. 

But to this fatal effect of derangement of the capillary lrculation and consequent congestion, it was shown that he system does not always submit without a struggle, Ithough such is the history of those almost instananeous deaths from cholera sometimes met with; on le contrary, when from the above cause the cavities of the heart and spleen are distended, (for I believe the spleen, with its sympathetic plexus and elastic structure here plays an important part,) the immediate effect is that produced by the distension of any hollow 



47 

iusi-li',— viz., a stimulus to contraction. This becomes source of excitement to the nervous energy of the ¦art, and through it to the sympathetic, in all its notions, and among others, to the resumption of its iwer over the capillary circulation. 

It was shown that in ague the commencement o re-action is evinced in general convulsive shivering o the whole frame, then by fever, and then by return t natural action ; but that in cholera the heart seldom experiences relief by simple re-action, without som mechanical aid to diminish the quantity of the bloo< thrust upon it from the extremities ; that this is effecte< either artificially by bleeding from a vein, or naturally by the exudation of the watery part of the interior blooc into the mucous or serous tissues. It was stated tha this mode of relief commonly, but not always, takes plac from the intestines, by the watery diarrhoea of cholera and is then either sufficient at once to relieve th circulation, and conduce to complete cure, or if in sufficient for complete cure, it may be adequate I prevent the immediate death which would result withou this relief to the congestion, and thereby permit th disease to reach its secondary stages ; or, third, failin both these methods of relief, the power of the hear succumbs to the oppression, after which the morbic impression, unopposed by circulation of arterial blood, attacks the cerebro-spinal system, and terminates the struggle in convulsion. 

Lastly, attention was invited to the fact that cholera, 



48 

on and remission, — that, therefore, extreme cautio s requisite to avoid attempting to give relief at a vies by the same means ; for bleeding, which w elieve all the symptoms in the first hours of an attac 'ill produce the very opposite effect some hours late nless we wait for the commencement of the ne ccession, when it will be equally applicable as in t ommencement of the first attack. 

It was also thrown out as a suggestion worthy of iquiry, whether cholera does not follow the course sual in quotidian agues, — namely, a tendency to run course of three days' repetition of congestion, where eath or cure does not interfere, for in that case the eturn of the congestive stage will not be so much to c dreaded on the fourth day as consecutive fever. 

In dwelling upon these points I was not so presumpuous as to hope that you would receive any one of them olely upon my individual statement, or even consid lem proved by the arguments adduced. Myintentio as rather to state them as points, which, after rune ejection and study of the subject, both in its gener eatures and in individual cases, appeared to me to 1 lose to which it was most important to direct attentio oth in reading and in practice ; because, if we are con vinced that the disordered action begins in the capillary circulation, — that the congestive stage and symptoms are direct consequences of this disturbance, — that 



49 

c whole attack, but goes through certain diurna hanges, — and that the general tendency is for the con estive stage to return on three successive days, an< terwards to run into more continued febrile action c shall then have a clearer perception of wha wanted in respect of treatment at each particula age of the disease, and can adapt our remedie cordingly ; and from knowing what to expect, we ar nabled to distinguish the effect of the remedies from lat of the disease they were intended to combat. 

I am aware that by many the theory of the disease may be considered to have been unnecessarily dwelt upon, especially in that part <>l' it which attributes the effects to morbid impression on the sympathetic, but this appeared to me important with regard to diseases associated with cholera, and in reference to the modus operandi of medicines which are found to exert a beneficial influence, in very different, and apparently very opposite, conditions of the system, arising from the same malarious influence. 

I have stated it to be the object of the present inquiry, to search for some enlarged principle for our guidance in the treatment of cholera, which the observation of individual symptoms only tends to confound; and it seemed absolutely necessary, before considering the means employed for cure, to inquire, as carefully as possible, into the essential nature of the malady, in order to comprehend distinctly the intention to be kept in view in administering medicine. 



50 

CONNECTION OF CHOLERA WITH OTHER EPIDEMICS, 

AND THE INFLUENCE OF ITS CAUSE ON THE CON- 

STITUTION. 

We have hitherto considered the nialnriuus influence ' which ague, cholera, and remittent fever are pro uced, only in its physiological effects on the humai dy, with little reference to their epidemic character d without attempting to fathom the origin or natur the cause. The cholera atmosphere, as it has been ermed, is generally believed to pervade chiefly the owest levels of a tract of country, and I believe this be correct; but it is singular, that one of the spots >ointed out to me as most fatal in Persia, was elevated ,000 feet above the level of the sea, another 8000, d another 5000; it is also said to follow chiefly the urses of rivers, — in Persia it has uniformly been ost fatal in the neighbourhood of the extinct vo noes which crown the great range that extends from rarat to Khorasan. Dr. Prout observed, that durin je prevalence of cholera, the atmosphere was pc ptibly heavier than at other limes. In 1834, it wa jserved in the great London breweries, while choler was at its height, that fermentation proceeded mor rapidly than was usual, and of late an attempt has bee made to connect it with certain remarkable electrical phenomena. Dr. Prout's observation has been verified, that during its prevalence a greater than usual tendency exists to the formntion of oxalates in the urine. Iti 



51 

fth its invasions of Europe, its progress has bee -y remarkable, and not in the direct commercia ite from India, having in its first advance adherec adily to a course nearly W. NW. from Hindostan d its second was nearly identical, but with greate tension of its left wing, towards the south.* 

Not only to medical men, but to the Government of 

I* Without attaching much importance to facts which nnot explain the progress of cholera in other directions, I ly mention as a contri tuition to its history in central A«ia. it its first advance upon l'ersia in 18i8-9 was preceded terrific earthquakes in 1827-8, extending for some huned miles around the extinct volcano Demawtind ; that ere then succeeded a perio I of repose from subterranean nvulsion till 1840, when a violent earthquake shook down portion of Mount Ararat, and continued to convulse the untry to the south-east of that mountain till December, 43, when for the first lime in the historical period a new lcano burst out near Shoomacha thirty miles to the est of the Caspian ami perhaps a hundred to the nor.h Ararat. That in 1841-2-3 the whole tract of country >ftween the mou:hs of the Indus and the Caucasus hud jeen overrun with unaccustomed dysentery, pestilential ver, and in some places cholera, but after this erupon earthquake ceased and the country became comparatively healthy till 184(5, when cholera again broke t with virulence in the same tract. Since (hen, the main ne of the advance of cholera has been in the direction of le volcanoes of Iceland I leave it to philosophers to de'ermine how far it is possible that extensive chemical action beneath the thin crust of this earth, evinced I y these carthqiiHkes may have had anything to do, either by disturbince of electrical currents or the evolution of imperceptible gases, n producing- so great an amount of disease, and in determinins the main direction of cholera cer the line of country which evidently overlies an immense volcanic tract, that extends In a direct line from Cutch, late the scene of extensive subterranean disturbance, over the Elboorz and the Caucasian mountains, towards the piin- Cipal volcano of north western latitudes 



52 

very country through which cholera has passed, i irogress has been a subject of great interest in referenc o the question of contagion, ever since its first recordec utbreak in Lord Hastings' army in India, in 181 ut although none of the well-contrived barriers opposet o its advance by cordons samtaires, or quarantin egnlations, have yet succeeded in delaying its marc single hour, the question is not yet settled. Tl acts just alluded to all display the general pervasio ' something unknown, which influences the physica s well as the animal world, but is wholly beyond th >ower of man to stay; and, did time permit, othe ight be added still more convincing, bearing upon tl lange observable in the features of disease, both i le animal and the vegetable kingdom, long before tl ctual appearance of cholera. If, then, the connectio f these facts with cholera were better determined, an< ollected, it seems to be impossible to doubt, that tl vidence of the existence of a cause, infinitely mo eneral than mere contagion, would soon prove so con usive as to set the question at rest for ever. 

These are points, however, far beyond my depth, nd foreign to our present object, which is practical bservation of the facts which indicate the relation of holera to other diseases, and to inquire what useful nferences may be deduced from them. 

