CHOLERA: ITS PATHOLOLOGY, DIAGNOSIS AND TREATMENT. 

WILLIAM §TORY, 



LICENTIATE OF THE KING AND QUEEN'S COLLEGE OF PHYSICIANS, IRELAND; FELLOW OF THE ROYAL COLLEGE OF SURGEONS, ENGLAND; 

FELLOW OF THE ANTHROPOLOGIGAL SOCIETY OF LONDON; MEMBER OF THE NEW SYDENHAM SOCIETY, LONDON. 

LONDON: E. & F. N. SPON, 16, BUCKLERSBURY. 

1865, 



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PRELIMINARY OBSERVATIONS. 

When the Cholera in 1832 caused so much alarm and made such fearful havoc in this country, I was a student at the London Hospital, and almost commenced my professional career when this direful pestilence was at its height. It was the talk of the whole country, and certainly the bete noire of the profession. The medical Staff of this and every other hospital in London were undecided as to its nature, and the Medical Societies could do little more than listen to descriptions of its destructive effects. During this period of uncertainty, I was daily witnessing cases in the Whitechapel and Mile End Unions. The Medical Staff at that time,* embodied names still held in venerable esteem, and their monitions were listened to with all the warmth and ardour of confiding neophytes. In conjunction with the above 

* Dr. Billing, Dr. Frampton, Dr. Gordon, Dr. Thomas Davies, Sir W. Blizard, Mr. John Scott, Mr. Andrews, Mr. Luke, Dr. Cobb, Dr. Pereira, Mr. John Adamg, were amongst the number. 



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advice and witnessed the treatment of my brothe Mr. John Story, then Medical Officer of the Mi End Union, here it was I observed some of th most fatal cases, and transfusion into the veins wa resorted to as a last resource. The sudden and almos miraculous revival by this means produced an im pression on my youthful mind which has lastec through life, and although every case in which it was tried to ended fatally, still the idea that it was the remedy when all others failed has never been effaced. At this distance of time (thirty years) to recall all the remedies suggested, and the doses of some actually given, almost deprives one of breath — Drachms and even Ounces of Calomel were reported to have been administered in Bethnal Green, where a talented senior fellow-student was engaged throughout that critical and trying period. Terchloride of Gold and other such kindred agents were exhibited and at length distrusted ; every remedy and every theory discussed served only to lead to its overthrow, and as is usual, a total apathy and disbelief in anything became general, until at last cold water was pronounced to be the ne plus ultra therapeutic 



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agency. My next encounter with Cholera was during my residence in Jessore, in the East Indies, in the years 1838-40, where the disease is said to have originated, and with all the severity its native habitat could lend to it. And here I felt the full force of the )eneficial effects of the treatment hereafter given, it )eing based upon the practice of the native Hakeems, and here its non-contagious nature was fully confirmed in my mind, this being the belief of the natives themselves. On my return to England, I settled down at the East End of London, when in 1848 this hydra-headed monster again appeared, and finding us wofully unprepared in sanitary armour, lis attack was most deadly. I have the satisfaction of knowing, that the treatment then relied on was )ased upon experience and was highly successful, a act which may be proved by the Roman Catholic Clergymen with whom I came into daily contact vhile performing their sacred ministrations. 

The pestilence left the land. It also left in th minds of many, thoughts of the utter fallibility o man's vaunted knowledge, in endeavouring to cope with a fatal agency of whose origin or cause he hac not the slightest suspicion. Out of evil comes good 



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T? A' V\" »1 4 1 ' A ' t-' i' 1 -* felt the truth of the maxim, that " cleanliness is next to godliness ;" and, henceforward, Sanitary Reform became the ruling idea. Those who have laboured in this work, and are still carrying it on, have done and are doing more to benefit mankind, and deprive this bugbear of its terrors, than all the subtle refinements the most hypermetaphysical mind can suggest. To the valuable directions of the Board of Health the public should rely with confiding faith. Should another epidemic again ravage the country, which appears only too. probable, the one great maxim from Land's End to John O 'Groat's should be — Sanitary Purity ; and thus, whatever may be the specific nature of this grim monster, he will be harmless to all such as rigidly obey the laws of health, and are cleanly and godly. 

