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A TREATISE ON EPIDEMIC CHOLERA. 





A TREATISE ON EPIDEMIC CHOLERA, 

AS OBSERVED IN THE 

DUANE-STREET CHOLERA HOSPITAL, 

NEW-YORK, 

DURING ITS PREVALENCE THERE IN 1834. 

FLOYD T. FERRIS, 



MEMBER OF THE MEDICAL SOCIETY OF THE STATE OF NEW-YORK, LATE PHYSICIAN TO THE DUANE-STREET HOSPITAL, ETC. 

/^.¦nr 

NEW-YORK: 

PUBLISHED BY HARPER & BROTHERS, 

183 5. 



We 

[Entered, according to Act of Congress, in the year 1835, by Hakpkk & Brothers, in the Clerk's Office of the Southern District of New-York.] 



TO 

THE PRESIDENT 

AND 

MEMBERS OF THE BOARD OF HEALTH 

OF THE 

CITY AND COUNTY OF NEW-YORK, 

Who, during the visitation of Cholera in 1834, were alike zealous in the cause of humanity and devoted to the faithful performance of the important duties committed to their charge, this work is most respectfully dedicated, by their obedient servant, 

THE AUTHOR. 





PREFACE. 

On receiving the appointment of Physician to the Duane-street Cholera Hospital in 1834, my attention was necessarily directed to a close and careful investigation of the disease, and my duty would be but imperfectly performed without presenting the results to my professional brethren. 

Entertaining such views, then, and the period having long since passed by when I might have been disposed to figure as an author, my readers, I trust, will properly appreciate the motives which influence me in this publication. Whatever opinions may be entertained of the views which I advance, one thing is certain, that an examination of the record of the institution will show that the success of the plan of treatment which was adopted, will bear a fair comparison with the results in similar institutions. 

Medical readers are so familiar with the history of Cholera Asphyxia, that I consider it superfluous to enter minutely into the details of its origin and progress, and shall content myself with merely noticing its history, referring, at the same time, to most of the authors who have written on the subject. Among the best essays on its 



8 

PREFACE. 

history in India, may be mentioned the learned discourse on Epidemic Cholera of Professor Joseph M. Smith of this city. 

From the writings of Bontius, Sonnerat, Paisley, Curtis, and others, we infer that the disease has at intervals prevailed in Asia for the last two centuries. 

In 1817 the epidemic commenced in Jessore, a city about one hundred miles from Calcutta ; and after committing frightful ravages throughout Asia and Europe, it appeared in Quebec, on our own continent, in June, 1832, and, as is well known, extended over a great part of our country, attacking many of our principal cities with variable violence. The disease has lingered among us from that period to the present time, and has reappeared in many places with great virulence. The city of New- York was attacked in 1832, and again visited in 1834. 

By what particular route, or manner, the epidemic reached us is entirely left to conjecture. Whether it reached this continent by way of northern Russia, Greenland, &c, or crossed the broad Atlantic direct, or whether it arose spontaneously, or was generated here, are subjects as yet quite hypothetical and undetermined. 

As it is my intention, in the following pages, to confine myself simply to an account of my own observations, it will not be expected that I should take up the question of contagion ; I may, however, state that my previous opinion of its non-contagious character was fully confirmed by my experience in the Duane-street Hospital. 



A TREATISE ON EPIDEMIC CHOLERA 

CHAPTER I. 

SYMPTOMS OF CHOLERA ASPHYXIA. 

Cholera, always commences with more or less derangement of the digestive organs. The patient generally complains of uneasiness and distress in the epigastrium and umbilicus, and a sense of weight, fulness, and tension throughout the whole intestinal track, with constipation, which is frequently attended with flatulence and burning heat in these organs ; in some cases there are occasional shooting pains in the umbilicus, with distended bowels and slight colic, which soon pass off, and consequently do not call the attention of the patient to the real nature of his complaint. The functions of the stomach are not much impaired at this time, and the patient takes his regular meals, though perhaps with not the usual relish. 

These symptoms continue for a longer or shorter period ; in some for several days, and in others but a few hours, depending on the constitution, manner of living, and habits 

B 



10 

A TREATISE ON 

of the patient. Sooner or later, however, he suddenly has a desire to go to stool, which is generally preceded by one of the colic pains. He then discharges his bowels promptly and freely, without pain, and feels much gratified at the result, thinking he will be entirely relieved of the unpleasant symptoms, particularly the constipation, to which he attributes all his ailment. 

The pulse at this time, in most of those who are complaining, is frequent and contracted, but sometimes full and bounding. In the first evacuations he passes off the solid and feculent contents of the bowels, and at no great interval of time, he is again called upon to go to stool. This evacuation is more fluid than the preceding, and generally unattended with pain. Sometimes the evacuations are attended with slight pains or colics, but not sufficient to attract much attention or create alarm ; he supposes it to be the ordinary bowel complaint of the season, and that it will soon pass over as similar attacks had frequently done before. The neglect of these primary symptoms is too frequently a fatal error. These calls soon become more frequent, and the feculent matter being passed off, the intestines become empty, and the pathognomonic and characteristic marks of Cholera are speedily developed. 

The discharges now consist of an inodorous, whitish, serous or aqueous fluid, interspersed with particles of mucous or albuminous flakes ; sometimes the mucous matter is intimately mixed with the serum, giving it a milky appearance ; in other cases it is tinged with bile throughout the whole course of the disease. 

The tongue is moist, broad, and flattened, and slightly coated with a whitish fur. 



11 

EPIDEMIC CHOLERA. 

The pulse, which was in the beginning frequent, hard, and contracted, and sometimes full, soon becomes, in consequence of these large serous evacuations, feeble and weak. 

The disease now progresses with more rapidity and violence ; the stomach soon becomes involved ; nausea succeeds, and is soon followed by vomiting. The contents of the stomach are first ejected, which is succeeded by the vomiting of matter resembling the serous dejections from the bowels. The vomiting at first is frequently painful. Cramps soon follow, and begin in the fingers and toes, which at first are slight. The patient complains of great weakness and an indescribable feeling of exhaustion and sinking, accompanied with faintness and giddiness, roaring or buzzing in the ears, and sometimes of deafness. 

The discharges are not painful, and are frequently involuntary. He now feels a sensation of violent burning in the epigastrium, which sometimes extends over the whole abdomen, and is accompanied with constant and ardent thirst, and an intolerable desire for cold drinks, which he swallows with avidity, and which when taken are almost immediately rejected, especially if taken in large quantities. The cramps, which were at first confined to the toes and fingers, assume a greater degree of intensity, and extend successively throughout the superior and inferior extremities and abdominal muscles, and in the last place to the thoracic and diaphragmatic muscles, but rarely to the muscles of the face. They are rather of the elonic than of the tonic character, and are extremely painful, which is evinced by the groans and cries of the patient. 



12 

A TREATISE ON 

The pulse gradually becomes weak, feeble, and slow; sometimes, however, it is increased in frequency. The vomiting and purging continue increasing in violence ; the body generally, begins to lose its plumpness and rotundity, and an evident diminution is perceptible. The muscles are more distinct and better defined ; the features of the face are contracted, and its lineaments are strongly marked ; the eyes are sunken and hollow, and surrounded with a livid circle ; the lips begin to assume a bluish colour ; the body becomes cold, more particularly the extremities, and is covered with a cold, clammy sweat ; the circulation in all the extreme vessels now becomes feeble and tardy, and the patient complains of a difficulty of breathing, and of a sense of weight in the region of the epigastrium. 

In many cases the whole surface of the body is covered with a thin watery perspiration, which literally drenches the patient, his linen and bedding being completely saturated, so that the watery fluids of the blood appear to be discharged from the skin, almost as rapidly as from the stomach and bowels. This profuse perspiration may be considered as a most unfavourable symptom. The integuments are shrivelled and corrugated, and appear as if they had been soaked for a long time in warm water ; the fingers and toes are diminished at least one-third their usual volume, and are much pointed ; the pulse is rapidly sinking — it is contracted, thready, small to excess, scarcely perceptible, and soon becomes extinct. 

The tongue is white, broad, flaccid, and cold. This last symptom is peculiar to Cholera, and is never found to accompany any other. 



13 

EPIDEMIC CHOLERA. 

The blood abstracted at this period, is black, thick, and grumous, and escapes with difficulty from the veins ; it flows drop by drop, and is cold to the touch. 

The voice becomes feeble and sepulchral. The urine, which before was small in quantity and voided with difficulty and pain, is now entirely suppressed, and the secretion is completely suspended, as autopsic examination proves the complete vacuity of the bladder ; and all /the natural and healthy secretions, as bile, saliva, &c, are also suppressed, or very much diminished. Respiration is now becoming still more irregular and imperfect, and more laborious and difficult. At every two or three inspirations he gives a deep sigh ; his expirations are quick, and his breath is cold. This is peculiarly characteristic of the disease, and may be considered a fatal symptom. 

The patient is extremely restless, constantly turning from one side of the bed to the other, and throwing or tossing his arms about. The skin grows darker and darker as the disease progresses ; in some it is livid, in others it assumes a leaden hue, or becomes almost black. This variety in colour depends much on the natural complexion of the patient : dark skins incline to black, and light complexions assume a dingy or yellowish cast : the blue colour of these last is confined to the lips and mouth. The pulse now becomes extinct in all the extreme parts .of the body, and the action of the heart very feeble ; the countenance expresses great anxiety and supplication, and the patient in this stage of the disease has lost in a great measure his muscular power, is dull and heavy, disinclined to speak, and wishes to be quiescent, and remain at rest, and he is indifferent to what is doing for his relief, and to 



14 

A TREATISE ON 

every thing that is going on about him. The loss of muscular power, however, does not always take place at this period of the disease. In many cases patients retain great muscular strength after the pulse at the wrist has become extinct, and even until within a few minutes of death, are able to rise from bed and walk about the room, but soon become exhausted. 

If the disease be not arrested, the patient rapidly sinks ; an icy, death-like coldness pervades the whole body ; the skin is livid, and becomes inelastic and doughy, first in the extremities, and then the whole surface becomes involved, and it will, when pinched, retain whatever shape is given it, showing an apparent loss of vitality. I have never witnessed a favourable termination of a single case after this occurrence, and it may be considered a most fatal symptom. 

As the disease advances, the body becomes greatly contracted, and the muscles are more strongly marked ; the muscles of the abdomen fall in upon the spine ; the diaphragm appears to be drawn into the thorax ; the face is greatly shrunken ; the eyes are more hollow, and surrounded with a dark livid circle ; the cornea becomes flaccid, and the conjunctiva suffused with blood ; the eye is turned inward and upward, and is half closed, showing only the conjunctiva ; the nose is pinched, the lips blue, the face livid, and the whole features attenuated, giving the patient that cadaverous and most hideous aspect which is so characteristic of the disease. 

The hearing becomes much impaired, and the voice, which before was feeble and husky, is now reduced to a mere whisper ; and, as Broussais aptly expresses it, his 



15 

EPIDEMIC CHOLERA. 

words are rather "breathed than pronounced," and he articulates but one word at a time ; in short, the patient is in a state of asphyxia. 

The evacuations from the stomach and bowels in this stage of the disease are very much lessened, and sometimes entirely suppressed. It will be necessary to pay attention to this circumstance, in order that we may not be deceived as to the probable result of the case. The suspension of the evacuations does not arise from any mitigation of the disease, but because the fluids of the body are already drained off by the previous discharges. What evacuations do take place are less watery, and are mostly of a gelatinous appearance ; sometimes the matter passed off is in long strings resembling the mucous lining of the intestines ; and no doubt is part of the adventitious membrane formed in the small intestines, which I have seen in many cases after death. 

The cramps subside with all the irritability. In this state the patient lies upon his back an awful spectacle, completely overwhelmed with the disease. His intellect is generally unimpaired, almost to the last. He still retains the power of thinking and expressing his thoughts, and his answers to questions when he is roused, are generally correct, but he is averse to speaking, and is impatient of disturbance, and immediately relapses into the same lethargic and inanimate state. His intellectual faculties now soon become lost, he evidently shows great anxiety and distress, which is announced by a laborious heaving of the chest and abdomen, and this is the precursor of his dissolution, which generally takes place, where there has been no reaction in from six to twenty-six hours after the inva- 



• 

16 

A TREATISE ON 









sion of the disease. Sometimes the patient dies suddenly on being raised from a horizontal position, or in an effort to move himself in his bed from one place to another. 

Such is the most ordinary course of the disease when reaction has not taken place, or when its progress has not been arrested by the interposition of art. 

¦ 



EPIDEMIC CHOLERA. 

17 

CHAPTER 11. 

PATHOLOGY OF CHOLERA ASPHYXIA. 

In the examinations, post mortem, I have made a distinction between those that died in the hospital without medical treatment, and those that were treated from the commencement of the disease without success. There were many patients received into the hospital who were in articulo-mortis at the time of their admission, and who died soon after ; some of whom had not received any medical treatment from the commencement of the disease, until the death of the patient. 