With respect to the epidemic influence of the cause of cholera in this country, a great change in the character of disease must have been remarked by the 



53 

elders of the profession since its first advent; and it is notable to younger practitioners, that there is an obvious difference in the practice of the generation of physicians which is now passing from among us and their own, — those of the old school are much more stringent in the article of diet, more cautious of the use of slimu lants, and altogether much more apprehensive o inflammation, than we of more modern days ; it is als notorious, that tonics are now much more universall prescribed than they were five and twenty years ago All this is attributed by some to fashion in medicine but it is evidently not so. Tn the commencement o the present century, the prevailing fever was attendee with high arterial action, and the more acute forms o inflammation were much more general, insomuch tha the lancet, calomel, and antimony, were then the sheet-anchors of the practitioner; but since a few years previous to the first inroad of cholera, a great change has occurred, bleeding in fever is now almost obsolete, a much more generous diet has become necessary, and calomel is comparatively disused. Since 1843, the type of sporadic fever of this country has approached more nearly to that of the remittents of tropical climates, displaying an unusual tendency to relapse and to local congestions. Neuralgia has also greatly increased ; and Bright's disease, and dropsy after scarlatina, &c, become more general. This particular type of fever has pursued so remarkable a course, that before submitting to you the account of the 



54 

trious forms in which it appeared in Persia in 1842-3, len obviously and essentially connected with cholera, think it of some importance to trace its progress m India to this country, great part of which I have rself had the opportunity of witnessing. 

»In 1841, a fever of remittent and quotidian inlerttent type broke out in Scinde, where it destroyed any of our best troops, alternating occasionally with tolera. Both proved severe in Caratchee: it spread trough Beloochistan, and appeared at Bunder Abbas n the Persian Gulph, early in 1842; also at Yezd. t thence spread westward to Shiraz, and northwards wards Ispahan and Tehran, proving everywhere xtremely fatal ; but its further progress to the northwest as arrested for a time, on the high grounds of Sultanieh,by the setting in of winter. Next spring it resumed its course, overspread Aderbijan, Erivan, Georgia, and the whole shores of the Caspian, crossed the Caucasus, and was very fatal in Veronish in the centre of Southern Russia. I here lost sight of it iv November, 1843, but was not a little surprised to find it again in December, on my arrival in Edinburgh. It was there modified it is true, and displayed less of an intermittent character, but was fully characterized by other symptoms, especially the tendency to relapse, and the pale tongue. Late in 1844, it appeared in Manchester, especially in Ancoats, where it was very severe. In 1845, it became epidemic in Liverpool, somewhat more modified in type, and the fever of 



55 

1346-7 in Manchester, still preserved much of its ?culiarites, especially in the frequency with which it as accompanied with jaundice, and in running a uirse of seven, fourteen, or twenty-one days, and lapsing at these intervals. 

nearly two years, the typhus fever imported in Ireland has rendered this type somewhat obscure, ut within the last few weeks, beginning in the middle September, the same form of fever has become gain prevalent and very severe. This will suffice to tew that not only cholera has spread to us from the ast, but that since its arrival the very constitution of ur fevers has partaken of a similar oriental character, nd that not fashion but necessity has demanded the markable change of practice alluded to. The best vidence that this is not an imported change is to be ound in those fevers which arise sporadically from the (¦composition of vegetable matters, for these always ssume the character of the epidemic then prevailing; 8 when plague broke out in Oxford, caused by a ollection of putri Tying cabbages, in the reign of harles the 11., and the most exaggerated form of the pc of fever we are now considering appeared in a arm-house in Peebleshire, in 1846, caused by the ecoraposition of stable manure; so cholera generally makes its first apearance in the neighbourhood of cesspools, and in the most filthy parts of a city, and judging from my own experience, I should think that 



56 

many within the last three years in badly-drained bouses. But it may be remarked, that the epidemic constitution of disease is not only displayed in the fevers of a country, but equally so in every aberration from health, and ever since the first appearance of cholera in this country, these have been such as to require a much more extensive use of tonic medicines. In proportion as the lancet has fallen into disuse, iron has come into rogue in another shape, for although seldom prescribed five and twenty years ago, except for chlorosis, in the form of Griffiths' mixture, the greater proportion of diseases are now treated with chalybeates, a perfect evidence to my mind, not of the influence of fashion, but of necessity, and offering, I think, good grounds for attributing to iron some especial influence over the effects of the prevailing epidemic constitution in this country. For, whereas, thirty years ago this was marked by a highly inflammatory tendency, what we have now chiefly to combat, is feeble and imperfect arterial action, and a great and general disposition to venous congestion, not only in fever but in other diseases. 

The usual indication for the use of iron is a pale tongue } and this is a special characteristic of cholera, also in quotidian intermittenls and remittents, at particular stages. Its modus operandi is generally considered to be to increase the facility with which oxygen is absorbed by the blood, thereby aiding its transmission through the pulmonary circulation, preventing conestion 



57 

on the right side of the heart, increasing tli tulity of the arterial blood, and promoting capillar tion in general, but it would also appear that iro xerts a peculiar, and perhaps independent, toni nfluence on the nervous system ; hence its effect i c-doloureux, sciatica, and spasmodic affections, sue hysteria and chorea. Its use as an opponent t ercury is pretty well known, and in moderating con ;estion, and regulating secretion, in menorrhagia menorrhoea, and Brighl's disease, while its wonde ul effect on spleen disease produced by ague, is we mown to East Indian practitioners. These considera ons, which would each admit of extended coimnen 11 serve as an introduction to what I have to su f my experience of its effects in the epidemics lave now to describe, beginning in forms very differen roan cholera, yet ending in that disease, and whi leir history will demonstrate their near connection wit lolera, it will also exhibit the singular effects of iro n various disordered conditions of the nervous system >roduced by malarious influence, and in restoring the >propriate action to medicines whose operation ha( )een disturbed by the same cause, especially that o >urgatives on the intestiues, and of quinine on th apillary circulation in general as an antiperiodic. 

In our present ignorance of the modus operandi of medicinal agents, the efficacy of iron in counteracting deranged action produced by malaria in the several systems,—-nervous, circulating, and digestive, over which 



58 

lie sympathetic exercises its controlling and combining nfluence, will be looked upon as little more than a urious fact, but as all the diseases I am at present bout to bring to jour notice occurred in a single year, etween January, 1842, and January, 1843, the fact of ron having been found influential in all, must iu-cesarily be taken as strong evidence of identity in the ause of those diseases to which it proved an antidote, nd therefore strongly presumptive of a closer conection between tetanus, neuralgia, remittent fever, gue, and cholera, than is generally admitted. 

The circumstance which first drew my attention to iron 8 an opponent to venous congestion, and to mercury, was a severe case of spleen fever, with much cerebral xcitement; the symptoms were not such as to induce ne to trust to a tonic medicine for the cure, and on tie authority of Dr. Abercrombie I treated my patient with calomel, antimony, and salines. He quickly ecame salivated, an effect as readily produced in pleen disease as in Bright's disease of the kidney. Jpon this he got alarmingly worse, fever and delirium ncreased, and he was only saved by immediate change f treatment to that recommended in Mr. Twining's work on " Diseases of Bengal," — namely, the combina- Ef sulphate of iron with purgatives. Under this he quickly recovered from the salivation and and by perseverance for a few weeks the spleen iuced to nearly its normal size. 





59 

epeated dilatation of the organ by successive fits o guish congestion, and as subsequent experience showec lat purgatives uncombined with inn did not produc 10 same effects on the spleen, it seems a fair conclu on that the iron operated by opposing the acquirei ndency to venous congestion. In my own practic o, I did not find quinine exert that miraculous file n diminishing the volume of the spleen which ttributed to it by American and French physician nd which has been exhibited by experiments on dogs n the contrary, it often produced irritative fever, whic never did in combination with iron. The probab! iisou of this difference in the results is, that I e<n oyed it most where the prevailing type of ague wa uotidian; others, where the type was tertian, hich the effects of pure quinine seem more peculiar >propriate. 

I The next experience I had of iron as a remedy of lexpected power was a very singular form of epidemic sease, that exhibited extraordinary disorder of the ;rvous system. 

A few weeks be/ore this appeared in Tehran a somewhat similar epidemic had prevailed in Bagdad, but there it occurred in the form of angina pectoris, destroying life in a few minutes by spasm of the heart, particularly where any organic weakness existed in the organ, and similar, it may be conjectured, to the attack of which Lord George Bentinck and the corpulent Mrs. Armitage appear to have died. 