So much for my experience of the disease. The following pages have been penned, not with any desire of self-aggrandisement, nor to prove that my treatment is superior to other methods, but solely to bring the questions of theory and practice prominently into notice, nov^ that the disease is again upon us. The absolute uncertainty of everything yet 



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written, or rather want of unanimity of opinion, is one reason for expressing a hope, that a Cholera Congress might be called into being. Let such a body arise at once ; let the most practical and scientific from all countries join in such a project ; let the discussions be full and free ; let each opinion be weighed in the balance ; let the tares be sifted out and the wheat gathered into the garner : by this means much good may be done, — nothing like courting opinions for arriving at the truth : nothing like honesty of purpose for arriving at sound convictions. If remedies are useless, and sanitary measures all powerful, let it be acknowledged. If one plan of treatment be superior to another, let it be generously granted. If a useful combination be the plan, let it be avowed. Opinions from such a body will carry conviction throughout the land, and science will test the verdict. I believe I have fully acknowledged the opinions of others, herein quoted, as nothing could be further from my intention than to appro>riate ideas not my own. Should any such omission have occurred, I will willingly record it when made known to me. It was my intention to have added 



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a list of authors, amounting to some hundreds, and to have quoted the opinions of the most remarkable, but this would have extended the work far beyond its original limits. 



CHOLERA: ITS PATHOLOGY, DIAGNOSIS, AND TREATMENT. 



Writers of the greatest ability have fixed thei attention upon this mysterious destroyer. Where so much has been said, one would think there was little left to say; yet our knowledge of the treatment o cholera is precisely in that state which involves the greatest contradictions. 

Minutely scientific as is the age, here science appears to be baffled, and while accounts reach us of thousands being swept away by one epidemic, he must indeed be a bold man who would assert his treatment superior to all other methods ; and yet such are not unfrequently encountered. Let anyone read, as I have done, the voluminous mass of writings on this " much-vexed question," and he will be forcibly struck with the distressing discrepancy that exists in the opinions of the different writers, and more especially of those most entitled to give an opinion. Flat contradictions as to 



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methods of medicine, 0.110 nil possible and impossible conjectures on the theory of its origin reveal themselves in benumbing bewilderment ; and as each author is elevated to the shelf, the inquirer becomes confirmingly convinced that nothing is known but confusion, contradiction, and chaos itself. Ido not find the ideas contained in the following pages carried out anywhere, not that I profess them to be altogether new ; my object being to bring together as much evidence as possible from numerous authors in order to substantiate the stand-point I take, and, if possible, to advance a little nearer to the origin of this alarming malady, and arrive at such a course of treatment as shall harmonise with the theory of the disease. The majority of English authors confess heir inability to account for its origin ; and, it is said, one of the most distinguished ornaments of his professio — a man who, by his eminent attainments, has not unworthily gained immortality, makes the bold and startling assertion — " This disease begins in leath." Such is the emphatic language of Majendie —its destructive nature, and the ignorance of the profession as to its treatment, on its re-appearance in liis country in 1831-2, gives force to the remark. 



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An eminent lecturer, denies that cholera is an old disease. He gives no other reason than that he and all his metHcal friends had never treated it before, and states that it began its career in India in 1818, and that its advent was foretold. Were the plague to come amongst us now, would not the same remark apply ? How many members of the profession have seen or treated it ? Yet, two hundred years back it was common enough, and, according to Dr. William Farr, so was cholera. From his very able and accurate reports seven died in 1859, while in 1660 to 1679 one hundred and thirty died annually from this frightful scourge: and Dr. Billing says, "that t is not a new disease, but the same described by Sydenham in 1669, and subsequently by Morton and Frank — the same which occurs in Madras, sengal, Italy, Russia and England, and elsewhere. "f The propagation of the disease is another battleground for authors — contagionists and non-contagionists. Dr. Watson appears to favour the former, and draws a comparison between the itch, cholera, and influenza. "If the itch insect could fly," says Dr. Watson, "it would then represent what is con- 

* Dr. Watson. f " P™. of Med." p. ?A9. 