I will first note the post mortem examinations of these cases, and then the examination of those that died after having received medical treatment from the beginning. 

The external appearances after death closely resemble those exhibited by the patient while labouring under the disease. The surface is of a livid or black colour, the solids shrunk, the features of the face contracted, the skin of the feet and hands much corrugated, and the muscles well defined. There exists less tendency to putrefaction than in bodies dead of other diseases. 

Abdomen. Omentum. — On laying open the abdomen I always found the omentum highly injected, and very red, and this redness was greatest at its lower part. In some 

D 



18 

A TRE A.T ISE ON 

cases there were slight adhesions, in others it was thrown to one side of the cavity. 

The intestines for the most part were distended with flatus, and frequently they were found to be contracted at different points. The small intestines in all the subjects; exhibited a bright vermilion colour of greater or less intensity, and in others different shades, from the rose-coloured blush to the deep red. In some cases the upper portions, and in others the lower parts of the small intestines were most injected, but the upper portions most frequently and generally more highly coloured. 

The large intestines were distended with flatus, and showed much less evidence of disease. The arch of the colon in some few cases, was found to be considerably contracted, and here and there a few arboressing blood-vessels covered its surface. 

Peritoneum. — The peritoneum lining the parieties of the abdomen presented no morbid appearances ; and, indeed, that portion of it covering the viscera, on minute examination, was, with some exceptions, found not to have been affected by diseased action, although it appeared of a red colour. This redness arose from the highly injected state of the tissue immediately beneath it, and not from an engorgement of the membrane itself; but where the disease has been protracted for a considerable time before death, the peritoneum becomes involved in disease, in common with the mucous and other tissues beneath. This was particularly observable on a careful removal of a portion of the peritoneum, and by viewing it in a strong light; but except in these protracted cases, the appearances of inflammation were confined entirely to the mucous membrane 



19 

EPIDEMIC CHOLERA. 

lining the stomach and bowels, and coincided in character and appearance exactly with erysipelatous inflammation ; and I am inclined to think that this species of inflammation always accompanies and characterizes the disease. 

Stomach. — This organ presented the same indications of inflammation as the small intestines ; the external surface was of a vermilion colour at the pyloric orifice, and gradually became of a lighter shade towards the cardiac orifice. In some cases the entire lower half was involved, exhibiting a deep vermilion hue, which terminated abruptly about the middle of the stomach, so as to form a distinct line of demarcation, and as perfect as I ever observed it in erysipelatous inflammation of the surface. The upper or cardiac portion exhibited little or no signs of disease. {Plate 11, fig. 2.) This organ was found considerably corrugated, but not much contracted, and frequently contained a whitish gray, or milky fluid, resembling the matter sometimes ejected before death. In some cases the fluid was colourless and transparent, except that occasionally it contained mucous flocculi, and was generally without smell. 

An opaque viscid matter adhered to the mucous membrane, varying in density, and forming an adventitious lining, which was easily removed with the back of the scalpel. The mucous membrane was softened in places and swollen, and exhibited strong evidences of inflammation, corresponding in situation and colour with the external coat, except that it was always of a deeper tinge ; and distinct patches, the size of a dollar, of a bright red colour were observed in places where there was no discoloration of the opposite external coat whatever, which to my mind tends to " thicken other proofs" that the inflammation 



20 

A TREATISE ON 

always first commences in the mucous membrane. 

Intestines. — The small intestines contained a whitish, turbid, serous fluid, resembling that which was passed before death ; it was generally inodorous, but sometimes emitted a strong disagreeable smell. The mucous surface in some cases was lined throughout the whole extent with a whitish, dense, adventitious membrane, resembling that formed in the trachea of persons dying of croup, large fragments of which were easily displaced with the handle of the knife. In other cases it was less tenacious, slimy, and of the consistence of thick cream. The mucous membrane was of a deep red colour, the blood-vessels were highly injected, and exhibited a much deeper colour than on the external surface ; the morbid accumulation of blood in the vessels appeared evidently to be confined to the mucous tissue. 

Mesentery. — The mesentery bore evident marks of inflammation, being red and much injected. The larger blood-vessels of the mesentery contained blood of a very dark colour, were flaccid and collapsed, and did not possess the usual elasticity which is generally observed in the vessels when death is caused by other diseases. This want of elasticity was seen also in all the large blood-vessels within the abdomen, exhibiting the appearance of passive congestion. The blood flowed readily from one part of the vessels to the other, whenever the position of the parts was changed, leaving the most elevated portions empty and collapsed. 

This appearance of passive congestion is, no doubt, in a great measure owing to the fact, that the vital and stimulating 





21 

EPIDEMIC CHOLERA. 

portions of the blood are, from the immense discharges, withdrawn some time before death ; and, also, from the fact that a great portion of the remaining blood is arrested in the lungs immediately before life becomes extinct. 

Liver. — The liver occupied its natural situation, and in most cases appeared healthy, except that in some few it was a little more pale than usual ; in all other respects it appeared healthy. 

Gall-bladder. — The gall-bladder was distended with olive-coloured bile, which passed the ducts readily on pressure. 

Spleen. — The spleen for the most part was healthy. In some cases there were slight engorgements, and in others it was enlarged, which I think may be attributable to preexisting chronic disease, and unconnected with the death of the patient. 

Kidneys. — The kidneys were in a healthy state, though in a few instances somewhat paler than usual. 

Bladder. — The bladder was firmly contracted, and had the same solid, dense feel as an unimpregnated uterus, and was about the same size ; it was generally empty, and concealed behind the pubis. 

Thorax. Lungs. — On opening the thorax, the lungs were found collapsed and of a very dark colour, which in some cases extended over the whole surface — in other cases only partially. They were engorged with a large quantity of black, viscid blood ; contained but little air, and were much heavier than natural ; in some few they were found completely hepatized, and had lost all their characteristic appearances. 

Heart — The heart was generally flaccid ; the right 



22 

A TREATISE ON 



cavities were sometimes distended with blood, slightly coagulated, and of a very dark colour. The left cavities contained but little blood, but of the same dark colour as that found in the right cavities. The coronary vessels were loaded with blood possessing similar characteristics. 

Cranium. Brain. — The brain did not show any evidences of inflammation, nor was it much crowded with blood. The meninges of the brain in some instances appeared slightly engorged. The cerebral substance did not in any respect differ from healthy structure. In some cases where the disease had been protracted from seven to ten days, and in patients of intemperate habits, there were slight serous effusions in the ventricles. 

The blood contained in the vessels of the brain was dark, thick, and grumous, corresponding with the blood found in other parts of the body, and in all cases the blood was preternaturally thick, like tar, of a dark colour, being highly carbonized, and deprived of its saline and serous properties. 

I now proceed to note those patients that had been treated in such a manner as to protract life for several days, without final success. These exhibited on post mortem examination very different appearances from the preceding. The morbid structure was of a more intense character, and the evidences of inflammation and its consequences were more strongly marked ; and the more so, in proportion to the length of time the disease had been protracted, after the evacuations had ceased. The discoloration of the diseased parts, which in the former cases was of a vermilion hue, in these assumed a dark brown or mahogany colour ; and frequently, when the disease was protracted for several days, the various tunics of the 



23 

EPIDEMIC CHOLERA, 

whole digestive canal, from the oesophagus to the rectum, were gangrenous ; and in some cases, where the disease had continued twelve or fourteen days, the membrane was completely destroyed, and the whole substance of the stomach and intestines were in a state of sphacelus, and contained a very dark-coloured, tenacious, and fetid fluid, sometimes black. During life, where the disease was of many days standing, and in the congestive fever, I have seen the matter ejected from the stomach appear of a dark brown or black colour, resembling the black vomit in yellow fever. 

The bladder in these cases was less contracted and contained more urine ; in some it was nearly full, and appeared healthy. 

The brain did not exhibit any particular evidences of congestion, except that in a few long protracted cases there was an effusion of serum into the ventricles, but not in any great quantity. The cerebral substance, when cut into, was not soft or pulpy, but firm, and did not appear particularly surcharged with blood. 

The lungs were always of a dark colour, filled with black blood, collapsed, and more or less hepatized. 

I did not myself subject the blood of patients labouring under this disease to chymical analysis, but shall rely on the researches of others, particularly those of Doctor O'Shaughnessy, who has put forth the following opinions, showing the chymical changes in the blood, and which comprises the amount of his investigations on this subject. 

" Ist. The blood drawn in the worst cases of the Cholera is changed in its anatomical structure. 

" 2d. It has lost a large portion of its water ; 1000 parts 



24 

A TREATISE ON 

of cholera serum having but the average of 850 parts of water. 

" 3d. It has lost also a great proportion of its natural saline ingredients. 

" 4th. Of the free alkali contained in healthy serum, not a particle is present in some cases, and barely a trace in others. 

" sth. Urea exists in the cases where suppression of urine has been a marked symptom. 

" 6th. All the salts deficient in the blood, especially the alkali, or carbonate of soda, are present in large quantities in the peculiar white dejected matters" 

The dejections in Cholera, according to M. Lecanu, " were composed of water, mucus, carbonate, acetate, muriate, phosphate, and sulphate of soda. There was no albumen, neither traces of caseum, nor of the principles of bile. The flaky matters were composed of albumen and fibrine. It is of importance to add that the specimen examined was obtained before any medicines had been exhibited." 

" When blood is drawn from its vessels in the ' healthy' living animal, it soon concretes into a jelly-like mass, which afterward gradually separates into a fluid, serum, and a coagulated crassamentum, or cruror." 

"Doctors Marcet and Berzelius have each given an analysis of the serum of human blood. The following is the result of the analysis of Marcet : — 

"Water 900.0 Albumen 86.8 Muriates of Potass and Soda 6.6 



EPIDEMIC CHOLERA. 

25 

Muco-extractive matter 4.00 Carbonate of Soda l .65 Sulphate of Potass 0.35 Earthy phosphates 0.60 

1000.00" 

That animal life depends upon the blood, was known as far back as the days of Moses, as may be seen by reference to Leviticus, xvii chapter and eleventh verse : — " For the life of the flesh is in the blood ;" and also in the fourteenth verse : — " For the life of all flesh is the blood thereof ;" but it does not appear that the ancients were acquainted with the various ingredients composing the blood, or that they then knew, as now must be conceded, that if one or more of its component parts be withdrawn, or that if the due proportions of this fluid be much interrupted, health will be impaired, or life destroyed. These different effects will be induced, in proportion to the quantity that is withdrawn of either of its constituent parts from the general mass of the circulation. The result of the decomposition of the blood in cholera is the loss of its vital and stimulating properties, producing a general interruption of the functions of all the organs of the body, particularly the economy of the lungs ; and, although the air inhaled comes in contact with the usual extended pulmonary surface, yet the phenomenon of oxygenation or arteriorization of the blood does not take place. This arises from the decomposed state of the blood previous to its arriving at the lungs ; the blood being rendered unfit for receiving its usual impressions. This is a fact established beyond all contradiction by 

D 



26 

A TREATISE ON 

pathological anatomy, physiological experiments, and chymical analysis ; for, as has been observed before, the blood of cholera patients is black, thick, grumons, and highly carbonized, and devoid of a great portion of its fluid and saline parts. These appearances of the blood are as uniform as any symptom exhibited throughout the whole course of the disease. The blood having in a great measure lost its vital properties, is not capable of imparting to the heart and arteries the stimulating impressions necessary to produce the usual circulation imparted by healthy blood, and, together with its want of fluidity, the heart and arteries lose their power of action, and become gradually weaker and slower, until finally the power of the heart is so much weakened, that it is unable to propel the blood with its usual momentum, and the circulation becomes gradually impaired, and first ceases in the extreme vessels, these being the most remote from the centre of circulation. 

Consequent upon the immense fluid discharges from the stomach and bowels, the blood becomes impaired in its vital properties by the loss of its aqueous and saline parts -, the latter especially, as before-mentioned, are requisite ingredients in this fluid tc- render it capable of being acted on by the oxygen of the atmosphere in respiration. This truth is verified by the fact that in cases where collapse has existed for some time, and when the patient is in a perfect state of asphyxia, the skin nearly black and corrugated, breathing laborious and difficult, voice lost, and the pulse has ceased to beat in the extremities, — in this unfavourable state of things, if the saline injection be thrown into the blood-vessels, no sooner are the watery and saline parts restored than the whole aspect of affairs is changed,— 



27 

EPIDEMIC CHOLERA, 

the circulation resumes its wonted energy ; the heart, which before was oppressed with the highly carbonized, is now stimulated to action by the aeriated blood; the lungs are relieved from their accumulated load, and breathing becomes natural ; the skin is restored to its natural colour and temperature ; relief to the patient is prompt and immediate, which continues so long as the saline fluid remains in the blood-vessels. If blood be now drawn, it presents all the natural characteristics of that fluid in a state of health. 