60 

A notice of the disease in the forms in which I wi essed it, may be found in an extract of a letter fro me to my late brother, published in the Twenty-six Volume of the " Medico-Chirurgical Transactions;" am mention of a similar disease, as occurring in Strasbur n 1 842, is made in one of the numbers of the •' Britis nd Foreign Quarterly Review." 

This disease might be described as an epidem poplexy or epilepsy; it was characterized in the slight ases by sleeping of the hand and foot of one sii oming on periodically every night at a particular hou nd accompanied with palpitation of the heart, ncr usly excited pulse, and severe headache, but thoug >eriodical in its attacks, I could not distinguish an ling resembling a cold stage or actual fever. In t raver cases it appeared as coma, with hemiplegia, pileptic and tetanic convulsions, which, if mismanage* nded in death, at the same time facial neuralgia w nusually prevalent ; in fact there was scarcely a for f nervous disorder which this disease did not assum n the two months during which it continued to prevai 

In two of the earliest cases, misled by acute pain in the knees and shoulders, accompanied with great palpitation of the heart, I mistook it for rheumatism, with commencing carditis, and ordered bleeding, and calomel and opium. By this treatment the symptoms were much aggravated, but they susbequeutly yielded to repeated doses of iron. 

It were difficult to say what induced me to try this 



61 

emedy, but I fortunately hit upon it early in tl isease, and there was not a single case among ver many hundreds in which a few doses of iron did n uffice to effect a permanent cure; whereas qtiinin mrgatives, blood-letting, and mercury, all did mo larm than good, aud if uninterfered with, the disea ften continued to recur nightly for weeks. 

In the treatment of this epidemic, the Strasburg hysicians were less fortunate. It does not appear that ley had tried either iron or assafoetida, and the conusion come to when the epidemic disappeared was, lat " nothing seemed to do good, but that upon the hole, more of those who were bled rocovered than of lose who were not." 

This strange disease affords a good instance of a malarious poison producing its effects mainly on the nervous system, and a singular example of a disease so grave as to present symptoms which generally accom pany only the most serious lesions of the brai yielding completely and invariably to so simple remedy as a drachm or two of sesquioxide of iro There was hero no remarkable change in the secretion save that so long as it prevailed there was a gener tendency to constipation, and nervous irregularity o the bowels, which I shall have to remark, as occurrin again in a subsequent epidemic. For nearly two months while the disease lasted, I had occasion to observe that the action of purgative medicines was frequently either null, or it was unusually severe ; but I 



62 

soon found, that where I was giving iron at the same time, their effect became regular, and for some time I was obliged to combine iron with every purgative, in order to ensure its action, even in cases where there was no other symptom of the malady present. 

After the disappearance of this epidemic in March, c season was unusually healthy, with the excpption a few cases of a low form of apparently continued ver, but I believe really remittent, of the same nd with that which afterwards became epidemic in dinburgh,in 1843, and which exhibited an unusual ndency to relapse. 

In August, having few cases of importance to detain c, I quitted our sultry camp, then perfectly healthy, n an excursion into the Elboorz mountains, and pitched y tent at an elevation of 10,000 feet above the level f the sea, near the summit cone of the extinct, but ill smoking, volcano Demawund. I was surprised on y arrival to find the tribes already deserting these lebrated pastures, and moving off to the lower grounds, le reason assigned was, that fever and death were msy amongst them, and that they were fleeing from >estilence. I saw several of the sick, and believed the ver to be the usual typhus of the country, but thought strange to find it in such a locality. 

On my return on the fifth day to camp, I found about a dozen of our attendants ill of fever, one man being in nrticulo mortis, but he had newly arrived from the eastward, from which it appeared that this epidemic 



63 

as spreading. He died comatose, with a black tongue d symptoms that I now recognize as those of mala ous poisoning, and which sirailate effusion on il. train,* but which I did not then recognize as such, oik lieved his fever to be the typhus, such as I had bee customed to see in the five preceding summers i 'ersia, for I was not then convinced that eruption i agnostic of typhus. In the other cases the tongu as thickly coated, all the secretions disordered, and w no reason to depart from the routine treatment b lomel, antimony, and salines, which till then h<id >roved successful. None of my patients, however, mproved under this system ; on the contrary, they were etting worse, and one case seemed rapidly hastening a fatal conclusion, from excessive vomiting and irribility of stomach. 

lAt this time the Russian Embassy was without a lysician, and my attendance was besought for one of c atlachies, who was suffering from ague, to which, »wever, he had formerly been subject. Hitherto I had en a great deal of ague in Persia, but almost always 

• This is identical with the fearfully fatal fevers of the Persian Gulph, which generally prove mortal very rapidly, with symptoms of effusion on the brain; but post-mortem examination proves these fallacious, and the only constant pott-mortem feature is soft and friable spleen. Calomel and bleeding is the usual treatment, death the almost invariable consequence. I can confidently recommend rapidly repeated doses of quinine and sulphate of iron of each a grain, with a drachm of snlphate of magnesia, in three ounces of water, as most efficient in the cure of this much-dreaded lorm 01 fever. 



64 

Ethe tertian type, which very rarely indeed resisted c effect of a few small doses of quinine after a purgae. In this case the first two fits were tertian. I escribed, and promised immediate cure, but in place cure the third attack took place on the fourth day, nd others on the fifth and sixth, and the tongue becam ry, glazed, and cracked, such as I had not seen >efore in ague, but very like that which we see in tl orst forms of nervous fever, without eruption, now pr ailing in Manchester. My patient was encamped b le side of a stream, and under the shade of tree onceiving that this might be the cause of the unusua Ijverity of the attack, I had him removed to a house o ie top of a bill; still, however, he became worse, tl livering less decided, the fever more prolonged, am ie stage of sweating and of intermission more imperxt. It was now rather a remittent or a continued sver, like those in our own camp, than an intermittent ; uinine was evidently injurious, and I was hesitating hether to adopt the same treatment, with calomel and ntimony, that I was pursuing with the others, when, n examining the pnecordia, I found that there was much pain on pressure over the spleen ; upon this I etermined to try iron, in combination with quinine, nd gave him pills, composed of sulphate of iron and quinine, of each a grain, combined with one-third of a grain of aloes, every two or three hours. I entertained, however, but little hope of his recovery, for I then expected tho next accession to carry fcim off; it was, 



65 

larefore, with no small surprise and satisfaction, that und him sitting up next day at the hour which I hac xpected to be his last, and conversing with his friend 'he tongue, which had been glazed and dry, and s eeply and'painfully fissured as to prevent his speak-in, lad now become soft and moist, the pulse more free nd the shivering fit, which had been absent for th st two days, came fairly on, and he was well in w days. 

Returning to our camp full of the new light that lad thus broken upon me, as to the nature of the feve aich was now destroying hundreds in the neighbour g villages, and spreading with great rapidity, and t lich this intermittent was evidently nearly rolatei re-examined all my patients, and discovered in al ore or less tenderness in the region of the spleen or )igastrium, and on watching more narrowly, disnguished the remittent type, which had hitherto caped my observation, for I now perceived that all c symptoms became aggravated after three in the ternoon, and that an imperfect remission took place the morning; that the tongue, which towards evening, nd in the fore-part of the night, was dry, black, and oated, was soft and moist in the morning, except in the centre, and the edges pale and translucent. I pursued the same principle of treatment in all, by E; iron with quinine, camphor, aloes, salts, ling to circumstances, and adding venesection to the pit of the stomach in the worst cases, 

f 



66 

Eout the time which I judged to be the commencement the stage of congestion. No sooner was this change opted than I had the satisfaction of witnessing mediate improvement in all. 

I must, here, however, mention the case of one o le table servants of the Embassy, who had for som ays been affected with most obstinate constipation had given him castor-oil, senna and salts, calome alotnel and jalap, colocynth, and croton, all in vain — othing moved his bowels ; and, disgusted with m nefficient treatment, he betook himself to the natn )ractitioners in town. 

After two or three days spent in the repeated admin tration of enemata, only one very small evacuatio iad been produced. I encountered this man on m eturn from the Russian camp, looking wretchedl I, and in complete despair. I now remembered m brmer experience of combining iron with purgative nd gave him ten grains of jalap, powder, with on 

scruple of oxide of iron, which relieved him perfectly and afterwards a grain of sulphate of iron, with three of aloes, always operated freely on his bowels. 