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ceivable enough of the exciting cause of cholera," and Dr. Holland,! also leans to contagion and t affinity between cholera and influenza, althoug copious mucus secretions and irritating cough, wit shiverings, diagnose the latter. Abundant serou evacuations, total absence of cough and shiverings with suppression of tears, secretions of mouth am nose, characterise the former. Then, influenza ha been known and carefully described from the time o Hippocrates, whereas Dr. Holland says cholera is new disease ; and in carrying out his theory of msec life, he first of all clears the field by dismissing, a " improbable and impossible" all previous existing views of cholera, and proceeds most skilfully to sup port his own, which is,| " that a form of animal life minute beyond the reach of all sense, and not cog nizable by any direct means of research, is the viru which produces cholera." — " It is against all analogy to suppose this power (reproduction) to belong to inorganic matter. "| Inorganic matter, however, may produce disease and death, as in the case of the in 

* Lect. p. 490. 

f Medical Notes and Reflections, chap. xiv. 



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sensible and impalpable dust from arsenical papers the same disease, influenza, occurred to severa members^of the same family and at different periods This had only to be extended on a grand scale, anc then would insect life, or inorganic matter, have been the true theory, supposing the real cause had never been discovered. Indeed, poisoning by arsenic has often been mistaken for cholera, the resemblance is so striking. 

Phe following interesting case, communicated by friend, the Rev. Dr. Egan, as showing the extreme caution necessary on the part of medical men not trusting to appearances only, is valuable. Since it occurred, this very able physician has left the ranks of the profession for a higher and nobler pursuit, his loss as a practitioner and valuable contributor to medical science will be felt by all who had the good fortune to know him.* 

Case or Malignant Scarlet Fever simulating Asiatic Cholera* — Read at the Surgical Society in Dublin. 

" About ten o'clock on the night of Monday, the 25th of September, I was hastily 'summoned to visit W. H — , a boy, sixteen years of age, residing at the north side of the city, who was 

* Dublin Medical Press,' January 17, 1849. 



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represented by the messenger to be labouring under a bad form of cholera, with symptoms demanding prompt attention. Upon arriving at the house, his mother informed me that about an hour after breakfast on the morning of that day he complained for the first time of feeling unwell, and expressed a desire to go to bed. In about half an hour after lying down he was attacked with violent purging and vomiting, which was repeated during the day at intervals varying from fifteen to thirty minutes, and which continued with little intermission till the period of my ¦ visit. I was likewise informed that he had attended church the previous Sunday and also the Sunday school, and that he had been always healthy, with the exception of being subject from infancy to slight bilious attacks which were occasionally attendee by slight purgations. On examination I found the boy lying on his back with his legs slightly drawn up and in a semi-comatos condition. On being aroused and asked if he felt any pain o uneasiness in any particular part, he replied not, but upon being farther interrogated, he stated he felt a lightness in his head an< pain in the lower part of the abdomen. On passing my hanc over the chest and abdomen, I was particularly struck with a harsh, dry, and burning sensation imparted, and on making pressure over the abdominal cavity, I found it produced a degree of tenderness evinced by the wincing of the patient. On further and more minute examination, my attention was arrested by an unnatural continuous efflorescence of the cuticular surface, more vivid on the body, and shading off as it approached the extremities. The idea of scarlatina was at once suggested to my mind. Examination was next directed to the throat which I perceived considerably swollen on either side externally, although no complaint was made by the patient of any inconvenience attendant upon, or difficulty in deglutition. On opening the mouth and looking into the throat, I found to my astonishment, the tonsils considerably swollen and enlarged, the lower part covered by a thin coating of mucous, while in the upper, well-defined ulcers smeared over with an ashy coloured slough, were perceptible. 