The blood, when it arrives at the right side of the heart in this deteriorated state, and is propelled through the lungs, receiving the vivifying influence of the air inhaled, only in proportion as it has become more or less decomposed, is then sent to the left side of the heart in this imperfect state, lessening still more the contractility of that organ. This state' of things continues and augments as the disease progresses, the breathing not being much impaired in the commencement of the disease, but gradually increases until the patient becomes completely asphyxied, which terminates in death. 

The blood being loaded with carbon, and of a dark colour, approaching to black, gives the skin .that blue appearance so characteristic of cholera. 

I will here notice the remarkable impressions made by the morbid influence, or poison, wherever cholera has prevailed. 

Few individuals living in a cholera atmosphere escape the action of this poison in a greater or less degree, although this disease may not in all become finally developed. Almost every individual, in places where the disease prevails, 





28 

A TREATISE ON 

complains of more or less disturbance of the digestive organs, — -such as loss of appetite, flatulency, distention of the bowels, diarrhoea, and slight colics. These are the primitive effects of the poison upon almost every individual within the sphere of its action, and they arise in persons as well of a robust as of a delicate or sickly constitution, and take precedence or predominate over all other diseases. 

These symptoms manifestly indicate that the mucous membrane of the digestive canal is primarily affected, and in a state of irritation, and this may be considered the germ; or rudiment, of the disease. This opinion is strengthened in tracing the disease in its development and progress ; and as the symptoms assume a greater degree of intensity, the gastro-intestinal irritation, excessive thirst, burning pain in the epigastric, region, frequently extending over the whole abdomen, sero-mucous discharges followed by excessive vomiting, the appearance of symptoms of gastro-enteritis after the discharges have ceased, the development of pain in the abdomen, which is increased on pressure, together with the palpable appearance of diseased action, discovered on post mortem examinations, — such as the highly-injected state of the mucous membrane of the stomach and intestines, the colour of which varying from the vermilion tint to the deep purple, the adventitious membrane formed in the intestines, and the frequently disorganized state of these parts, are phenomena which are conclusive that the primitive seat of the disease is in the gastro-intestinal mucous system ; which fact is now supported by most of the respectable part of the profession who have attended particularly to the subject ; such as Broussais, Annesley, &c. And Doctor Scott observes, that. "in all cases in 



29 

EPIDEMIC CHOLERA. 



which the gastric symptoms appeared to be wanting, and which are very few, pathological anatomy demonstrates that the digestive organs have been the principal seat of the disease." 

It being self-evident, then, that Cholera Asphyxia is primarily seated in the gastro-intestinal mucous tissue, the inquiry in order is, the real nature and character of the affection. In viewing a patient labouring under a severe form of the disease, we are irresistibly led to the conclusion that he is acted upon by some very deleterious agent, the truth of which cannot be doubted, and which, by common consent, is considered to be a peculiar and subtil poison existing in the atmosphere, the real nature and identity of which has not been discovered ; and little is known about it, except what is derived from its effects on the human body. 

It is presumable, however, that this poison is of a specific character, and has a- peculiar action on the system ; and that in its general character it is governed by laws common to all poisons in its action on organized matter. The general effect of most poisons is to produce erysipelatous inflammation in the part within the sphere of its influence, and which peculiar variety of inflammation we think we have found decidedly to exist in the mucous membrane of the stomach and bowels of persons labouring under this disease. And the violent burning heat in Cholera may also be mentioned as another coincidence remarkable in cases of poisoning generally. 

The predisposing and exciting causes of Cholera, are the same as those which usually precede the development of intestinal inflammation ; such as exposure to 



30 

A TREATISE ON 

cold, sudden vicissitudes of weather, exposure to a damp atmosphere, irregularity of bowels, unwholesome diet, deficiency of clothing, free living, great use of ardent spirits, depressing passions, fear, mental anxiety, &c. 

Many prominent members of the profession maintain that no inflammation in this disease exists in the digestive canal ; which opinion is founded on the fact, that on examination after death no redness of the coats of the stomach and intestines was found. This, however, was not the case in a single instance in the numerous post mortem examinations made by myself at the Duane-street Hospital, in 1834, This want of redness of the mucous coat in cases dying during the profuse evacuations, may be satisfactorily accounted for from the fact, that the engorgement of these parts is in a measure relieved by the immense secretions that are taking place immediately from the parts affected ; but if life is protracted after these evacuations have ceased, there is no doubt in my mind that the redness in such cases will be produced ; besides, the absence of vascularity and redness is no more a proof of the non-existence of inflam= mation, than redness of a part is an evidence of it. For proofs of inflammation, pathologists rather confide in the well-known results of that action ; and we certainly have results in Cholera which demonstrate that inflammation exists in the mucous membrane of the stomach and bowels. The burning heat, the profuse sero-mucous evacuations and occasional spontaneous hemorrhages, the creamy, pultaceous matter covering the mucous surface, and the dense adventitious membrane lining and plugging up the intestinal tube, &-c. &c., all go to prove the existence of inflammatory action. 



31 

EPIDEMIC CHOLERA. 

From the preceding investigations, I think it cannot be said that pathological anatomy furnishes nothing positive in relation to the character of Cholera, and that this disease is not accompanied with constant lesions. We have found evidences of disease strongly characteristic and peculiar, and which, we think, sufficiently account for. the symptoms of the disease and its termination. Although these pathological evidences are not all peculiar to this disease, yet many of them are constant and unvarying. Neither do the alterations always present themselves together ; but some are occasionally wanting, while many are secondary or accidental. 

Some of the most important appearances observable on examination after death, and which may be said to be peculiar to Cholera, may be ranked in the following order, viz. : — 

Ist. The intestines present a vermilion colour, and the redness, in the first stages of the disease, is confined to the gastro-intestinal mucous tissues, more particularly to the pyloric extremity of the stomach, and the small intestines. The mesentery, also, is highly injected and engorged. 

2d. The mucous surface of the stomach and intestines is always covered with an adherent, clammy substance, in variable quantities, and the digestive canal always contains more or less mucous and gelatinous secretions. 

3d. There is always existing in the lungs and venous system an accumulation of thick, black, and highly carbonized blood, which is deficient in serum and saline partides. 

From the foregoing symptoms, as also from the anatom- 



32 

A TREATISE ON 

ical lesions, and facts furnished by pathological anatomy, I have arrived at the following deductions :—: — 

Ist. That Cholera is the result of a specific poison applied to the system ; arid hence we learn the essential difference between it and the common cholera morbus, which may be regarded as an internal inflammatory action, sei up in consequence of cold and moisture applied to the external surface. 

2d. This poison is a stimulus, the first effect of which, when conveyed into the system, is, to set up inflammation in the digestive mucous surface, the parts first affected. Its first symptoms are gastric irritation. 

3d. The inflammation so induced is erysipelatous, first affecting the mucous coat, and afterward extending to the tissue beneath, and lastly to the peritoneal coat ; this last is affected with inflammation but seldom, unless life has been protracted after the profuse discharges have ceased^ and reaction commences. 

4th. This poison once conveyed into the system produces decomposition of the blood, and consequently the loss of vitality of this fluid ; and it is to this change in the blood that all the important phenomena arise. It is incapable of imparting to the heart and arteries that healthful stimulus necessary to sustain the circulation, and death is. the consequence. 

sth. The cause of death in all who die during the profuse evacuations, and without reaction, is a privation of the heart of its natural stimulus, healthy blood, arising from its decomposition and loss of vitality, and its final arrest in the lungs ; hence the great engorgement of these organs found after death. 



EPIDEMIC CHOLERA. 

33 

6th. The decomposition of the blood arises from the specific action of the poison on this fluid when received into the system, or from the increased secretions and serous exhalations from the digestive mucous surface, the results of the inflammatory action in these parts, or from both these causes combined. 

7th. The brain, that great centre of the nervous system, is in a state of asthenia, from the want of its natural stimulus, healthy blood ; hence the great depression and diminution of innervation, and the want of the vivifying influence of the nervous upon the other systems, and upon the various organs of the economy. 

Bth. The derangement of the economy and functions of the lungs is secondary, and is the result of, and in the inverse ratio to, the decomposition of the blood. No difficulty or interruption in respiration is perceptible in the early stages of the disease. 

9th. The great loss of animal heat arises from the arterialization of the blood being greatly modified, or wholly interrupted in the lungs ; the immediate cause of which is a deficiency of serum and salts in this fluid ; serum and the saline parts being necessary to this change. 

10th. Those who die of the disease secondary to the stage of collapse, are destroyed from lesions of the stomach and bowels, and the conjoined effects of the loss of vitality of the blood. 

E 



34 

A TREATISE 035 

CHAPTER 111. 

TREATMENT. 

The indications which present themselves to be fulfilled in the treatment of this disease appear to be as follows :—: — 

Ist. To allay the irritation of the stomach and bowels, and arrest the serous discharges from the intestinal mucous surface, and thereby prevent the decomposition of the blood. 

2d. To combat the inflammation of the digestive canal, so as to guard against the congestion of these organs. 

After having described the disease, as it appeared in this city, and the proximate cause, as shown by the actual state of the body on dissection, we are prepared in a measure to understand the principles which ought to guide us in its treatment. 

From observing the extraordinary prevalence of diarrhoea during the prevalence of cholera, and the slight causes which produce it, and the unusually violent action of cathartic medicines, and also from observing the injurious effects of the stimulating plan of treatment, such as administering calomel combined with opium, and the exhi= bition of a variety of the most powerful and diffusible stimuli, not only without success, but at all times with evident injury to the patient, I was early induced to adopt the more rational method of treatment, founded on pathological investigations, and recommended by the distinguished M. Broussais. Subsequent observation and experience have confirmed me in the belief of the correctness of this 



35 

EPIDEMIC CHOLERA, 

method of treatment, and I have not only no cause to regret having imbibed these views, but felicitate myself on having early adopted them in my practice. 

In describing the treatment of this disease, I will commence by taking it up as it usually exhibits itself in the earliest stage, to wit, in the form of diarrhoea, and proceed to give the treatment adopted by me through its several gradations. * 

TREATMENT IN THE PRIMARY STAGE. 

The first or forming stage of cholera is always attended with diarrhoea, which is sometimes accompanied with colic or griping pains, and cramps in the extremities. Sometimes the diarrhoea is attended with nausea and vomiting. These symptoms of themselves are sufficient to indicate the locality of the parts affected ; and that there is a highly irritable state of the digestive mucous surface, is evident from the slight causes which induce the diarrhoea, — such as deviations from the, customary regimen, taking small quantities of indigestible food, exposure to a cold or moist atmosphere, and the influence of the depressing passions, such as fear, mental anxiety, &c. In addition to these proofs of the locality of the disease in its incipient stage, we have the positive evidence arising from post mortem examinations, that the duodenum is the part of the intestinal canal, on the irritation of which the watery and serous discharges depend. 

The question then arises by what method are we to treat this incipient stage, so that it shall not run into, or be followed by, the more advanced and too frequently fatal stage of collapse ; certainly we would not administer 



36 

A TREATISE ON 

stimulating or irritating remedies of any kind, for these would only contribute to keep up, and increase, the morbid condition of the digestive mucous surface, which pathology teaches us exists in a very great degree. 

Upon the pathological views which I have taken is founded the treatment which I have adopted in my practice. The remedies I mostly rely upon in the treatment of this disease, are a free use of ice internally, copious depletion, both general and topical, and external stimulants, or revulsive applications to the surface. In adopting this mode of treatment, I am sustained by some of the best authorities ; those who have had unusual advantages in seeing the disease under every possible aspect, as well in Europe and Asia as in America. 