At the time of which I have been speaking, while my Russian patient was so ill, 1 was called to see a poor French girl, whose father was a general in the Persian service, and encamped in a damp and thickly-wooded orchard near the town, about seven miles from our tents. She was apparently suffering from dysentery, passing blcod and mucus, the skin hot, and pulse about 130. 



67 

treated her according to the Calcutta practice a yen by Mr. Twining, with ipecacuanha, blue pi nd extract of gentian, in which my experience of th tal dysentery of the preceding year had given me th tniost confidence. No improvement, however, too ace, and it appeared to me that there was no resourc ut to bleed from the arm, for I had frequently prove le efficacy of venesection even in the most reducec ases of dysentery without meeting with a sing ntoward circumstance to make me dread its effect y surprise and dismay were therefore great, when, a oon as a few ounces were drawn, she became faint in ollapsed, and the body mottled, blue, and cold. It w nly now that I learned by cross-examination of h ttendants, that in the first commencement uf b Iness she had had one or two shivering fits, and sine hen had each night become extremely cold, butwitho hivering. I had hitherto unfortunately only seen h n the forenoon, when hot and feverish, and none le symptoms led me to suspect ague, which was n s yet prevalent. She revived a little by the use o imulants, and I then left her, being called away nother patient, where I was detained so long that the ty gates were shut, and I was prevented from visiting or again that night. 

The patient I was called to was a man of some importance, who had been out on a hunting excursion the day before, and had slept by the side of a stream. He was awakened by excruciating pain along 



68 

fj spino and in the chest, so severe that he could ircely breathe ; the pain was now most in the igastrium, and so acute that he could not bear the ghtest pressure; the agony appeared too acute for inflammation, and other evidences of pleuritis and peritonitis were wanting ; the skin was warm, and the E small, contracted, and very rapid. Much at a loss, re a large dose of morphia, and exhausted ever s of allaying the pain, with the intention o ing further symptoms, but the pain continued t increase until about midnight when the difficulty o breathing became so extreme that I determined t bleed him ; blood flowed freely at first, but scarcel had four ounces been drawn when it suddenly stoppec coagulating, black, and tarry on the wound. He instan taneously became blue and mottled, and was seize with terrific tetanic convulsions, bent backwards nearl double in opisthotonos, and in a quarter of an hour he was dead of cholera. 

It was not till next morning that I learned that my poor French patient had died at the same hour, with exactly similar symptoms. 

{The two cases I have detailed were the first of the nd which had occurred, and first pointed to what c epidemic I was dealing with was tending, and made me aware of the fatal mistake I had committed in both ; for I had bled late in the hot stage of what might be considered an intermittent, and brought on collapse by the very means which, if used in the 



69 

ttecedent period of commencing congestion, might ssibly have insured safety. 

1 was not mistaken in believing that the epidem laracter of disease which now spread rapidly ant xtensively over the whole district, was but a modific on of Asiatic cholera, to which the fresh cases whic ccurred became daily more and more assimilate ntil the various divergent forms for a time merge ompletely into cholera, as it has everywhere appearec n all these different forms it was an invariable featur lat if periodicity was to be traced at all, it was always ccurately quotidian, and this was the case in a very arge proportion of the sick. 

I shall not detain you with a detailed account of th arious forms of disease allied to cholera which the >re vailed, because I have already published a synops f them, in the 32nd No. of the British and Foreig tedical Quarterly Review for 1843, under the title, — Epidemic Ague of Persia, a Species of Cholera. 'he character of disease was greatly varied, both i ntensity and symptoms, appearing as simple tic oloureux, and intermitting hemicrania; paralysi general or partial, of every part, and in every degree ; in congestion of the brain, simulating apoplexy or epilepsy ; in shivering ague, or ague without shivering. By and bye this form was more frequently accompanied with vomiting, purging, and cramps, so as to constitute, in every respect, an intermitting cholera; whereas others had attacks resembling cholera in every particular, 



70 

Icept that instead of the more usual exudation from c bowels, this took place by the abundant out-pouring the fluid of the blood from the skin, or sometime to the cellular texture, either of whole or par the body, producing either partial or genera ropsy in the course of a few hours. This latter form as more especially frequent in infants and children ometimes, too, this serous exudation occured in a form ot less rapidly fatal than the worst kind of cholera, b reducing suffocation, in consequence of sudden cedem f the lungs. All these however, and various othe nomalous affections, at length gave place to cholera i 8 ordinary form, with vomiting, purging, and spasm s little marked by intermission as it ever is, and di ering in no respect from that I had witnessed i Edinburgh and London. Its temporary disappearanc as then followed by the return of remittent fever. I very one of these forms, however, the urine was invaribly scanty, and of a dark porter colour, or wholly uppressed. In its second onset two years afterwards, cholera did not approach so gradually, but after having indicated its advent by a few cases of cerebral congestion and sudden death, it fell at once upon the population, with all the fatality with which its first arrival is everywhere characterized. Suffice it to say, that in all of these I found the same principle of treatment hold good, and even the same doses of a combination of iron with quinine, together with a careful use of bleeding in the commencement of the congestive 



71 

\ 

age, universally applicable; whether in the slighte ases of mere nervous affection, in the more decided! >eriodical forms, or in those graver cases including tru lolera, where the congestion was evidently too extrem be within the power of medicine to overcome, withou he mechanical aid afforded by the use of the lance nd where the stage of intermission was only to b iscovered by calculation of the time, and the mo mute investigation. 

I shall conclude this division of the subject by the old assertion, as it may seem to many, even of those ho have witnessed cases of the description I allude o, that within the last few weeks, commencing from le middle of September, several cases of quotidian ongestion of the brain or other organs, so grave as o threaten life, and sudden unaccountable deal om affection of the heart have occurred in Mancheste nd I believe all over the country; and that these a ttributable in my opinion, solely to the alread retailing tendency to venous congestion, and nervou disturbance proceeding from the cause, and perha preceding the actual appearance of the more obviou forms of cholera. The cases which I have myself met with lately of this character, have been total insensibility, resembling apoplexy, with extreme collapse, return of warmth, and again a stage of collapse on the following day ; also hemiplegia without other symptoms of apoplexy, both yielding to quinine andiron; intermitting hemicrania, neuralgia, unusual pain and tension 



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f the epigastrium, pains resembling rheumatism very part of the body, aggravated by the usual trea lent for rheumatism, but relieved by iron, and ofte ccompanied with cold chill at a particular hour eac ay ; also sudden attacks of vomiting and purgin ithout tenesmus. These I shall probably have a jportunity of bringing to the notice of the professio n another place ; my object here is not to detail case hich others must have met with as well as myself, b y sketching the course of these diseases generally, low how maladies, that, taken separately and withou eference to the prevailing epidemic character appe o differ in every possible symptom, may yet be foun hen regarded en masse, to be very intimately connecte( 

I have been particularly desirous that yourattentio lould be directed by the history I have just conclude o the fact, that in every form of disease there mentione( oriodicity has been a prominent characteristic, an hat though obscure in remittent fever, in actual choler id in some nervous affections, the close connectio xisting between them and decided quotidian ague i ontemporaneous occurrence, sequence, and in the ssential symptoms and means of cure, would scarce Jmit of a doubt that periodicity exists in these als yen if it were more difficult to distinguish in practi ian I have found it to be. 