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The pulse at this time was 120, but not very compressible tongue slightly coated, but presenting no characteristic appear ance ; eyes much injected, pupils contracted ; extremities warm While making these observations, the patient was sudden! attacked with convulsions, the left side of the body being mor powerfully acted on than the right. The paroxysm lasted abou two minutes. This I was informed was the fourth or fifth re currence of this symptom since morning, and was mistaken b; the parents for the cramps usually attendant upon Asiati Cholera. The treatment which I adopted consisted in the appli cation of the solid nitrate of silver to the tonsils, with leeches to the exterior of the fauces, to be followed up by the use of a warm poultice to extend from ear to ear. The hair was cut closely, and cold applications were directed to the head. With a view to arrest the vomiting and purging which appeared to b running down and exhausting the strength of the patient, prescribed two grains of acetate of lead and a quarter of a grain of opium in pill, to be repeated every hour till the urgency o those symptoms abated. Sinapisms likewise applied to th abdomen, which, although it produced considerable redness o the skin, seemed to give very little uneasiness to the patient On my visit at ten o'clock the next morning, I was informe< that the vomiting and purging had nearly entirely ceased afte the third repetition of the pills, which were now directed to b discontinued, but insensibility had increased ; he evinced, how ever, some symptoms of consciousness during the night by struggling to get out of bed in order to pass water. Hi breathing was stertorous, and from the firm manner in which hi teeth were clenched all my attempts to open his mouth were fruitless. He was convulsed twice in the course of the night and he had a slight paroxysm previous to my entering the room the action of which had not altogether ceased on the left side o the face. The redness which pervaded the skin had almost receded, and it is now assuming its natural complexion. As the power of swallowing still remained, although from the symptoms 



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detailed it was evident that for the prospect of recovery there was scarcely a shadow of hope, I ordered a saturated solution of carbonate of ammonia in camphor mixture with lemon juice, two tablespoonsful to be given every hour. I left my patient stating to his parents my conviction that it was more than pro bable he would not survive beyond the latter end of the day On repeating my visit at 8 p.m., my worst apprehensions wer realized, and was informed he had breathed his last about a hour previously. In commenting on the above, Dr. Egan proceed to remark, " the foregoing case presents some interesting, if no novel features, and would appear to come under that class described by Dr. Graves as resulting from an "intense poison of the system by the animal miasma of the scarlet fever." Dr. Egan then recapitulates the points of interest, and in the discussion which followed, Dr. Kennedy confirmed Dr. Egan's remarks, and referred to cases which bore a striking analogy to cholera. 

And why not an insensible mineral cause, as well as a non-cognizable animal one ? Spectrum analysis* renders it quite as probable that minerals sent by the sun's atmosphere, and of which we have at iresent no knowledge, beyond unknown dark lines n the spectrum, should produce this disease under all known varieties of atmosphere, as well as " noncognizable animal life ; and as Dr. Holland states that " any new opinion or line of research, has almost the force of argument in the annulling of all common theories," the above remark is justified. 

* Bunsen and»Kirchoff. 



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My experience leads me to side with the non-contagionists on this point. Dr. Ralph Moore, who has been connected with India for the last forty years, has communicated to me the following remarkable instance : — On one occasion several of the European women in Calcutta were attacked with Asiatic Cholera, while the European men escaped. He mentioned this circumstance to several eminent men in the profession without getting any solution for this curious preference. I suggested the probability, that by one of those singular coincidences which occasionally happens the greater number of these females were at the menstrual period, the crasis of the blood being destroyed, with less of vital heat generated, rendering them the peculiar recipients of this malady, from the fact that no cases were observed under the age of puberty this opinion seems the more 

I now proceed to a description of cholera as given >y most authors. A person in health feels chilly and sick, next alarming debilit)' with hurried and anxious breathing,* the face becomes deadly pale, 

E* The circumstances which tend to reduce temperature in olera are — absence of food, inactivity, loss of serum, inspira- 

B 



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eyes sunken and surrounded by a livid circle, the voice and the skin shrivelled and corpse-like, the pulse almost imperceptible, and, I may add, the pupils small, the countenance one of anxiety and fright, the voice peculiar and squeaking, the tongue feels cold as the touch of a reptile, the breath has an icy chill, vomiting and purging follow, but not invariably, the nails turn blue, the fingers and toes become dry and withered, decomposing force has completed th destruction of the blood, a total absence of vita heat follows, commonly called death. I think in the above no one can fail to observe the sudden am blighting effects of cold : " With this coldness and blueness there was a manifest shrinking and diminution of the bulk of the body."* The direct effect o cold is diminished vital activity. How the firs degree of cooling in the blood occurs in the lungs whether by an arrest of the chemical and mechanical combination which takes place on the change from venous to arterial blood — from the supposed spores or germs of epidemic diseases in the air — from the 

tion being shortened, and expiration lenthened ; this lessens the Eity of oxygen necessary for arterialization, evaporation from ngs is increased, and with it reduction of temperature. 