The looseness of the bowels at the commencement of the disease ought not, in my opinion, to be viewed merely in the light of a simple diarrhoea, which may have a tendency to run into cholera, but ought rather to be considered as the incipient stage of the disease itself, and as constituting an integral part of it, and as such it ought to be treated. The practitioner must proceed at once with promptness and decision to the treatment of cholera with this view of the case ; for in this stage of the disease, it is entirely under the control of art, and a favourable termination may, with great certainty, be relied upon, if the proper remedies have been administered, and the disease judiciously managed ; except, however, the patient has been labouring under long standing or chronic disease, or worn down with age, or his constitution broken up either by intemperate habits, or other causes. In these cases, the chance of success is doubtful ; and we need not flatter ourselves that a cure will 



37 

EPIDEMIC CHOLERA, 

be readily or easily accomplished. The patient should be directed to go immediately to bed. and keep quiet : rest and an incumbent posture being among the best means to check diarrhoea and allay intestinal irritation. The warmth of the skin should be restored, and kept up by additional clothing,- and the application of stimulants externally ; such as the foot-bath impregnated with cayenne pepper or mustard, and heated irons, or bricks, or sinapisms applied to the feet, also sinapisms or bladders of warm water to the abdomen. If the diarrhoea should be accompanied with much griping pains and colics, or spasmodic twitchings of the muscles, copious bleeding should be resorted to, for it is in this early stage of the disease that bleeding is mostly indicated ; indeed, I have observed a state of excitement in all cases to accompany an attack of cholera. If the patient be young and of a robust habit of body, and the inflammatory symptoms are strongly developed, pulse full and strong, or wiry and contracted, or accompanied with headache, say from twelve to twenty-four or even thirty ounces of blood maybe taken from the arm with advantage, and there will be less hazard of his running into the second or more strongly marked stage of the disease ; but the extent to which venesection should be carried must be left to the judgment of the practitioner, regard being had to the constitution of the individual, and the extent of pain and tenderness of the abdomen, and vascular irritation. If the patient should be debilitated by age, or his constitution broken down and enfeebled by other causes, and bleeding from the arm should appear of doubtful propriety, recourse may be had to leeching, say the application of twenty or thirty to the epigastric and umbilical regions, and repeated as often as the circumstances 



38 

A T REATI SE ON 

and the urgency of the case may indicate. Early depletion I have found to be a powerful means for allaying the irritation of the stomach and bowels, and preventing the subsequent congestion with which these organs are threatened. It is still a question with some practitioners of high standing, as to the propriety of depletion in cholera, and it is certainly a very important question ; but a very large majority of European and Eastern practitioners of great respectability, who have had abundant experience in the treatment of this disease, give strong testimony in favour of the efficacy of early and copious blood-letting. Mr. Kennedy says where blood was freely obtained to the extent of twenty or thirty ounces, and where depletion was followed by proper care, the patients have usually recovered. George Hamilton Bell considers blood-letting the principal remedy. He recommends that it be had recourse to under the most unpromising circumstances, as he has known its employment successful in cases where the individual appeared almost at the point of death. We have also the testimony in favour of early and copious bloodletting of Broussais, Gravier, Annesley, Scott, and many of the most respectable practitioners of Russia, Poland, Germany, and this country. The necessity of depletion is clearly indicated from the appearances on dissection ; the stomach and bowels being always found in a state of congestion and inflammation, which must inevitably prove fatal in a few hours, unless relieved. Bleeding is undoubtedly demanded by the ordinary and established rules of medical science, and experience proves it to be the best and most efficacious means of relieving arterial irritation and high inflammatory action ; besides the great benefits derived 



EPIDEMIC CHOLERA. 

39 

from bleeding in subduing inflammation and preventing congestions of the abdominal viscera, I have always found it one of the most efficacious means for controlling the obstinate spasms so distressing to the patient. 

At the same time that these curative means are employed, it is necessary to give ice to the patient freely and liberally, as recommended by Broussais. The ice should be broken in small pieces, and given to the patient with injunctions to swallow it as large as possible. If this remedy be persisted in, you may rely with great certainty that it will stop the purging, and allay the nausea and vomiting. The free use of ice is perhaps the most efficacious remedy made use of in the treatment of the disease ; and I may safely say, the only internal remedy that I know of, that has so decided an effect in arresting the serous secretions that are running off by the intestinal mucous surface, and thereby counteracting the action of the morbific poison on the blood, arresting the decomposition of this fluid, and restoring heat to the surface. The modus operandi, or the manner in which it operates, I am not able to determine ; it is sufficient, however, for all practical purposes, that we know the fact. I have known a great many patients recover from an apparently hopeless or blue stage of collapse, by the free use of ice internally, together with the use of stimulants externally, or revulsive applications to the skin ; on the contrary, I do not recollect to have seen a single instance of recovery from this stage, where diffusible stimulants had been given and persisted in. The exhibition of ice is, moreover, exceedingly grateful to the patient ; he swallows it with great avidity and delight ; it allays the inordinate thirst, and the excessive heat and distress 



40 

A TREATISE ON 

in the epigastrium, so tormenting to the patient, and the stomach becomes calm and retentive, and the diarrhoea is controlled by its use. The patient must also be restricted to absolute diet so long as any irritation exists in the digestive canal ; the practitioner must be positive on this point, and insist upon its being adhered to with severity. The patient will frequently have an inclination for food, and both he and his friends will be very solicitous that he should have something to eat; but if he be indulged, the vomiting and purging will return, and before the discharges can be arrested, collapse will supervene, and the patient in all probability will be lost. The slightest quantity of food taken into the stomach, will frequently bring on a return of both vomiting and purging, even after they have been arrested for twenty-four hours. In the Duane-street hospital an incident occurred illustrative of this fact. The nurse who had charge of the convalescents in the male department being ill, his place was temporarily supplied by another, who, instead of giving strained ricewater, as had been directed, gave the patients (ten in number) the rice itself to eat, which brought on a return of the vomiting and purging in every case, three of whom died in collapse, in from eight to ten hours after the food had been given. 

Bearing in mind the great influx of fluids to the mucous surface of the stomach and intestines, and the great irritability of these organs, we will greatly expedite the cure by the assistance of external stimulants, or revulsive applications to the skin, as before observed ; the propriety of which, when used with judgment, I believe is unanimously agreed upon by the profession ; and there is no stage of 



41 

EPIDEMIC CHOLERA. 

» 





the disease in which they may not be employed with advantage. 

Among the most powerful and successful applications for the purpose of restoring action, and determining the fluids from the internal organs, is the stimulating pediluvium, composed of capsicum and mustard, each four ounces to one gallon of water, at the temperature of from 100° to 110° Fahrenheit. This should be had recourse to as soon as it can be got ready, and the feet should be retained in it until it has produced a decided effect upon the skin, and the patient feels a smarting sensation. If the patient complain of much pain or griping in the bowels, or if there be much sickness of stomach, the application of a sinapism to the abdomen has been found to give great relief. These remedies should be persevered in continually, or repeated at intervals so long as the disease continues, and the use of them be indicated. Indeed, it is sufficient oftentimes to effect a cure in the incipient stage of the disease, for the patient to bathe his feet in the stimulating bath, go to bed, use ice freely, and restrict himself to an absolute diet for a short time. 

It is of the utmost importance to prevent the patient from drinking large quantities of fluids, even of the most bland or mucilaginous nature ; for the stomach, being in a state of great irritability or inflammation, is very sensitive to any thing received into it, and large draughts of fluids act mechanically from their bulk, and are immediately ejected ; but if they should be retained by the stomach, purgation is always increased by them, which makes them equally objectionable on that account. You at once obviate this difficulty by the administration of ice instead of 

F 



42 

ATREATiSE OK 

water, as it absorbs more caloric from the stomach, and is not objectionable on account of its bulk. 

Second Stage. — If the patient should not be relieved in the early or incipient stage, and the diarrhoea is suffered to continue, and the serous discharges are of considerable quantity and of long duration, with a manifest tendency to collapse, and the pulse small and greatly increased or diminished in frequency, and the skin assume a colliquative humidity ; and if the extremities become cold, and the patient complain of a sense of weight or sinking at the breast, with weakness or feebleness of the voluntary muscles, and roaring or ringing in the ears ; or if collapse has taken place, — you are to rely principally upon the internal use of ice, and the application of revulsives to the skin, for restoring heat and reaction. The ice must be given alone, unencumbered with any other remedy ; for if given in combination with stimulants or cathartics, or irritating drugs, they will produce a pernicious effect, which will not be counterbalanced by the ice, and the hazard of the patient will be increased, and your labour lost. 

I have been thus particular in recommending the use of ice, because I" consider it vitally important for restoring the circulation and heat to the surface. At' the same time, you should persevere and promote the heat of the body by external applications, such as bags of warm sand applied to different parts of the body, or bottles filled with warm water, — the latter are preferable on account of their being more easily and quickly procured ; and because of their rounded form, they keep in constant contact with the body. Stimulating pediluvia, as before mentioned, and' frictions of rubefacients to the extremities. An ointment 



43 

EPIDEMIC CHOIiE-RA. 





composed of camphor, capsicum, and lard, which was first used by my friend Dr. S. C. Roe, of this city, in 1832, I consider among the best of this kind of remedies. All alcoholic preparations should be avoided, on account of the •loss of heat that is necessarily sustained by their rapid evaporation, which does more injury than counterbalances their stimulating properties. « Sinapisms are among the ¦most powerful and successful revulsive remedies; their application to the inside of the calves of the legs, the wrists, the abdomen, and along the spine, have been found very beneficial, and should never be omitted. 

When diarrhoea has been excessive, an enema of from half a pint, to a pint of iced water, or flax-seed tea, iced, with about fifteen or twenty drops of laudanum, I have found of great advantage in controlling it, and of great use in arresting the inordinate serous discharges and allaying 4he pain and spasm of the bowels. Administered in this manner, the opium is less liable to produce injurious consequences that when given by the mouth. I have never ventured to exceed twenty to thirty drops of laudanum ; and when, from the great irritability of the intestines, or from the relaxation of the sphincter ani muscle, it has not been retained, a suppository of ice has been used with advantage ; it often allays the pain and brings on a contraction of the sphincter muscle, so that the ice-water or cold iiax-seed tea injections are readily retained. 

This plan of treatment, steadily persisted in, I have often found to cause reaction, and in a short time I have been enabled to obtain the requisite quantity of blood which the emergency -of the case called for,.. .and which, from the 



44 

A TREATISE ON 



feeble condition of the circulation, could not by any means be procured before. 

Third Stage. — The first symptoms that indicate reaction are a diminution of the evacuations ; the tongue, before pale, flattened, and flabby, in consequence of the previous profuse evacuations, begins to become red about its edges, which gradually extends until the whole surface assumes the same colour; the breathing is less embarrassed, the skin resumes its natural colour, and the heat of the body is gradually and equally restored ; the pulse, which was slight and feeble, or perhaps extinct in the extremities, gradually acquires strength and fulness, and the patient not unfrequently falls into a short, calm, and refreshing sleep, and when he awakes expresses himself as feeling much better ; his appetite returns, and he expresses great desire for something to eat. His appetite must not be indulged, for, as has been before observed, if he be permitted to eat much, the vomiting and purging will return, which is generally uncontrollable, and the patient will rapidly sink into collapse, and in all probability die in a few hours. 

The physician must not be thrown off his guard by the flattering hopes that his difficulties are now all over, and that his patient is out of danger ; for it must be recollected that there is yet a period of the disease to ensue, of inflammation and congestion of the digestive organs, calling for decisive treatment and unremitting attention. It is this disorganizing inflammation of the stomach and bowels that we have to combat in this stage of the disease, and we must use all the means in our power to moderate the excitement, for it is from, inflammation of these organs, and its consequences, 



45 

EPIDEMIC CHOLERA. 









that the great danger is now to be apprehended, and not from the congestion of the brain, as is generally supposed. Congestion of this organ seldom, if ever, happens, unless the patient has been treated in the previous stages with stimulants and narcotics. The drowsiness and stupor of the patient are not owing to congestion, nor a surcharged state of the brain, as is generally supposed, but doubtless to a depression of its vital energies, arising from the want of the natural excitement of this organ, produced only by healthy blood ; indeed, this cannot be called a comatose state of the patient, in the ordinary acceptation of the term, for if you excite him, or speak to him, he will answer correctly, but manifests much impatience in speaking. 

The inflammation and congestion of those organs appeared to exist, or to be increased, in proportion to the duration and extent of collapse, and to the improper use of internal stimulants ; and the reaction that follows the stage of collapse, after the prodigal administration of narcotics, stimulants, and irritating medicines, internally, may be considered, for the most part, beyond the control of art, and almost uniformly fatal ; for in all cases where stimulants were withheld, and the patient was freely bled in the beginning, the consecutive fever was comparatively light, and easily controlled. On the contrary, where stimulants were freely administered, if the patient were so fortunate as to recover from collapse, he generally died of congestion of the stomach and bowels, notwithstanding he had been treated with assiduity, and I,he most decisive measures had been resorted to. 

As a general rule, the treatment to be adopted in the 



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A TREATISE ON 

consecutive fever, as it is called, or in this stage of reaction, is the same as that pursued in inflammation and congestion, arising from other causes, — such as general and topical bleeding, with revulsives to the extremities, &c. &c. You are not to wait for a perfect reaction in the sanguineous system before you take measures to arrest the congestion ; if you do, you will probably fail in controlling it: but as soon as reaction is manifestly begun, leeches ought to be applied to the umbilicus or the anus ; the latter place is preferable, as you get the blood from the hsemorrhoidal vessels, and more immediately from the parts affected; and the bleeding should be encouraged by frequently sponging with tepid water. If the circulation should be augmented rapidly, recourse must be had to venesection, which should be performed while the patient is in a horizontal position ; for if he sit up in bed syncope will be induced, and you will not be able to procure the quantity that the emergency of the case requires. The syncope arises in a great measure from the deprivation which the brain has previously sustained of its natural stimulus, healthy blood, and the erect position increases the tendency to fainting still more by suddenly diverting a portion of the remaining blood to other parts of the body. These circumstances, I think, go far to sustain the position that the brain is not the seat of congestion. If the patient does not bleed freely, which will frequently be the case, suspend the operation for an hour or two ; at the same time continue to give ice freely and liberally ; this, from its refrigerant and sedative powers, is, no doubt, the best internal remedy used in the disease : resort must be had also to sinapisms, blisters, and other . revulsives, as before directed. The extent to 



47 

EP I DTE MIC CHOLERA. 



which bleeding should be carried must depend on the circumstances and exigences of the case, — such as the constitution and previous habits of the patient, the violence of the disease, and the duration of the collapse, which can only be judged of by the practitioner ; and you are to persevere in judicious, general, and local depletion, and the refrigerant practice, so long as inflammation or congestion exists. We must not be deterred from bleeding by the smallness of the pulse ; for in this stage of the disease, as in peritonitis and enteritis, bleeding ought to be carried further than the condition of the pulse seems to warrant; and we find generally after bleeding that the pulse becomes fuller and softer, which may always be considered a favourable symptom. 