Kis another point which can scarcely have your observation in these forms of disease, — great variety of effects produced by the same 



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exciting cause. Now, on the brain and nerves, with various, or without any, remarkable disturbance of the circulation; — now, on the bowels by constipation; — now, by diarrhoea ; — now, by dry vomiting ;— on the capillary circulation generally in ague, remittent fever, and cholera ; — or locally, by arrest of certain secretions, or by exudations from the compressed and congested blood into a great variety of structures, &c, &c, for this alone I conceive would suffice to show, that such diversity of effect without a single constant concomitant, such as fever, could never be the result of altered blood without nervous impression, and functional 

The invariable efficacy of iron in all these forms o disease, whether simply or in combination withquinin will also, I think, sufficiently illustrate what it w formerly attempted to argue, that the different con ditions of the nervous system and of the circulatio occurring in agues of different type, require a differe action in the medicines by which the morbid iniluen is to be counteracted, according to the type or duratio of intermission; for, in speaking of ague, it w remarked, that in quartan the febrile stage is greatest, — that in tertian all three stages are well developed,— but that in quotidian the congestive stage is always the most severe, sometimes oven to the exclusion of the others;— that, in proportion as the intermission is prolonged, the congestion is less severe, and the energy of arterial 



74 

le vital powers to the morbid impression becomes mor mplete, the period of repose is curtailed, the febril age less perfect, and capillary action more impaired pecially in that part of it which belongs to the venou stem. Thus quinine, which almost invariably cure rtian, is often found inferior in effect to arsenic i uartan, and in quotidian we have found it prove pos vely injurious till modified by admixture with iron, b hich its ill effects were obviated, and its antiperiodi ction restored, — a fact of no small interest in explainin le failure that has always attended the attempts t eat cholera with quinine and arsenic uncombined. 

Little now remains to be said with regard to th nature of cholera, if I have succeeded in convincin you that the disease does not exist essentially in th blood, but in disordered function of the nerves sin blood-vessels, and if my arguments have carried an conviction of the truth of the following points — 

11st. That an attack of cholera begins, and essentially isists, in disordered capillary circulation. 

2nd. That congestion is the effect of this condition, and the cause of the other symptoms, and of death. 

[3rd. That the diarrhoea is a natural mode of relief congestion, and thereby tends to the prolongation life, and that being an exudation, it is not con (liable by means applicable to excretion. 

4th. That each period of twenty-four hours, in every attack of cholera (which extends beyond that period,) is 



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>arative capillary relaxation and partial reaction ; anc th. A period of renewed capillary disturbance an ngestion, commencing at the expiration of twenu ur hours j not from the first purging, but from th rst effect of the influence in capillary disturbance id if the case proceed onwards without death o ure, that similar changes may be traced (often no ithstanding very active interference,) in the tw übsequent periods of twenty-four hours each. 

sth. Which I have rather asserted from observation, than attempted to assign any reason for, that the fourth day after the occurrence of algide symptoms is not characterized by the return of a distinct stage of congestion, but that the disease then goes on to consecutive 

It was my original intention to have selected cases from published works, by writers of authority, to illustrate these points, and to show by examples how the natural stages of the disease may be mistaken for the effects of treatment; to illustrate the evils of bleeding from an artery, or of mistimed venesection, in producing collapse; the injurious influence of stimulants and opium ; the torments induced by hot applications ; the effect of calomel in causing consecutive fever, Sec. ; but this course might appear invidious, and I am satisfied would be unnecessary, for it appears to me that a very small proportion of well-recorded cases of cholera will bo found which do not bear on 



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one or more of these five points, and to this test I most willingly submit the opinions which I have attempted to inculcate with regard to its nature and reatment, always providing, however, that due allow, ance be made in applying the test for the effects of any treatment that is consistent with the views here advocated. 

tLet us now proceed to consider some of the more ictical points of the treatment of cholera, especially reference to heat and stimulants. 

When the body is cold and exhibits so great a wa f energy in the cuticular capillaries, the most obviou means of removing this condition which suggest thei elves to every one are external heat and diffusib minimus; but as these are not at all times attendee vith the beneficial effects that might have been a cipated, it is necessary to examine the reason of th ailure by enquiring into the particular nature of tl bject to be gained. Finding that the disturbance ital action commences in the capillary circulation, anc ot in the heart, it would appear that to begin b imulating the heart is to begin at the wrong end o le chain of actions, and that to fulfil the indicatio ome means is required that will act by giving pow o the capillary circulation, independently of the heart ction. 

Unfortunately all the medicines usually classed as stimulants excite the capillary circulation only by exciting the heart's action; secondarily and slightly, 



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y sympathy with the heart ; but principally in con equence of the distension produced by the increase orce with which blood is injected into these vessels or to them, as to the heart, distension is the mo irect means of exciting irritability and action ; bu ' these vessels are not distended, capillary action ot directly excited by exciting the heart. 

In the stage of congestion in cholera, we have ndeavoured to shew that this increased propulsion of rterial blood does not take place, for the quantity of rterial blood in the system is diminished by the lungs pposing the free transmission of blood to the left side f the heart. We have shewn, that so soon as conge on commences, the heart becomes excited by its mo lowerful stimulus, — viz., distension of its cavities, east on the right side, but that its action is opposed b ie condition of the pulmonary vessels, and opprosse y the accumulation of venous blood from the extrem es ; it is evident, then, that to add stimulus to th hicb is already excited to the utmost in vain, can c 0 good, unless it can add power, but as it cannot c o in this condition, stimulus can only exhaust th 1 liability of the muscle, but not propel arterial lood in the quantity necessary to distend and excite he capillaries. If the power of the heart have not been yet excited to the utmost, a stimulant may prove useful by urging it to still greater exertions to overcome tho obstruction, but if already excited in vain, it is quite evident that additional excitement can 



78 

nly do barm, by producing exhaustion of muscular )ower. If, however, we have reason to believe, that bynd-by the obstruction to the heart's action by the capilries of the lungs, and impulsion of blood upon it •m the veins, will both gradually cease, at least iv me degree, it will be evident, that if it only retain fficient power, the heart will then be in a condition restore the circulation to a more normal state, am erefore that our efforts should be directed to husban c power of the heart, instead of exhausting it; buttl nly means of doing so consistent with the maintenanc sufficient systemic circulation, is to endeavour b very possible means to promote capillary action, am to diminish the labour of the heart by removing ti bstruction to its efforts, not by subduing the excitemen f the heart by opiates. The whole question, therefore, ies in the means of doing this. We have shewn that hen opportunity offers, — that is while the powers c heart are as yet unexhausted, and its irritabili nimpaired,— this may be accomplished by freely open ing the veins of both arms, thereby soliciting tl blood from the extremities, and relieving the heart fro part at least of its oppression a teryo, but both exper ence and reason have warned us against attemptin this after the heart has been too long subjected excitement. What then is our resource in this condition ? This is exactly the point which the long history of disease that I have submitted to you is intended to illustrate, — viz., that we actually possess medicines 



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hich have the power of stimulating and fortifying tb apillary circulation without first exciting the heart ction. Many of the preceding remarks have bee irected to show that the action of antiperiodic mcd nes is of this nature, only that as the morbid effec vinced in periodical disease of different types are no lentical, neither can the antidotal effect required from medicine be identical. I have endeavoured to pom ut that, although quinine alone does no good in thes iseases, the. combination of quinine with iron ha jroved in my own experience to possess this power i uotidian ague and in cholera, in a very remarkab egree. I have found it check the vomiting and purgin ften in a few minutes, and gradually restore the circu ation and warmth, and the secretions, without th ssistance of any other applications, not, be it remarkec y exerting an astringent effect in moderating th iarrhcea, for it proved equally useful whether th ymptom existed or not, but by removing the cause i he disorder of the capillary circulation. 

But it is not enough to consider a question of so much importance as that of the use of heat and stimulants merely theoretically ; I must, therefore, add my testimony to that of many authors against the use of diffusible stimuli where congestion is fully established. I have tried it carefully, and anxiously watched the result of each dose with my ear to the heart, and I can positively assert that each dose, in cases where contth 



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increase of all the symptoms, dangers, and suffergs attending congestion. 

tThe first time I was myself attacked with cholera c symptoms were at once arrested by a glass o brandy taken on the first occurrence of the bluenes purging, and cramps, because congestion, being at one elieved by the diarrhoea, had not reached the point o )pressing the heart's action, and the stimulant aide ie action of the heart to excite the capillaries ; but o my second attack, the effect of this stimulant was ver ifferent, and excessively painful and suffocating ecause not being relieved by diarrhoea, the congestio t once attacked the vital functions, and 1 was obligee o have recourse to quinine and iron, which soo elieved the suffocation. 