* Dr. Watson, p. 486, Lect. 



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generation of some unknown subtle poison in the body itself, as from the gradual individual death of the elementary corpuscles by electro-magnetism in :he body,* especially the pulmonary elementary organisms, or from any diminution or excess of unknown metals in our atmosphere to be ascertained )y spectrum analysis, remains for future physiologists to determine. But that cold is the destroying agent in cholera few can doubt. This is sufficiently attested by the reduction in the temperature and sudden diminution in the volume of the body.f As the temperature of the blood continues to fall, so does he contraction of the living, tissues follow — " the cutaneous tissue becomes shrivelled, the muscular issue becomes spasmodically contracted, the blood vessels in common with all other living parts suffer contraction, the quantity of blood in them is lessened and its motion retarded, the secretions and exhalations are stopped, partly as a consequence of the effect on the circulation of that portion of the body, >artly by the contractions of the secreting and 

* Brticke. 

Xl man of fourteen stone was reduced to less than ten after tack of cholera. I have known three gallons of fluid ns to pass in the first few hours of a choleraic attack. 

B 2 



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exhaling organs. Should the temperature still fail, torpefaction ensues, to be followed by death."* It is a law that heat expands all bodies, and the human form retains its natural bulk and proportions by heat, and heat alone ; the blood in its normal condition is at 98 deg. of farh., and the evidence that this temperature is reduced seems conclusive. 

Dr.Ryanf states that in cholera the blood is 88 deg. farh., and in the third report of Drs. Russell and Barry, to the Board of Health, in describing the first stage of cholera as it occurred in Russia, they say, " If blood be obtained in this state it is black, flows by drops, is thick, and feels cold to the finger." In experiments with the thermometer, I found the blood in health register 98 to 100 deg. farh. If the urine be passed on the bulb of a thermometer it will register 98 deg. After full meals, or active exercise, 100 deg. ; solid stools mark 94 or 96 deg. j fluid stools, 98 deg. farh. ; therefore, the blood and urine run pari passu ; in cholera the urine is suppressed, but the heat of the fluid ejections can be easily ascertained, and in this way the blood. The breath 

* Pereira. 

f The only author as far as I can learn who has made this 



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meter registers 90 to 92 deg. farh. in health, and i you raise the mercury to 100 deg. or 150 deg. b putting it to the fire, you cannot keep it at that heigh by the breath, it will fall to 90 deg., and here i can be maintained by breathing upon it. Now, in a confirmed case of Asiatic Cholera, both the blood and the breath have lost so many degrees of heat, according to the severity of the attack ; if only two or three degrees the patient may recover, but if the blood descends to eight or ten degrees below its normal standard, death is certain ; and I do not believe that any cholera patient has ever been cured where the blood-heat was below 90 deg. farh., except perhaps by transfusion. In all the boasted cures of cholera, by this or that plan of treatment, I do not believe the blood was ever below its healthy standard, or very slightly so — at least I do not find in any of the authors through which I have gone that the heat of the blood has been at all considered, excepting those mentioned ; and, until I have better proof that the hydrargyrists and salinists have cured a patient whose blood-heat had descended to 90 or 

88 deg. farh., I shall remain a disbeliever in the 

? 