It would be proper also to mention that cathartics, even of the mildest kind, are always, and in all stages, inadmissible. If they should be administered, they will often induce such an uncontrollable purgation, as will run the patient down into collapse, from which it will be impossible to recover him, and he will die in a few hours. The only thing of a relaxing nature (if it may be so called) that I have ventured to give is flax-seed tea enema, and with which I have always been enabled to open the bowels. 

The most favourable symptoms are, a gradual return of the natural secretions* particularly a full and early secretion of urine, the skin resuming its natural heat and elasticity, and the tongue becoming moist, and assuming its natural colour. These are symptoms on which you may rely, and safely prognosticate the recovery of your patient. On the contrary, if there be a dry red tongue ; teeth and mouth covered with sordes ; small, contracted, or sluggish 













48 

A TREATISE ON 



pulse, and the patient remains drowsy; and if the skin is cold and doughy, and the urine scanty, accompanied with dark-coloured flaky dejections, much reasonable doubt may be entertained of a final recovery. 





49 

EPIDEMIC CHOLERA. 



CASES. 

In presenting a history of several cases of Cholera which occurred in the Duane-street Hospital, in 1834, I would beg leave to state that regular and accurate records of every case which occurred were kept by Drs. S. L. Griswold, John Conning, Stuart, and Mr. T. W. Le Foy ; and I take this occasion to testify to the zeal and fidelity of those gentlemen during the whole period of the existence of the disease, and thus publicly present my thanks to them for their unwearied assiduity. It will naturally be supposed, that, as this was the principal institution* established by the Board of Health in 1834, the class of patients was of a most unfavourable character for successful treatment ; the idle, the dissolute, and the debauched were too frequently its inmates ; while there were but few of the better classes of society, who happened to be attracted there from favourable reports of the successful result of the mode of treatment. Many of the cases, previous to admission, had been subjected to medical treatment ; ancjl I feel bound to state, that, as a general rule, when the stimulating, the camphor, the calomel, and opium plans had been previously pursued, scarcely a single patient recovered. 

I have also preserved with tolerable accuracy the results of my private practice, and as the class of cases was of a totally different character from that which occurred in hospital practice, I think it proper to append the following summary :- — Total number of private cases one hundred and seven ; of which four died, and one hundred and three were cured. Of seven cases in which I was called in consultation at a late period of the disease, all died : making the total number of deaths eleven, out of one hundred and fourteen cases. 

* My friend Dr. S. C. Roe had charge of the hospital .in Greenwich vil- lage, where the number of patients was necessarily limited in comparison. 

G 



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Case No. 1. — Transfusion Unsuccessful. Thomas Burns sailor, aetat twenty-two years, temperament bilious, very intern perate habits, was the first patient admitted, August 9th, at halfpast 6 o'clock P. M., before the house was ready to receive patients. When brought in he was in a perfect state of collapse ; and, as we could learn nothing of his name or history, he being in articulo mortis, I was induced to perform transfusion : accordingly I injected six pints of the saline solution ; after which he was immediately resuscitated, and gave all the above particulars of his history in a clear and distinct voice. Becoming comatose soon after, he was bled to twelve ounces ; but during the night he had two evacuations, resembling rice-water in appearance, and continued rapidly to sink until he died, at 5 A. M. 

This case illustrates an important fact : had it not been for the transfusion, he must inevitably have died, " a stranger in a strange land," without his friends having ever been able to know his end. 

Case No. 8. — Transfusion Successful. Rufus Sinclair, setat twenty-four years, sailor, sanguine temperament, habits intemperate, was found in the street, and brought to the hospital, on the 11th of August, at noon. 

Symptoms on admission. — Vomiting and purging of a serous fluid, resembling rice-water ; pulse feeble, and easily compressed ; tongue flattened ; skin natural. Says he has had diarrhoea twentyfour hours previous to admission. 

Treatment. — Stimulating pediluviuin of mustard and capsicum, 110° Fahrenheit; sinapisms to the abdomen and lower extremities ; ice ad libitum, and ice suppository. 

8 P. M. — Vomiting subsided ; has had several evacuations from his bowels ; pulse of moderate strength, 90 ; enema of icewater and 25 drops of laudanum. 

12th, 8 A. M. — Reported to have passed a comfortable night; retained the injection; has passed a small quantity of urine; pulse rather improved ; skin warm. Says he would wish to have something to eat ; allowed arrow-root. 

)3th. 8 A. M. — Continues better. 

2 P. M. — Attacked with vomiting and purging while Dr. Griswold and myself were standing at the bedside, the first evacuation from his bowels being copious, serous, and flocculent ; pulse immediately sunk ; skin became cold. Ordered stimulating pediluviuin, cataplasms of mustard to the abdomen, and frictions of capsicum and camphor ointment to the extremities and along the spine ; ice suppository to be repeated. 

4^ P. M. — Has had two copious serous evacuations, and is in complete collapse ; skin and tongue cold ; hands and feet corrugated; 



EPIDEMIC CHOLERA. 

51 







eyes sunken ; countenance livid, and body appeared to be shrunken. 

6^ P. M. — la articulo mortis. The sphincter ani relaxed, skin much discoloured, and breathing very laborious ; no perceptible pulse at the wrist ; a slight pulsation in the brachial artery. In the presence of Oliver M. Lovvndes, Esq. and several physicians, injected in the median vein six and a half pints of water, at 114° Fahrenheit, containing two drachms of muriate of soda to seven pints of water : restoration immediate ; pulse at the wrist returned ; breathing relieved ; natural colour and heat of skin restored. 

lIP. M. — Slight convulsions, which soon passed off. 

14th, 8 A. M. — Reported to have passed the latter part of the night comfortably ; symptoms less favourable than immediately after the injection of the fluid ; pulse sluggish, and natural in frequency ; skin cold and inelastic ; extremities livid, particularly the lower. Cupped over the temples, and obtained four ounces of blood ; blister to the nape of the neck ; frictions to the lower extremities, of capsicum and camphor ointment. 

2P. M. — Slight delirium ; otherwise the same as in the morning. 

10 P. M. — Wild and incoherent; pupils dilated; blister not vesicated. Opened the temporal artery, and obtained ten ounces of blood ; applied blisters to the calves of the legs. 

15^, 8 A. M. — Much improved; appears sensible; answers questions correctly when spoken to ; skin continues cold and discoloured ; blisters vesicated, but contained very little serum. Dressed with camphorated mercurial ointment; allowed ricewater. 

16th, 8 A. M. — Somewhat improved ; skin more natural. 

11th, 8 A. M. — Continues better ; complains much of his blisters, which were dressed with simple cerate ; urine secreted freely ; has had a copious feculent dejection ; continued to improve gradually from this day till the 25th instant, when he was discharged, cured, and was made porter to the establishment, in which capacity he continued for some time. 

Case No. 17.— Margaret Mulloney, married, aetat forty-two years, sanguine temperament, habits doubtful ; admitted August 14th, 2 o'clock P. M. ; had been vomiting and purging since 11 o'clock A. M. of the day preceding ; had diarrhoea for three days previous to being attacked with vomiting ; had received no regular medical treatment previous to admission. 

Symptoms when admitted. — Collapse complete : vomiting and purging of serous fluid ; cramps of the extremities ; surface cold ; hands and feet corrugated ; eyes sunken, encircled with a dark areola; lips blue; tongue flattened and cold; pulse not perceptible 



52 

A TREATISE ON 

at the wrist ; urine suppressed ; countenance haggard ; voice sepulchral. 

Treatment. — Stimulating pediluvium of mustard and capsicum, 110° Fahrenheit; sinapisms to the abdomen; frictions of camphor and capsicum ointment to the extremities, to be frequently repeated ; ice ad libitum ; ice suppository, and to be repeated. 

BP. M.— Much improved ; reaction complete ; pulse full, in frequency 100; tongue red ; skin warm and moist. Bled from the arm ten ounces. 

15th, BA. M. — Pulse continues full and frequent ; eyes slightly suffused ; opened the temporal artery, and obtained about eight ounces of blood. 

9P. M. — Continues better ; has passed urine in considerable quantities during the day ; had one large bilious evacuation from the bowels. Allowed rice-water. 

16tk, 9 A. M. — Reported to have passed a comfortable night; says she feels well ; pulse full, strong, and frequent. Bled twelve ounces. 

17th. — Very much improved, and so continued until the 19th, when she was removed to the convalescent hospital, where she entirely recovered. 

Case No. 55.— H. L., gentleman, setat twenty-seven years, of sanguine temperament, and temperate habits, came to the hospital of his own accord, being a stranger, and alone in the city, on the 18th August, at 11 o'clock A. M. Has had diarrhoea for three days ; was attacked with vomiting at 8 A. M., between which hour and his admission he had vomited several times ; had no previous treatment. 

Symptoms on admission. — Vomiting and purging of a fluid matter, resembling rice-water ; severe cramps of the extremities and abdominal muscles ; countenance dejected ; eyes somewhat sunken ; fingers and toes slightly corrugated ; pulse small and feeble; urine suppressed; complains of roaring in the ears. 

Treatment. — Stimulating pediluvium of mustard and capsicum, 110° Fahrenheit ; sinapisms to the abdomen and extremities, with ice ad libitum ; enema of one pint of ice-water and 30 gutt. of laudanum, to be repeated. 

8 P. M. — Very much improved ; cramps subsided ; pulse rising ; tongue red ; vomiting allayed ; has had two injections, and retained the last for two hours ; the abdomen much vesicated with the sinapism. Dressed with simple cerate, and allowed ricewater. 

19th, 8 A. M. — Reported to have passed a comfortable night ; pulse full, 96 ; tongue red ; skin warm ; has passed his urine during the night, and had two or three watery stools. Bled 



EPIDEMIC CHOLERA. 

53 

twelve ounces ; an enema of ice-water, and 25 gutt. of laudanum. 

8 P. M. — Very much improved ; retained the enema for two hours. 

20th, 8 A. M. — Much better, and continued to improve till 22d, when he was discharged cured. 

Case No. 71. — Margaret Ferguson, orphan, aetat six years, sanguine temperament, admitted at 3P. M. 20th of August ; had been vomiting and purging since last night; could not ascertain whether she had previous diarrhoea ; had received no previous treatment. 

Symptoms on admission. — Vomiting and purging of serous fluid, and severe cramps of the extremities ; face haggard ; eyes sunk, and surrounded with a livid circle ; lips blue ; tongue moist, cold, broad, and charged with a light fur ; feet and hands cold and corrugated ; respiration slow and laborious ; no perceptible pulse at the wrist; brachial pulsation feeble, but distinct; great precordial anxiety and restlessness ; voice husky and feeble. 

Treatment. — Stimulating pediluvium of capsicum and mustard, 110° Fahrenheit ; sinapisms to the abdomen and extremities ; ice ad libitum ; and ice-water injections, to be repeated. 

10 P. M. — Very much improved ; reaction established ; has neither vomited nor purged for the last three hours ; skin warm and dry; tongue red and moist; still complains of great thirst, and takes ice with avidity ; pulse full, 90. Bled five ounces. 

21st, 8 A. M. — Reported to have had a restless night ; had no evacuations from her bowels, but has passed a small quantity of urine ; skin hot and dry ; pulse full, 80; tongue red, and rather inclined to dryness ; complains of great thirst ; eyes slightly suffused. Bled six ounces ; allowed rice-water. 

22d, BA. M. — Very much improved ; reported to have slept well through the night ; has had two small bilious evacuations during the night ; urine secreted abundantly ; pulse soft and pleasant; skin warm and moist. Allowed a small quantity of arrow-root. 

23d, 8 A. M. — Convalescent; and proceeded to improve very rapidly from this time forward, and was discharged cured on the 30th. 

Case No. 99. — Yeophili Ixdebski, a Polish emigrant, astat twenty-three years, sanguine temperament, habits temperate, came to the house on the 23d of August, at 3 o'clock P. M., ot his own accord ; had been vomiting and purging for 24 hours, and 



54 

A TREATISE ON 

labouring under diarrhoea for two days previous to being attacked with vomiting. 

Symptoms when admitted. — Vomiting and purging of serous fluid ; cramps of the lower extremities ; skin warm ; tongue slightly coated with a white fur ; pulse tense, and 90. 