The case in which I had the best opportunity of arefully studying this effect of stimulants was that of ie late Chief Physician of Persia, a native of that ountry, who had been educated at St. George's ospital, London, and an intense admirer of calomel, is attack was not cne of pure cholera in its usual rm, with purging and vomiting, for he was one of the arliest sufferers from the disease, while the digestive rgans were as yet seldom affected, and when it pre-11 ted many of the characteristics of ague. I attended him as an intimate friend, night and day, although no persuasions could induce him to try either the medicines I recommended, or bleeding. He felt so bilious that he was sure nothing would do but calomel. His attack 



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lasted for several days, in each of which, the cold stage that at first was followed by return of warmth, was more prolonged, till at length intermission ceased ; the relief which was denied by the bowels was here effected by the skin, and the quantity of ice-cold watery exudation with which all the body but the breast was constantly bedewed, proved the rapidity with which the iced-water he was incessantly imbibing was both absorbed and exuded. He was much colder than I have ever found cholera patients in whom the characteristic diarrhoea existed. After resisting every proposal I made for treatment, he at length consented to try stimulants, for it appeared he was determined to die a martyr to medical prejudice, accordingly, I administered to him large doses of icther and alcohol. After each dose, on >plying my ear to the heart, I heard a sudden increase ' confusion in its action, a sort of indescribable mining sound, as if it would burst,— not as if it were getting rid of its contents, but rather constantly agitating le same portion of fluid, — and at each fresh effort of is sort, the icy exudation from the skin burst forth in doubled quantity. I repeated this experiment until I lad again and again proved the effects, and then, as in oing so, it was plain that more harm than good resulted, I left the case to nature, determined to watch the symptoms as they proceeded. It was not till the Kthat the brain became materially affected, , in the course of four or five days, I am ot above half a pint of urine was secreted ; 

r. 



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le then became insensible, the pulse became imporeptible, and at night, being seized with fearful tetanic onvulsions, which lasted for two or three hours, he ied. The first case of cholera, with purging, occurred n the day of his death in the next house, in a child, nd was fatal in two or three hours. 

This effect of stimulants in a congestive disease s cry nearly allied to cholera, completely confirmed wha had formerly seen of the result of their exhibition i le more common form of cholera at home, insomuc mt I have not since been tempted to repeat th xperiment unless conjoined with bleeding, or in th cry first moments of an attack, when there can be n oubt of their efficacy, or that of any other means o nducing an impression calculated to rouse the sym athetic through any single function, to a perceptio f its other natural stimuli. 

A diffusible stimulant can, therefore, only do good hile the heart possesses more power than has yet been ailed into action, or before it has yet become so comletely oppressed as to be unable to respond effectually o the stimulus. The same reasoning might be applied o the question of using external heat as a stimulus, or though heat and pain are as powerful excitants to ocal action as brandy to the stomach, they unfortunately also act directly as stimulants of the heart's action. Difficult, however, as it may be to-explain their effects, I feel bound, in conjunction with many others of great nractical experience, to protest against the use of botb, 



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Pc case has reached the stage of confirmed in ; for though in the preceding period, external f be as useful as a diffusible stimulus, it is not rious in the second. On this subject I cannot r than quote from one of our most recent as :— Mr. Parkes says, " Warm baths, vapour id warmth applied in any way to the surface, ever appeared to me to be of the slightest service in ue cholera; tha spasms were sometimes relieved, but io algide symptoms were almost invariably increased, 'he depressing effects of the warm bath were sometimes marked and unmistakeable; I have seen a man walk irmly to the bath, with a pulse of tolerable volume, nd a cool, but not cold surface, and in five or ten minutes, have seen the same man carried from the bath with a pulse almost imperceptible, and a cold and clammy skin." 

These remarks perfectly coincide with my own experience of external heat. I have used the hot-air bath, so much recommended in this country, to such an extent as even to scorch the skin, without producing the slightest reaction, but apparently the worst effect, and have searched in vain for an excuse for the torture to which so many patients have been subjected by such attempts to restore warmth. These would not have been cruelty, whatever the sufferings, if really beneficial; but I am now convinced of the contrary, and that they are not only useless, but injurious. Without knowing more of the actions which take place in the systemic 



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apillaries in health, and their changed operation in its disease, it is impossible to account for these njarious effects, unless by excitement of the heart, or n the principle which prevents us applying heat to a rozen limb, to which the condition of the circulation somewhat analogous ; practically I have come to the onclusion that external heat is always injurious when ongestion is extreme. In my opinion, medio tutissimus is in this respect, and that it is better to be content ith a moderate temperature in the room, sufficient to tromote any tendency to reaction, but not to force it 

The question, however, is one of no mean importance — whether if we are not to yield to our natural impressions regarding the necessity of restoring warmth, we may not cede to the adjurations of the patient to indulge him with cold? This is a question which I am not bold enough to decide. There is I think much more evidence in favour of cold than of heat, yet both may be wrong, and according to my own experience both extremes are unnecessary. One friend writes to me from Tehran, that his practice of immersing the patient to the neck in cold water, till reaction took place, was very successful; another that he cured his patient with frictions with snow, in Erzeroom, where the cholera occurred in the winter season, and where the cold is intense. In Russia, and in Hamburgh, iced drinks have been much used. lam well acquinted with two Persian gentlemen, who were laid out for dead, in the cholera of 1829, but who recovered on 



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being washed in the open court-yard in a winter's night, as a preparation for interment, with water, to obtain which the ice had to be broken, and I was once called to the public burial ground of the city to see a dead man whose veins had begun to bleed while they were washing his body. The man, it appeared, had been attacked with one of those forms of disease already alluded to — a species of cholera without purging—had dropped down as if struck with appoplexy ; an attempt had been made to bleed him in both arms without success, he was left for dead and carried off for interment, when what I have related occurred on his being deluged with cold water ; unfortunately no one had presence of mind to bind up his arms and protect him from the cold, and he was really dead when I arrived. These are strong arguments for the use of cold, but may perhaps be met by equally convincing arguments against it. I look upon these as instances of powerful nervous impression made at a suitable stage of the disease, and that if the remarks formerly made of the post-mortem return of heat in the corpse be attended to, no such accidents can arise as those fearful cases sometimes mentioned of persons being buried alive. If one, apparently dead of cholera, become warm from the extremities upwards, no doubt of death can exist, and no chance of recovery; if this does not take place, or, on the contrary, if warmth proceed from the trunk to the extremities, there is a possibility that he may be alire. 



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I consider the question of the excessive externa >plication of heat as fully determined in the negative a the congestive stage, but open to a certain degree 1 mt which succeeds it, and that the question of co )plications is still sub judice, and subject to objectio n the stage succeeding congestion, which, however, o difficult to fix precisely, that both extremes a ¦tier avoided, especially as 1 am convinced that eatment conducted on other principles will almost ways prove successful without either. 

Now, with respect to the diarrhoea,— enough has ormerly been said on this subject to show that it ias been considered rather as a means of relief to ngestion, than in itself a source of danger, as nding to prolong life, rather than as the cause of eath in cholera, insomuch, that even if we had it in ur power to check it by a word, it is a word which we lould hesitate to pronounce, unless we were assured lat the cause rather than the effect would be influenced. ', then, it is to be considered in itself as rather a good an an evil, it must, nevertheless, be always looked )on as a sign of imminent peril to life, which, as its irect restraint would endanger immediate collapse, lould the more impress us with the necessity of moving its cause without delay; for when the disease is in the neighbourhood, and sudden evacuation of this kind occurs, even though not another symptom of cholera be present, the case is to be considered one of cholera. It is not a secretion from the bowels, for 



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that is a vital action of the capillaries ; this is the very reverse— an exudation, showing that the capillaries of the bowels have succumbed to the same cause of impaired action which we have throughout considered essential to the disease. The capillaries of the skin may yet perform their functions, the disorder may be almost local in the bowels, but it is essential, and were it possible by ligature, or any mechanical means, to arrest the exudation, without arresting its cause, it is scarcely possible to doubt that the effect would be congestion and oppression to the heart; that this would be attended with diminished circulation of arterial blood, and impaired powers in the whole system, which would then succumb to the anti-vital influence, and terminate in collapse. To what purpose. then would we use mere astringents to check the diarrhoea ? Have we not rather reason to congratulate ourselves that such means are for the most part wholly inoperative? In the perusal of cases it is impossible not to be struck with the complacency with which the authors seem to regard the effect of pills of lead and opium, chalk mixtures, catechu, &c, when administered at the very period of the disease, in which we should naturally expect to find congestion on the decline, (if the disease be really one of quotidian periodicity.) an effect which, if real, instead of apparent, would only be to be deplored. If, however, we check the diarrhoea, by removing the cause, restore their wonted action to the capillaries, and thereby prevent the effect of their 



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disturbance, we cure, rather than restrain, the diarrhoea. Here, however, a difficulty meets us; the congested condition of the vessels, and their reverse current of blood, afford very obvious reasons for expecting but little effect from any medicine that can act only by absorption into the blood from the alimentary canal ; Everthaless, experience proves that absorption does ie place to a degree much greater than might have en anticipated. However great the amount of exation of the fluid of the blood into the intestines, this occurs only at intervals, and paradoxical as it may appear, while the congestion continues unrelieved, there seems to be a great tendency to restore fluid to the blood, during these intervals. Sufficient evidence of the absorption of salts in solution, in the fluids of which the patient drinks with such avidity, is to be found in the fact, that tartar emetic produces its effects when given in this manner, and those I have so often witnessed from quinine and iron, given in weak solution, have been so immediate, as to excite my astonishment. Thirty drops of muriated tincture of fon, with a grain of quinine, in a wine-glassful of ater, will often stop vomiting and purging that has resisted large doses of laudanum, and of solution of morphia. That so small a dose of this combination 

should ever prove effectual is singular enough, but I do not think it very wonderful that opium should rather increase than diminish these symptoms, if they are really mechanical effects of congestion, and the 



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results of loss of irritability in the capillary vessels, (not of irritation in the viscera,) for opium will evidently tend to subdue whatever irritability may be left in the nervous system, and thereby give more scope to the anti-vital influence, instead of opposing it. Theoretically, such should be the effects of opium, and practically, I am very sure, that it more frequently tends to keep up the vomiting and purging, and the algide symptoms, than to cure them. If the symptoms proceed from partial paralysis, or loss of irritability of the sympathetic, nothing could be better calculated to augment them than opium, for in at least half the cases in which opium is prescribed in ordinary practice, its sole object is to subdue morbid irritability of the sympathetic system. If, however, our reasoning upon the etiology of cholera has had any foundation at all, it goes to prove that the great object of cure is to maintain the vital sensibilities active, and to husband the power of the heart, and neither to exhaust irritability by undue excitement, nor to lull it into insensibility by opiates, for our hopes all depend on the integrity of these qualities, when the period of capillary relaxation arrives. 

With respect to most medicines given in pill, I consider them nearly inert in the congestive stage of cholera, more especially those which are uot soluble in water, but require the action of the secreted juices of the stomach for their solution, for we know that Buch secretion does not then take place. Calomel is fortunately one of this class, and in cholera passes 



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through the bowels almost unchanged, and I am told on good authority may often be found at the bottom of the bed-pan in the form of a grey powder. With respect to the influence of calomel in this disease, I am fully satisfied that the most mistaken opinions prevail. We have already alluded to the effect of tartar emetio which is said to be eminently curative, and on th principles of nervous impression, we can well conceiv that it will be far from inactive, if it produce itscharac teristic effect, because that effect is a vital one of grea influence on the whole of the sympathetic system, am were we destitute of safer and more appropriate mcdi cines, it might be well worthy of trial. In like manne croton oil has been recommended : it may act like the diarrhoea of cholera, or venesection, in reducing the volume of the blood ; but if it produce secretion, which is a vital action of the bowels in opposition to exudation, may operate as a stimulant to the vital energies of the sympathetic, and prove curative. (The danger of inducing syncope by these means is, however, too evident to require comment.) So also may any othe medicine or means whatever cure, which produces a powerful impression on the nervous system, provided i do not act by injuriously stimulating the hean's action, — by impairing the force of capillary circulation, or th excitability of the nervous system, — or, in other words, if it be not calculated to produce the very effects which are caused by the exciting cause of the disease. Upon 



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prove beneficial, but if it affect the constitution, it can only be detrimental This, I think, will become evident, if we consider the action of mercury but for a moment; its chief value is in subduing inflammation, but all our observatious tend to shew that the condition, both of the blood and of the capillarie in cholera, is diametrically opposed to that of iuflam mation. The medicines most useful in cholera anc allied diseases, — viz., iron and quinine, are those mos opposed to the effects of mercury, and most curative o lem. All experience goes to prove that mercury, if an rritant, is at the same time a cause of positive weak ess of capillary circulation, with the single exception, nd that a doubtful one, of its effect upon the liver, here is no point in medicine on which I feel more ntirely convinced, than that the constitutional effects mercury are invariably injurious in cholera, and nd to produce consecutive fever. Soon after cholera >peared to have ceased, in 1843, I submitted two Kuicuts to a course of mercury for chancre at the same time, — one, a groom, died collapsed as soon as the gums became affected, though a very healthy powerful man; the other, the Persian High Treasurer, fell into the same condition, and was only saved by large and quickly-repeated doses of quinine and iron, and went through a severe attack of consecutive fever. 

Mr. Farkes mentions, that two syphilitic patients, while under the influence of mercury, were attacked by cholera in his hospital, as proof that mercury is not 



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prophylactic, I might mention several instances to prove it really a predisponent ; but so many points of difference will suggest themselves in the condition of one labouring under cholera, from that in which we should be anxious to produce ptyalism, that it is unnecessary to pursue the subject farther. 

I There now remains I think but one material point the treatment of cholera, viz., that connected with the c of frictions and rubefacients. Of these, it may sufficient to say that their efficacy will depend upon the period at which they are applied, which is always difficult to decide, and on the degree of fatigue thereby occasioned to the patient, they partake much of the nature of heat and stimulants ; but if applied without disturbing the patient, may perhaps be beneficial, although I have not myself very much confidence in them. Disturbance of the patient is a question of much more importance. In a report of the Commissioners of Public Health, much evidence is adduced by the examination of several medical men practising in liOndon during the former visitation of cholera, as to the ill effects of removing cholera patients to temporary hospitals. There is very obvious reason for desiring to remove them from the locality in which they have actually acquired the disease, because, undoubtedly the cause exists there, and will continue to operate powerfully against the effects of remedial measures, and will also endanger the health of those who are in attendance, and if any of them happen to be attacked, it is sure to 



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contagion; but if the disease have been acquired elsewhere than in the dwelling, no object is to be gained by removal unless to a very decidedly more healthful locality, while on the other hand, the evidence is conclusive that danger often attends the practice. In considering the stages of cholera, it was remarked that there is a time when the patient appears rather indifferent than stupid — not asleep— for sleep nerer occurs in cholera, but as if resigned to fate rather than willing to make the slightest exertion. This condition marks that stage in which the tendency to cessation of morbid inaction exists rather than reaction of the powers which circulate the blood, that, namely, in which the influence that causes the disorder is so equally balanced against the resistance of the vital powers, that the slightest disturbance or source of exhaustion will turn the scale, and it is the merest chance whether a stimulant will now rouse the vital powers to throw off the oppression, or by disturbing the circulation then in progress to partial recovery, renew the congestion. It is at this period that the greatest danger of syncope and collapse is incurred by an attempt at removal, and even frictions or anything that tends to disturb the patient may induce syncope and collapse ; but sinapisms and blisters that can be applied without disturbance, may prove beneficial. 

It is almost needless now to state the practice that I should myself pursue in this disease. If asked what 



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should do in a case of cholera, I should auswer tha tat depends very much on the stage in which I fount y patient, hut in all cases and in all stages I shoulc ertainly give a largely-diluted solution of some sa " iron and quinine, with a view to counteract the mor d inactivity of capillary circulation, and repeat it a ften as the patient would drink of it till warmth wa estored. If called to one of those cases of sudde 

Ellapse, with little vomiting and purging, reported t ive frequently caused death in eight hours in Scotlam should be satisfied that mechanical assistance wa equired to relieve actual congestion, and if I arrivet ufficiently early would open the veins of both arm ying to induce sneezing and coughing, or almost an jowerful vital action, likely to give an impulse to th lood, and cause it to flow. If, however, I arrived to ate to bleed, I should not hesitate to conjoin Epso alts with the mixture, however heterodox such prac cc may appear, because such cases are general! ithout purging, and purging is a safer and mor irect source of relief than bleeding late in such ase; and I have followed this practice largely wit uccess. I should neither give stimulants nor app leat, should limit external applications to a blister ncture of capsicum to the spine, be careful of disturbin my patient unnecessarily, and endeavour thus to carry him over the first twenty hours with life ; if his condition was then such as to give little hope of his being able to sustain a fresh attack of congestion, I 



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amount that the colour should become florid and it motion free, and should continue the medicine till th secretions became fully re-established — till the hue o health returned to the complexion and the lips an< tongue bad lost their pallor. 