Treatment. — Stimulating pediluvium of capsicum and mustard, 110° Fahrenheit; sinapisms to the abdomen and lower extremities ; ice ad libitum ; and ice-water injections, to be repeated. Bled ten ounces. 

24th, BA. M. — Much improved ; reported to have passed a good night ; has not vomited or purged since the early part of last evening. Allowed rice-water. 

SP. M. — Much improved ; expressed a strong wish to return to his lodgings ; permission was given, though with reluctance. 

11th. — Returned to the house at half-past 3 o'clpck P. M. ; had been vomiting and purging at intervals for the last 18 hours. 

Symptoms on readmission. — Approaching collapse ; surface cold ; countenance haggard ; eyes sunken ; tongue cold ; voice husky ; hands and feet slightly corrugated ; pulse at the wrists feeble and easily compressed ; urine suspended. 

Treatment. — Stimulating pediluvium of capsicum and mustard, 1 10° Fahrenheit; sinapisms to the abdomen ; frictions to the lower extremities, of camphor and capsicum ointment, to be repeated ; ice ad libitum; ice-water enema, with 25 gutt. laudanum, to be repeated. 

10 P. M. — Reacting ; skin warm ; pulse rising ; vomiting allayed ; has had several enemas, and has retained the last. Pediluvium repeated, and sinapisms to the extremities. 

28th, BA. M. — Reported to have had a comfortable night ; has purged none ; has copious secretion of urine ; skin warm ; pulse full, 90. Bled twelve ounces ; allowed rice-water. 

29th, 8 A. M. — Very much improved ; pulse soft and natural ; skin pleasant ; has had one copious bilious evacuation, as also a copious secretion of urine. 

30th, BA. M. — Continues better. At SP. M. was sent to his lodgings, when he speedily recovered. 

Case No. 1 17. — Joseph Shaves, setat twenty-six years, a native of Portugal, sailor, admitted on the 26th of August, at half-past 7 o'clock A. M. ; has had vomiting and purging, and severe cramps of the extremities, since yesterday ; had diarrhoea for 24 hours previous to being attacked with vomiting ; no medical treatment previous to admission. 

Symptoms. — Collapse complete; vomiting and purging of serous fluid, resembling rice-water ; cramps of the lower extremities ; pulse not perceptible at the wrist ; feeble pulsation at the 



55 

EPIDEMIC CHOLERA. 

brachial arteries ; eyes sunken ; countenance livid ; tongue cold, broad, and flat ; hands and feet very much corrugated ; voice whispering ; breathing laborious ; urine suppressed. 

Treatment. — Ice ad libitum ; stimulating pediluviura of mustard and capsicum ; cataplasm to the abdomen ; frictions of camphor and capsicum ointment to the extremities and along the spine ; ice suppository. 

12 o'clock, noon. — Slight reaction ; vomiting allayed ; has had several small evacuations from his bowels. Repeat pediluvium ; enema of half-pint ice-water and 25 gutt. of laudanum ; frictions to the extremities continued. 

BP. M. — Reaction established ; skin warm ; breathing relieved ; pulse full, 88. Bled twelve ounces — blood of dark colour, and flowed freely. 

27ht, 8 A. M. — Reported to have passed a comfortable night ; has passed urine, and had several bilious evacuations ; pulse full and labouring ; eyes suffused ; seems rather drowsy and sluggish. Bled from the temporal artery ten ounces ; blister to the abdomen and thighs ; allowed rice-water. 

8 P. M. — Somewhat better ; blisters drawn well, and contained considerable serum ; dressed with camphorated mercurial ointment ; urine secreted in moderate quantities. 

28th, BA. M. — Passed a comfortable night ; much less drowsy than yesterday. Cups applied to the back of the neck ; obtained four ounces of blood. 

29th, BA. M. — Much better ; urine more abundantly secreted ; the dejections more natural; eyes less suffused; pulse soft and natural. Continued steadily to improve from this day, and was discharged on the 2d of September, cured. 

Case No. 141. — Collapse; Hcematemesis affording relief- — Cure. James Ricketts, black, a3tat thirty-four years, habits intemperate, admitted on the 27th of August, at 8 P. M. ; has been vomiting and purging during the day ; had diarrhoea for two days previous to being attacked with vomiting ; had been treated before coming to the house. 

Symptoms on admission. — Vomiting and purging of fluid resembling rice-water; cramps of the extremities ; skin cold; hands and feet corrugated ; eyes sunken ; voice husky ; tongue broad and cold ; no perceptible pulse at the wrist ; breathing difficult ; great thirst ; urine suppressed. 

Treatment. — Stimulating pediluvium ; sinapisms to the abdomen, and frictions to the extremities, of camphor and capsicum ointment ; ice ad libitum ; ice suppository, to be repeated. 

10 P. M. — Slight reaction ; cramps relieved ; pulse feeble and 



56 

A TREATISE ON 

frequent ; has thrown at intervals from his stomach from a halfpint to a pint of fluid blood. 

28th, 8 A. M. — This patient continued to vomit blood at intervals during the night, in all from two to three pints ; is very much improved ; has not vomited or purged for the last four hours ; pulse soft, and a little increased in frequency ; skin natural in temperature; tongue slightly red. Allowed rice-water. 

9 P. M. — Has passed urine once during the day. 

29th, 8 A. M. — Reported to have passed a comfortable night ; says he feels quite well, with the exception of being weak. Allowed arrow-root. 

30th, 8 A. M. — Much better, and continued to improve, without a single unpleasant symptom intervening ; and was discharged cured on the 2d day of September. 

Case No. 250. — Michael M'Laughlin, aetat ten years, sanguine temperament, admitted September Bth, at half-past 9 o'clock A. M. ; was attacked the day before with vomiting and purging ; could not ascertain if he had had previous diarrhoea. 

Symptoms on admission. — A state of collapse ; no perceptible pulse at the wrist ; thirst excessive ; skin cold and inelastic ; respiration laborious ; hands and feet corrugated ; tongue flattened and cold ; lips blue ; eyes sunken, and encircled with a dark areola ; expression of face haggard ; no previous medical treatment. 

Treatment. — Stimulating pediluvium of mustard and capsicum, 1 10° Fahrenheit ; sinapisms to the abdomen ; frictions of capsicum and camphor ointment, to be repeated ; ice ad libitum ; ice suppository, to be repeated until purging is allayed. 

12 o'clock, noon. — Slight reaction ; frictions of the comphor and capsicum ointment have been employed three times ; vomiting and purging" allayed ; breathing more easy ; skin warmer. Pediluvium repeated ; sinapisms to the extremities. 

12 P. M. — Reaction established ; tongue red and pointed ; pulse full and labouring ; breathing good ; countenance improved. Bled eight ounces ; allowed rice-water, which brought on vomiting and purging. This was discontinued, and he was confined to ice, which soon allayed it. 

9th, 8 A. M. — Reported to have had a tolerably comfortable night ; has had one or two dark gelatinous stools, and has passed a small quantity of urine ; pulse rather full and labouring ; skin natural ; tongue red ; eyes suffused, and appears dull and drowsy. One dozen leeches to the temples, which filled slowly, and bled but little ; blister to the nape of the neck. 

10th, 8 A. M. — Much the same as day before ; still in a partial state of stupor ; has passed urine, and had two bilious stools ; 



57 

EPIDEMIC CHOLERA. 

blister has drawn well. Applied one dozen leeches to the temples. 

11th, 8 A. M. — Still continues drowsy and sluggish; pulse labouring ; urine secreted in small quantities ; has had nothing pass his bowels ; complains of great thirst. Twenty leeches to the epigastrium, which bled freely ; head shaved, and bladders of ice-water applied. 

12th, BA. M. — Somewhat improved since yesterday ; pulse less laborious ; thirst somewhat abated ; drowsiness and stupor still continue ; has had a free evacuation from his bowels, which appeared more natural. Six leeches to the anus, which bled but little. 

13th, 8 A. M. — Much the same as day before; stupor and drowsiness still continue. Bled five ounces from the arm. 

142/t, 8 A. M. — Much improved ; urine more freely secreted ; little or no drowsiness ; tongue natural ; skin pleasant. Allowed a small quantity of arrow-root and rice ; and from this day he continued to improve, and was discharged cured on the 22d instant. 

Case No. 270. — Collapse ; Hmmorrhage from the Bowels — Cure. W. Purdy, setat 23 years, a native of New- York, sanguine temperament, habits intemperate, admitted September 9th, at 12 o'clock ; had been vomiting and purging at intervals since the night of the 7th, previous to which time he had been labouring under diarrhoea for 24 hours. 

Symptoms on admission. — Vomiting and purging of serous fluid , cramps of the extremities, particularly the lower ; countenance haggard ; eyes sunken, and surrounded with a dark livid circle ; lips blue ; tongue broad and cold ; voice husky ; hands and feet cold and corrugated ; breathing difficult ; urine suppressed ; no perceptible pulse at the wrists ; great thirst. 

Treatment. — Stimulating pediluvium of capsicum and mustard, 110° Fahrenheit; sinapisms to the abdomen; frictions of capsicum and camphor ointment to the extremities and spine, to be repeated ; ice ad libitum ; ice-water enemas. 

10 P. M. — Vomiting allayed, and purges but little ; slight reaction ; pulse distinct at the wrist, but feeble ; tongue red at the edges, and inclined to dryness ; skin warm, and complains of pain on pressure over the abdomen. Enema of half-pint of ice-water and 25 drops of laudanum, to be repeated. 

\Oth, 8 A. M. — Has slept at intervals during the night; has had two enemas, and retained the last for several hours ; tongue red and dry; still complains of pain on pressure over the abdomen ; pulse slow and feeble ; skin warm, and complains of great thirst. Blister to the abdomen, and allowed rice-water. 

1 P. M. — Has used the chamber several different times this 

H 



58 

A TREATISE ON 

morning, and passed from a pint to three hall-pints of blood froih the bowels ; also passed a small quantity of urine ; says he feels much better since passing the blood ; pain of the abdomen very much relieved ; tongue more moist, and its edges red ; has less thirst. 

lltk, BA. M. — Has had a good night ; has not had any thing pass his bowels since he evacuated the blood yesterday morning ; urine secreted more freely ; blister has vesicated ; pulse soft and pleasant; skin natural; tongue moist, and more natural as to colour. 

12th, BA. 31. — Continues better ; and improved rapidly until the 14th, when he was discharged cured. 

Remarks. — It will be observed that in the above, as well as in the case of James Rickett, mentioned at page 55, after the free evacuation of blood from the stomach and bowels, the relief afforded was great, and the convalescence rapid. 

Case No. 293. — William Thompson, black, aetat forty-two years, habits intemperate, admitted on the 11th of September, at half-past 2 o'clock P. M. ; had diarrhoea for three days previous to admission ; had been treated before received into the hospital. 

Symptoms when admitted. — Vomiting and purging serous fluid, interspersed with iloculent mucous matter ; severe cramps of the extremities ; fingers and toes slightly corrugated ; pulse very small and feeble ; skin warm ; tongue flattened and broad ; complained of giddiness and great thirst. 

Treatment. — Stimulating pediluvium of mustard and capsicum, 110° B'ahrenheit ; sinapism to the abdomen ; frictions of camphor and capsicum ointment to the lower extremities and along the spine, to be repeated ; ice freely, and ice-water injections, to be repeated. 

9P. M. — Vomiting allayed ; purging still continues, though somewhat abated. Ice-water injections, to be administered through the night, and frictions continued. 

12th, 9 A. M. — Reported to have passed a tolerably comfortable night ; no vomiting ; retains the injections for some considerable length of time, say from one to two hours ; pulse improved j tongue red, particularly the edges. Pediluvium repeated, and mustard cataplasms to the calves of the legs. 

Noon. — Reaction fairly established. Bled six ounces — blood thick, of a dark colour, and flowed slowly from the vein. 

9 P. M. — Continues better; has had two bilious stools, and passed his urine. 

13th, 8 A. M. — Reported to have passed a comfortable night j urine secreted more abundantly ; eyes slightly suffused ; tongue red ; skin warm and dry ; complains of slight headache. Cups 



59 

EPIDEMIC CHOLERA. 





applied to the nape of the neck, and obtained about four ounces of blood ; allowed rice-water. 

I4t7i, 8 A. M. — Much as yesterday ; rather drowsy. Bled from the arm four ounces, being all that could be obtained. 

15th, 8 A. 31. — Pulse full; tongue red; skin warm; stupor increased from yesterday ; opened the temporal artery, and obtained eight ounces of blood ; has had three scanty stools, of a dark and bilious character ; urine secreted in small quantities. Blister to the nape of the neck. 

16th, BA. M. — No improvement ; blister drawn well ; tongue very red, and inclined to dryness. Bled ten ounces, from the arm. 

17th, BA. M. — Much the same as yesterday. Blisters to the lower extremities. 

ISth, 8 A. M. — Slight delirium ; pulse slow — about 60. 