Tn all cases of consecutive fever my experience points the use of the same remedies conjoined with salts nd diminished quantity of quinine, which in excess, r even if not in very small quantity, tends to produce ryness of the tongue, but which I think necessary, evertheless, for a time. Perseverance in this treatcut long after the secretions are restored, no doubt ometimes tends to produce a red, furred, and bilious ngue, very different from the clean, glazed, and dry ed surface, or pale-edged darkly-coated appearance lat preceded it, but then the fever has become bilious, nd may safely be treated with a smart dose o alomel, or what I find still better, sweating in the w beet of the hydropaths. The same treatment is appr >riate to the prevailing form of remittent, common ailed low fever unpreceded by cholera or noteab ollapse, and unaccompanied with macula; or typhoi( rruption, but characterized by the appearance of ti ongue. If the spleen be tender on pressure, a sho trial of sulphate of iron with sulphate of magnesia, withont, or with not more than half a grain of quinine to each dose, with occasional application of leeches to the epigastrium, (in the forenoon,) will, T think, show 



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lat there is something in the treatment recommended, nothing in the theory. Post-mortem examination in is type of fever constantly exhibits more or less ftening of the spleen, a characteristic of tropical mittents, and in my opinion a positive indication for c exhibition of iron. 

!I must now conclude, but I confess 1 leave the sub;t with much reluctance, for there are many points of uch practical importance left untouched ; among hers, the influence of the epidemic constitution (while olera prevails) upon other diseases apparently uncon:cted with it, is full of interest. 

Of these I cannot refrain from mentioning one xample before concluding. While cholera prevailed had two patients with pannus oculi, in which I had ied every possible local application in vain ; one of cm, however, had on one occasion a slight shivering it when he visited me, and I gave him a mixture of uinine and iron, the pannus immediately began to diminish, and I tried the same medicine on the other, omitting local applications, and in both a cure was effected in the course of ten days. Similar effects were observed in a great variety of other diseases. I am very well aware, that in this laudation of a particular combination of drugs, I have subjected myself to the charge of empiricism, and in a certain degree I must acknowledge the charge to be just, for nothing could be more purely empirical than the grounds upon which 



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I was first induced to make trial of it, whatever m subsequent endeavours to explain its operation ; but m object now has been only to recommend the combinatio of iron with quinine to your consideration, as a mean well fitted to attain the end in view, — viz., to promote th oxygenation of the blood, to fortify capillary action an nervous irritability, to confirm the tendency to remissio (whether apparent or too obscure to be noteable bu presumable,) and to prevent periodical return of venou congestion. I have endeavoured to shew that thes are the primary objects requiring attention ; relief o congestion by mechanical means the secondary one. 

If I have over-rated the effect of the medicine ecommended, I must be allowed to say that I have no een induced to do so by theory alone, for that which aye offered to you is solely the result of reflcctio ter I had used it in many thousand cases effectually ut purely empirically. While the epidemic provaile n Tehran, my court-yard was daily crowded wit mndreds of poor wretches, praying for the love of Go or a supply of the bitter water, or water of life as the ailed it. It was served out to them in p hit- and -half mixtures of water, containing twelve grains of quinine, me of sulphate of iron, and thirty drops nf dilute sulphuric acid, with directions to take a coffee-cupful for a dose; these orders, however, were not always attended to, and in some of the most remarkably rapid cures I witnessed, the whole was swallowed at a draught. One of these I particularly remember. 

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Iv visiting one of the princesses, the wife of the Chief trologer, I observed a wretched object, who had dragd himself to the tank in the outer court of the house; th difficulty I recognized him as the tutor of the mily. He had been vomiting and purging, and oniztul by cramps, and his thirst had impelled him to c position in which I found him. I immediately sent m a quart bottle of the mixture described, and I was ever so much surprised as to see him in the afternoon my house with his bottle, whither he had walked early a mile, to beg a fresh supply, having swallowed c whole at once, and felt immediately revived. I had >reviously known him as, both from religious prejudice nd as an epicurean, an abhorrer of medicine; and this rtainly was noi nectar. Villanous though the coin>ound may seem, it appears to be peculiarly grateful to le patient, by appeasing the thirst and sense of heat in c stomach, which even ice fails to allay, and I have klom seen it vomited after the first dose or two. I aye met with one or two instances in which it was bund impossible to obtain blood from the veins, but here, shortly after a few doses of the medicine had een taken, bleeding was practised with success. 

In the cases of simple diarrhoea without tenesmus now prevailing, I find the most immediate effect produced by a grain or two of quinine given with half a drachm of the muriated tincture of iron, in a wine glassful of water. With respect to the cramps and spasms, I have been iv the habit of looking upon them as mere 



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Inptoms, only to be obviated by removing the cause ; would, however, appear from the observation of iris, that, apart from the more fatal symptoms of jpressed arterial circulation evinced in convulsions ; ) cramps in the legs, &c, are closely connected with ; contracted condition of the colon, and I should irefore feel inclined to try the effect of assafcetida ections. 

I have now, gentlemen, only to thank you for th tention with which you have listened to my remarks 'he treatment which I chanced to adopt on purel mpirical grounds appeared to me more than usuall ccessful, and I was led to enquire whether there wa nything in the nature of the disease, or the remedie lat was explicable on known and acknowledged prin pies of physiology and therapeutics; the result wa lat there existed a deficiency of facts by which t etermine the question, and, till these were settled, as impossible that all should agree on the treatmen r deductions, at the same time it was evident that ther ere facts which, if generally admitted, would necessita niversal concurrence in a broad principle of treatmen the exclusion of a vast amount of erratic practic hat might be termed a blind groping for facts o liich to reason. 

In my endeavour to ascertain what were the established facts, it appeared that beyond a rehearsal of symptoms there was not one universally admitted, 



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aye the constant existence of venous congestion,— ontagion, the effect on the blood, the cause of deat le influence of particular treatment, were all sub ects of hot contention, and the medical profession wa ivided into as many parties, and more, than ther ere sections in the materia medica. Under sue rcumstances it appeared that the weight of any sing vidence could not possibly turn the scale of opinio nd that the only chance of arriving at a useful con usion was to examine the disease in all its forms, a ley relate to its cause, its course, its terminations, and s connection with other diseases. The result of this I have endeavoured to lay before you, in the reduction of the essential facts to six, not one of which is generally admitted, but if they be proved to be facts, the deductions from them are too evident to require comment. These which have previously been stated at length are shortly as follow : — 

tlst. That cholera is the effect of impression on the mpathetic system, — that its cause does not primarily bet the blood, is incapable of reproduction in the dy, and, therefore, incommunicable. 

2nd. That its effects begin by impaired vitality and disordered function of the capillary circulation. 

3rd. That congestion of the thoracic and abdominal veins is the consequence of the above condition, and the cause of other symptoms. 

4th. That exudation of the watery particles of the blood, whether through the mucous, or into the serous 



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tissues, constitutes the natural mode of relief to this congestion. 

sth. That cholera goes through certain diurnal stages, of which capillary disturbance is the first, venous congestion the second, moreor less intermission or cessation of capillary disturbance the third. 

[6ih. That the natural tendency of cholera is to go rough these successive changes for three days, and en cease, or to run into consecutive or remittent constive fever. 

It appears to me that if these are facts (the establishment 

of which will depend on the observation 

nd reading of every practical man,) a principle reatment is inevitably established along with them >ecause they are facts on which the whole patholoj f the disease may rest, and the whole course of trea ment depend. If they prove otherwise, I have wastec our time and my own, in a feeble attempt to recom mend a combination of quinine with iron, as only on of the numerous medicines said to be beneficial i cholera, but the action of which will then be total! inexplicable; and I shall owe you all much apology for inviting you to listen to the arguments by which I have attempted to substantiate as facts, what another process of reasoning may, perhaps, demonstrate a-.-