19th, 9A. M. — Delirium increased ; extremities becoming cold ; circulation evidently retiring. 

20th. — Sinking fast. Died on the morning of the 21st, at 5 o'clock. 

POST MORTEM EXAMINATION. 

Brain. — On opening the cranium, the brain and its membranes presented a natural appearance ; there was a slight effusion of transparent fluid into the ventricles. 

Thorax. — Heart natural ; lungs collapsed, and loaded with dark grumous blood ; the cells contained very little air. 

Abdomen. — Omentum majus gangrenous; peritoneum lining the abdomen appears free of disease ; liver natural ; gall-bladder distended, and filled with olive-coloured bile ; spleen enlarged ; stomach covered with patches of gangrene — it contained a dark fluid matter, resembling black vomit, and tore into pieces on raising it; large intestines gangrenous throughout; small intestines so tender that they would not bear their own weight ; bladder contained about a gill and a half of urine ; kidneys natural. 

Case No. 301. — J. Winters, setat seventeen years, a native of Germany, sanguine temperament, habits temperate, admitted on the 12th day of September, at one o'clock P. M. ; had vomiting, purging, and cramps since the afternoon of the 11th, previous to which had been labouring under diarrhoea for 24 hours ; had not been under treatment. 

Symptoms on admission. — Vomiting and purging of serous fluid, with mucous flocculi ; cramps of the extremities ; countenance dejected ; eyes sunken, and encircled with dark areola ; 



60 

A TREATISE ON 

lips blue ; tongue cold and broad ; voice husky, and great thirst ; surface cold ; hands and feet corrugated ; pulse at the wrist scarcely perceptible ; breathing laborious ; urine suspended. 

Treatment. — Stimulating pediluvia of capsicum and mustard ; sinapisms to the abdomen ; frictions of capsicum and camphor ointment to the extremities and spine ; ice ad libitum ; ice-water enemas, to be repeated. 

10 P. M. — Vomiting allayed ; slight reaction ; pulse more distinct, though feeble ; tongue red at the edges ; skin warm ; breathing relieved ; retained the injections for some time. Repeat pediluvium, and sinapisms to the extremities. 

13th, BA. M. — Reaction established ; reported to have had a good night ; has had but two or three small slimy stools, and passed a small quantity of urine ; pulse full, labouring, and slow ; tongue red ; eyes suffused. Bled twelve ounces — blood dark, and flowed freely ; allowed rice-water. 

14th, 8 A. M. — Symptoms much as yesterday, except rather drowsy and heavy, and evinces pain upon pressure on the abdomen ; has had a bilious evacuation, and passed urine. Bled ten ounces ; blister to the epigastric region. 

15th, 8 A.M. — Passed a quiet night ; skin warm ; urine scantily secreted ; pulse full and labouring ; eyes much suffused. Head shaved, and bladders of ice-water applied to the top of the head ; blister to the nape of the neck ; bled eighteen ounces. 

16th) BA. M. — Somewhat improved from yesterday ; eyes less suffused ; pulse rather better, though still labouring ; blister vesicated ; complains of great giddiness, particularly on rising. Blister dressed with camphorated mercurial ointment. 

17th, BA. M. — Passed the night quietly ; skin warm ; tongue red, though rather inclined to dryness ; pulse full, and more frequent than yesterday. Bled twelve ounces. 

18th, 8 A. M. — Has passed rather an uncomfortable night ; slept but little ; tongue red and dry ; complains of great thirst. Bled ten ounces. 

19th, 8 A. M. — Reported to have rested much better than the night previous ; slept several hours, at intervals; tongue moist, and paler ; complains very much of his blister. 

20th, BA. M. — Much improved ; pulse soft and pleasant ; tongue more natural ; says he feels better, and expresses a desire for some nourishment. Allowed arrow-root. 

Discharged on the 24th, cured. 

Case No. 321. — [Plate iit. Fig. I.] A. F., aetat thirty years, sanguine temperament, intemperate habits, admitted on the 15th of September, at 7P. M. ; has had diarrhoea for several days ; 



61 

EPIDEMIC CHOLERA. 

was attacked last night with vomiting and purging, and severe cramps of the extremities, particularly the lower, which continued at intervals up to the hour of admission. 

Symptoms on admission. — Collapse complete ; countenance haggard ; eyes sunken, and surrounded with a livid circle ; lips blue ; tongue cold, flat, broad, moist, and coated with a whitish fur; hands and feet very much corrugated, and of a dark livid colour ; occasional cramps of the toes and legs ; skin cold, and covered with a clammy sweat ; voice sepulchral ; breathing slow and laborious ; urine suppressed ; no perceptible pulse at the wrist ; brachial pulsation feeble, but distinct. 

Treatment. — Stimulating pediluvium of capsicum and mustard, 110° Fahrenheit; sinapisms to the abdomen and spine; ice ad libitum, and ice-water injections, to be repeated ; frictions of capsicum and camphor ointment to the extremities, to be repeated. 

Wth, 8 A. M. — Reported to have passed a very bad night ; vomited several times, accompanied with cramps of the lower extremities ; has had frequent small serous evacuations from the bowels, mixed with mucous matter ; countenance very haggard ; no perceptible pulse at the wrist ; skin rather warmer than on admission ; no urine secreted. Repeat pediluvium and frictions ; sinapisms and warm bricks to the extremities ; ice suppository. 

BP. M. — Slight improvement ; pulse perceptible at the wrist ; skin warmer ; has not vomited since morning ; evacuations from the bowels less frequent, but in appearance the same. 

17th, BA. M. — Reported to have passed a better night ; has had disturbed sleep ; countenance improved ; purging, vomiting, and cramps had entirely disappeared ; skin warm ; pulse slow and feeble ; rather inclined to drowsiness ; tongue red. Bled from the arm — blood was of a dark colour, flowed slowly, and obtained short of two ounces, the vein collapsing ; allowed ricewater. 

BP. M. — Much the same as in the morning ; pulse rather stronger. Bled four ounces, all that could be obtained — appearances of blood same as the last. 

18tk, 8 A. M. — Appearances more favourable ; slept considerable during the night ; has taken rice-water, which she retained on the stomach ; pulse slow and tense ; surface generally warm ; countenance appears more natural. Bled ten ounces. 

19^, BA. M. — Continues to improve ; has had considerable sleep during the night ; urine secreted more freely ; had two darkcoloured bilious evacuations from the bowels. 

20tk, 8 A. M. — Continues in a favourable state ; secretion of urine more abundant ; pulse rather tense, 80 ; tongue red. Bled ten ounces. 

21s£, 8 A.M. — Some improvement from yesterday; pulse rather less tense. Allowed arrow-root. 

22d, BA. M. — Much as yesterday ; had two or three slimy 



62 

A TREATISE ON 

bilious evacuations from the bowels ; tongue still continues red, but moist ; complains of no pain. Ordered a warm bath, temp, 100°, to remain in for fifteen minutes. 

23d, 8 A. M. — Symptoms all more favourable, and seemed to be improving gradually till the night of the 30th, when she was again attacked with a diarrhoea; had four or five thin watery evacuations, mixed with bilious matter ; pulse rather feeble and slow ; skin warm. Pediluvium of capsicum and mustard ; sinapisms to the abdomen and lower extremities ; ice-water enema, with 25 drops of laudanum, to be repeated ; ice ad libitum. 

31st, 8 A. M. — Had several fluid evacuations through the day, slightly discoloured, and mixed with gelatinous matter; pulse feeble and slower. 

October Ist, BA. M. — Passed a sleepless night ; had several gelatinous evacuations during the night ; skin cool, doughy, and inelastic ; pulse much as last evening ; tongue coated ; complains of pain on pressure over the abdomen. 

8 P. M. — Evidently declining ; pulse extremely feeble and slow ; extremities cold, particularly the lower ; had no evacuations from the bowels through the day ; appears heavy and sluggish. Applied warm bricks to her feet. 

2d, 8 A. M. — Appears labouring under stupor ; has been more or less so during the night ; surface cold ; pulse slow, and scarcely perceptible ; and died at 3P. M. 

POST MORTEM EXAMINATION. 

Thorax. — Heart healthy, rather flaccid — contained a small quantity of blood, of a dark colour ; lungs collapsed, exhibited a marbled appearance, and contained dark grumous blood — the cells contained but little air. 

Abdomen. — Peritoneum lining the cavity of the abdomen, healthy ; liver healthy ; gall-bladder filled with olive-coloured bile ; spleen healthy, and exhibited no engorgement ; kidneys healthy ; bladder contained about a gill of dark-coloured urine, and healthy ; stomach of a pink colour externally, deeper at its pyloric extremity — it contained a dark-coloured fluid ; internal mucous coat red, and highly inflamed through its whole extent ; small intestines dark red externally, and approaching the colour of mahogany — thickened and contracted — their internal mucous coat exhibited a greater degree of inflammation than appeared externally — was broken down in places, and easily lacerated ; large intestines slightly inflamed ; transverse arch of the colon contracted much below its ordinary size. 

The appearances presented in this case are represented in plate iii. figure 1. 



63 

EPIDEMIC CHOLERA. 

Case No. 343. — [Plate iv..] P. N., aetat twenty-three years, sanguine temperament, habits temperate, admitted September 20th, at half-past six o'clock A. M. ; was attacked with vomiting and purging about twelve o'clock the preceding night ; has had diarrhoea for 24 hours previous to being attacked with vomiting. 

Symptoms when admitted. — Collapse complete ; vomiting and purging of serous fluid ; cramps of the extremities ; eyes sunken, and encircled with a dark areola ; countenance haggard ; lips blue ; skin cold and sodden ; hands and feet corrugated ; tongue broad, flat, cold, and coated with thin white fur ; voice sepulchral ; breathing" difficult ; great thirst ; pulse not perceptible at the wrist ; pulsation of the brachial artery distinct ; urine suppressed. 

Treatment. — Stimulating pediluvium of mustard and capsicum, 110° Fahrenheit; sinapism to the abdomen; frictions of capsicum and camphor ointment to the extremities and along the spine, to be repeated ; ice internally ad libitum ; ice suppository, to be repeated. 

. 12 o'clock. — Slight reaction ; tongue more pointed, and slightly red on the edges ; tremulous pulse at the wrist ; vomiting allayed ; evacuations not so frequent, and less copious ; cramps subsided ; skin becoming warm. Enema of one pint of ice-water and 20 drops of laudanum. 

8 P. M. — Continues to improve ; countenance much less haggard ; breathing much relieved ; pulse at the wrist distinct, but feeble ; thirst abated ; has retained the ice-water injection Allowed a cup of rice-water, iced. 

2lst, 8 A. M. — Much improved ; reported to have passed a comfortable night ; has had two or three slimy bilious stools, and passed some urine ; pulse rather full and sluggish, but natural in frequency ; tongue red and moist — was covered with a florid and slightly elevated eruption ; temperature of the skin natural. Bled eight ounces — blood thick, and of a dark colour, flowed slowly from the vein. 

1 P. M. — Continues better. 

8 P. M. — Much the same as in the morning, except complains of pain from pressure on the abdomen. Bled six ounces. 

22d, 8 A. M. — Has had two or three dark-coloured evacuations during the night, passing a small quantity of urine each time ; pulse same as yesterday ; tongue red ; eyes slightly suffused, and appears rather drowsy. Bled ten ounces. 

1 P. M. — Not much alteration. 

8 P. M. — No perceptible alteration since the morning, except more drowsy. 

23d, 8 A. M. — Reported to have had a comfortable night ; has had nothing pass his bowels ; voided urine ; is more heavy and sluggish than yesterday ; answers correctly when spoken to ; eruption less florid ; lower extremities rather cold. Blisters to the inside of the legs ; twenty-four leeches to the umbilicus. 



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10 P. M. — Blisters vesicated, but contained little serum. Dressed with camphorated mercurial ointment. 

24th, 8 A. M. — Reported to have passed a restless night ; symptoms aggravated ; appears comotose ; is roused when spoken to, and answers correctly ; pulse slow. Cups applied to the temples — obtained four ounces of blood ; blister to the nape of the neck. 

BP. M.< — No improvement ; blister has drawn well. Dressed with camphorated mercurial ointment. 

25th, 8 A. M. — Sinking ; extremities cold ; skin doughy and inelastic ; tongue dry ; pulse slow, not more than 40. Died at 6 o'clock P. M. 

POST MORTEM EXAMINATION. 

Thorax. — Heart natural ; lungs highly congested, and contained dark grumous blood — the cells containing but little air. 

Abdomen. — The peritoneal lining healthy ; omentum gangrenous in spots ; liver nothing remarkable ; gall-bladder half-filled with dark olive-coloured bile ; spleen natural ; stomach externally exhibiting a purple colour, and contained a small quantity of darkcoloured fluid ; mucous coat softened, broken down, gangrenous in spots, particularly at the pyloric extremity ; the small intestines approaching to gangrene throughout, and of a dark mahogany colour ; the mucous coat softened and broken down, and the intestines contained a dark thick fluid matter ; large intestines gangrenous throughout their whole extent. 

Plate iv. is an accurate representation of the appearances presented in this case. 

Case No. 346. — [Plate ii. Fig. I.] L. H., a coloured female, aetat twenty-three years, admitted on the 20th of September, at 2 o'clock P. M. ; had been vomiting and purging since the evening of the 19th, previous to which time had had diarrhoea for two days. 

Symptoms when admitted. — Vomiting and purging of serous fluid ; no pulse at the wrist ; slight pulsation of the brachial artery ; eyes sunken ; countenance very much haggard ; voice whispering, and scarcely audible ; extremities cold ; hands and feet much corrugated ; body covered with a cold clammy sweat ; breathing laborious and difficult ; complained of suffocation and great thirst. Died within one hour after admission. 



I 

EPIDEMIC VIIOL E X A, 

65 

! 

POST MORTEM EXAMINATION. 

Brain. — Healthy, and no evidence of engorgement. 

Thorax. — Heart flaccid, and contained a small quantity of black blood ; lungs collapsed, and loaded with black grumous blood — so much so as to lose all their character — hepatized. 

Abdomen. — The peritoneum lining the abdomen appeared healthy ; omentum majus highly injected, and of a red colour ; liver healthy ; spleen natural ; gall-bladder half full of healthy bile, which passed the ducts readily on pressure. On bringing the stomach into view it exhibited a pink colour over its whole external surface, deepest at its pyloric extremity, and contained a small quantity of transparent fluid ; the mucous coat was of a deep vermilion colour throughout its whole extent, approaching to crimson at the pyloric extremity ; the small intestines were of a beautiful pink colour externally, and minutely injected — and, on placing them in a strong light, small bands of minute vessels were observed through the peritoneal coat, encircling the intestine at regular distances of three or four lines, and appeared to be confined to the tissue beneath the peritoneum : upon careful dissection, on removing the peritoneal coat, this proved to be the fact — the inflammation was confined to the mucous coat and tissue beneath ; the intestines contained serous fluid, mixed with mucous particles, and exhibited a much deeper colour than appeared externally, and were lined throughout with an adventitious membrane, varying in consistence and density; the large intestines appeared natural, and exhibited no evidence of inflammation ; a few small arborescing vessels were seen on the transverse arch of the colon ; kidneys rather pale ; bladder empty, and firmly contracted under the arch of the pubis ; uterus and its appendages healthy ; the large blood-vessels along the mesentery flaccid and collapsed, as also all the large blood-vessels in the cavity of the thorax and abdomen. 

See plate ii. figure 1. 

Cask No. 350. — [Plate i.] J. W., aetat twenty-four years, occupation shoemaker, sanguine temperament, of temperate habits, admitted on the 21st of September, at 10 P. M. ; was attacked the night previous to his admission with vomiting and purging, and severe cramps of the extremities ; had been labouring under diarrhoea for several days previous, and had received no medical treatment. 

Symptoms on admission. — Vomiting and purging of serous fluid ; eyes sunken, and encircled with dark areola ; lips blue ; countenance very haggard ; extremities cold, and very much cor- 

r 



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rugated ; pulse not perceptible at the wrist ; tongue cold, broad ? and flattened ; complains of great sense of suffocation. Died in a short time after admission. 

POST MOKTEM EXAMINATION. 

Thorax. — Heart flaccid, contained a small quantity of grumous blood in each auricle ; lungs very much collapsed, loaded with dark grumous blood, and completely hepatized. 

Abdomen. — Liver paler than natural ; gall-bladder full of olivecoloured bile, easily discharged on pressure ; spleen healthy ; stomach, on its external part, of a light pink colour, highly injected, as if in a high state of inflammation — contained a considerable quantity of thin dirty fluid ; mucous membrane exhibited a bright vermilion colour, and showed a much higher state of inflammation than the external surface, and highest at its pyloric extremity ; the small intestines inflated, and immensely injected, as in acute inflammation, exhibiting a pink colour externally throughout (see plate i.) — contained serous fluid in considerable quantities ; the mucous lining of a deep vermilion colour, softened in places, and coated with an adventitious mucous lining of a pearly whiteness and jelly-like consistence, and easily removed with the back of the scalpel ; large intestines inflated, and appeared healthy ; a few arborescing vessels were seen on the transverse arch of the colon — the intestine contained a fluid similar to that in the small ; bladder firmly contracted under the arch of the pubis — felt like an unimpregnatetJ uterus, and contained no urine ; the vessels of the mesentery were enlarged, collapsed, and contained dark-coloured blood, and had very much the appearance of passive congestion ; all the large blood-vessels of the cavity of the thorax and abdomen had a flaccid appearance, and contained dark grumous blood. 

Plate i. is an accurate representation of the appearances presented in this case. 

Case No. 367.— [Plates h. and ni. Figs. 2.] F. R., a native of Germany, eetat thirty years, bilious temperament, of temperate habits, has been vomiting and purging, and had cramps since last night ; has had diarrhoea for 48 hours, and has had no medical treatment ; admitted on the 24th of September, at noon. 

Symptoms on admission. — Collapse complete ; vomiting and purging of a transparent serous fluid, mixed with mucous matter, of white pearly appearance, and of considerable density, which came from him in fragments like pieces of tape, from four to six inches in length, and having the appearance of an adventitious membrane 



EPIDEMIC CHOLERA, 

67 

; skin cold, sodden, and livid; eyes sunken; countenance haggard ; voice whispering ; breathing laborious ; great sense of suffocation ; hands and feet corrugated ; no pulse at the wrist. Died very soon after admission. 

POST MORTEM EXAMINATION. 

Thorax. — Heart flaccid, contained but little blood, and that of a dark colour ; lungs collapsed, and loaded with dark grumous blood — the cells contained very little air. 

Abdomen. — -Peritoneum lining the abdomen healthy ; omentum majus red, and highly injected. On bringing the stomach into view, the lower half was highly inflamed, and of a pink colour externally — the upper half of a natural colour, and healthy — the line of demarcation was very distinct, as much so as I have ever seen in erysipelatous inflammation of the skin (plate ii. figure 2) — it contained a half-pint of fluid, resembling turbid rice-water ; the mucous coat was highly inflamed, and of a deep vermilion colour on the lower half, corresponding with the redness that it exhibited externally, and there were also two inflamed spots on the upper part, about the size of a dollar, which showed no corresponding marks externally (plate iii. figure 2) — it was covered with a thin glairy mucous, which was easily removed with a sponge ; the small intestines were distended with flatus, highly inflamed, of a pink colour, and minutely injected throughout — contained serous fluid; the mucous coat of a deep vermilion colour, swollen, and softened in places, and coated with a thick, dense, whitish membrane, which could be removed in flakes or large pieces with the handle of the scalpel ; large intestines distended, and appeared healthy ; liver healthy ; gall-bladder filled with bile ; the bladder was empty, and firmly contracted under the arch of the pubis ; kidneys healthy ; the vessels of the mesentery enlarged, flaccid, and contained dark blood, as was the case with all the larger vessels in the cavity of the thorax and abdomen. 

Case No. 385. — John Ross, black, employed as one of the sedan-carriers to the house, setat forty-three years, of temperate habits ; was attacked in the street with vomiting and cramps of the extremities, when bringing a patient to the house, on the morning of the 29th of September ; was brought in at 9 o'clock A. M. in collapse ; stated that he had had looseness of his bowels for two weeks.* 

. * It is a fact worthy of remark, that the nurses and attendants on the house, notwithstanding the precautions enjoined on them, frequently la- boured under diarrhoea for several days without reporting themselves to the medical department. 



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Symptoms on admission. — Vomiting and purging of serous fluid ; severe cramps of the extremities and abdominal muscles ; eyes sunken ; face haggard ; tongue broad, coated, and cold ; hands and feet corrugated ; breathing laborious ; no perceptible pulse at the wrist. 

Treatment. — Stimulating pediluvium of capsicum and mustard ; sinapism to the abdomen ; frictions of capsicum and camphor ointment to the extremities, to be repeated ; ice ad libitum, and ice suppositories. 

1 P. M. — Reacting ; has not vomited for the last two hours ; has had several small serous dejections ; tongue red at the edges ; skin warm ; pulse perceptible at the wrist, but feeble ; breathing relieved. Pediluvium repeated ; sinapisms to the extremities, and ice-water enema, with 25 gutt. laudanum. 

BP. M. — Reaction complete. Bled twelve ounces. 

30/ A, BA. M. — Continues better ; urine secreted moderately ; pulse full and sluggish. Bled twelve ounces ; allowed rice-water. 

October Ist, 8 A. M. — Very much improved ; pulse soft — in frequency natural ; copious secretion of urine ; bilious evacuations. Allowed arrow-root. From this day improved rapidly, and was discharged on the 4th, cured. 

Case No. 387. — Collapse; Hcematemesis — Cure. Emma Waters, black, aetat forty years, employed as nurse in the house, of good constitution and temperate habits ; has had diarrhoea, accompanied with slight colics, three days ; was attacked with vomiting on the 29th of September, at 11 P. M., which was soon followed by a large and copious serous dejection, at which time her situation was made known to the medical department ; and, on visiting her, she presented the following 

Symptoms. — Eyes sunken ; countenance dejected ; hands and feet cold, corrugated, and sodden ; tongue cold, broad, and flat ; voice feeble, and much changed ; intellectual faculties sound ; complains of pain in the epigastrium ; thirst urgent ; respiration slow, but does not complain of any suffocation ; urine suppressed ; no perceptible pulse at the wrist. 

Treatment. — Stimulating pediluvium of capsicum and mustard, 110° Fahrenheit ; sinapisms to the abdomen and extremities ; ice ad libitum, and ice suppository, to be repeated. 

30^, 8 A. ilf.-^-Reported to have had several small serous dejections during the night ; had vomited half a pint of blood, which gave her great relief; has not vomited since; pulse full, and 80; skin warm-; tongue red. Bled eight ounces ; allowed rice-water. 

October Ist, 8 A. M. — Reported to have rested well last night ; has had two copious bilious evacuations from her bowels, and 



EPIDEMIC CHOLERA. 

69 

passed urine freely ; pulse still full, and labouring ; other symptoms much as yesterday. Bled ten ounces. 

2d, BA. M. — rPulse good ; skin soft and pleasant ; no thirst ; urine secreted freely. Allowed arrow-root. Convalescence proceeded very rapidly, and she resumed her duties on the sth. 

Case No. 389.— James Franklin, setat twenty-two years, bilious temperament ; habits doubtful ; admitted at 11 o'clock P. M, on the 29th of September ; had diarrhoea for four days, and was attacked with vomiting and cramps during the afternoon ; had not been under treatment. 

Symptoms on admission. — Vomiting and purging of a fluid resembling rice-water ; skin cold ; hands and feet corrugated ; eyes sunken ; face livid ; tongue cold and broad ; breathing laborious ; voice sepulchral ; urine suppressed ; great tenderness of the abdomen on pressure ; no perceptible pulse at the wrist ; pulsation at the brachial artery. 

Treatment. — Stimulating pediluvium of capsicum and mustard, 110° Fahrenheit; sinapism to the abdomen; frictions of camphorated mercurial ointment to the extremities and along the spine, to be repeated ; ice ad libitum ; ice suppository, to be repeated. 

30^, BA. M. — Reacting ; skin warm, and less livid ; tongue red ; pulse at the wrist distinct, but feeble ; breathing relieved ; has not vomited or purged since midnight. Pediluvium repeated, and sinapisms to the lower extremities. 

BP. M. — Reaction established ; pulse full and labouring ; has passed urine. Bled sixteen ounces — blood of a dark colour, and flowed freely ; allowed rice-water. 

October Ist, 8 A. M.<— Reported to have had a comfortable night ; had two copious bilious evacuations from his bowels ; skin warm and moist ; symptoms rather more favourable than yesterday. Bled ten ounces. 

2<J, 8 A. M, — Convalescent ; and discharged on the sth, cured, 



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TABULAR VIEW OF CASES, HOSPITAL. Males, . . . 237 'j Of this number 15 were dead when Females, . . 169 ! admitted, and 19 died of other diseases. Total number, 406 J 34 15 died in 1 hour after their admission. 14 " 2 " " 8"3 " " 8«4 " " 6"5 " " 7 " 6 " '' 4«7 " " 11 " 8 " " <y a t) v 3 " 10 " " 5 " 11 " " 10 " 12 " « Total, 98 — who died within twelve hours after admission, but few of which were considered medicable cases, and nearly all of which had been subjected to other treatment previous. 14, Nurses were attacked. 13 " recovered. 1 " died. Total number of deaths, 206 From which substract, dead when admitted, 15 Died of other diseases, 19 Died within 12 hours, and not medicable cases, 98 132 Deaths, ....... 74 Total cured, 200 PRIVATE PRACTICE. Total number of cases 114 Died • . 11 Cured 103 

THE END.