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efficacy of such treatment as remedies to be relied on for the cure of cholera. The stand-point I take is the following — i.e., that cholera commences in the lungs, and that the loss of the natural heat of the breath of life, most probably by the generation of a gas, capable of destroying, neutralising, or absorbing the rays of heat transmitted with the air we breathe, and thus leaving the lungs unable to resist the dynamic effects of cold, is the only hypothesis that can be given, in the absence of any known principle which has been established by evidence. While these sheets were passing through the press, the following case was reported, which I extract from a daily paper : — 

Death from English Cholera — " On Thurday evening Mr. Humphreys, coroner, held an enquiry at the Acorn, Cambridge street, Hackney Road, respecting the death of Rosanna Sheppard, aged 7. It appeared from the evidence that the parents resided in Edith street, and the father was a whip thong maker. The deceased seemed to enjoy good health until Tuesday last, when she was seized with violent vomiting and purging in the middle of the night. The mother got up and assisted her> but deceased expired suddenly on the following morning. She had not been eating any fruit, and the mother could not account for the sudden illness. Mr. John Geely Fahnel, of the Hackney Road, said that when he was called deceased was dead. The body was pale and rather emaciated. He had since made a post 



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disease of the lungs, accelerated by a violent attack of English cholera. The jury returned a verdict accordingly." 

E.e can scarcely believe the air that a kind Proce gives us to breathe and enjoy is the lethal o o r ht for our extinction, unless this be one of nature's laws for the repression of our race ; rather do I believe, the elements of destruction to arise within the body itself, from vitiating causes almost inseparable from man's nature— that body so complex in its machinery— so wonderful in its chemical combinations — so incomprehensible as to its Genesis and end ! Is the blood vitalised and its heat generated in the lungs or not ? "In every circuit which the blood makes, when it reaches the pulmonary arteries it is loaded with the products of the decay of the body, when in these arteries this decayed material is converted into gas and expired out o the system as impure air. When in the pulmonar veins the blood is further revived by the inspiration of atmospheric air, and here the heat is evolved ; in this state it is carried on to the heart, and thus purified, well maintains circulation and the heat of the body.* 





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In that excellent little work by Mr. Hunt, o the skin, the following passage occurs :¦ — " Ther are certain organs which have a close sympath with the skin, the functions of which ought t be carefully watched j these are the lungs, th bowels, and the kidneys, which, together with th skin, form a fourfold way of escape for the effete materials which have to be separated from the bloo( during the process of assimilation and nutrition. 1 any of these effete elements remain in the blooc from the complete failure of any of the above-name( mportant organs, the blood is poisoned, and the >atient dies — instantly if the lungs fail, in a few lours if the kidneys fail, in a few days if the Dowels fail, in a few hours, days, or weeks if the skin fails. But when the failure is not complete then, by a beautiful provision of nature, one or more of these organs will to some extent perform he functions of another, for a sufficient time, at east, to allow of the maimed organs to recover." 

In a state of health nutrition and absorption, endosmotic phenomena, balance each other ; abstract vital heat either slowly or rapidly, and the parity is destroyed, absorption preponderates, the 



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body shrinks as in cholera, and the dead fluid is thrown off in rice-water ejections ; heat keeps the blood fluid, cold congeals it — cold in its dynamical sense, by changes in the condition of its vital properties. Abstract the blood from the body by venesection, so as to destroy vital heat faster than it is formed, and symptoms resembling cholera will be produced — faintness, sunken eyes, and cold sweat standing on the pallid skin,* caused by relaxation of extreme capillaries, as well by alteration of specific gravity of liquor sanguinis, and consequent metamorphosis of corpuscles, from loss of calidity — this non-conversion of liquid sweat in cholera into insensible perspiration may be produced by external atmospheric temperature above blood heat, as well as by internal diminution of heat force, producing atony of capillaries. Compare the similarity 

* This sweat I consider one of Nature's curative laws. The conversion of a fluid into a vapour is attended with the absorption of heat, and in this way nature endeavours to conserve the heat o the body, as the superficial vessels contract perspiration diminishes According to Dr. Well's theory of Dew (as shown by Tyndall in lis Lectures), moisture prevents formation of ice or cold, the fluic absorbs heat from the atmosphere, and thus radiation of heat from the body is checked, and absorption from surrounding air takes place 



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of death from severe hemorrhage, although gradua — pallor, clammy sweats, irregular pulse ; and a vital heat is withdrawn, nausea, vomiting, restless ness, irregular sighing and respiration, with convul sions. Ague, produced by constantly inhaling a cold moist atmosphere, and a low vitality ensuing symptoms of cholera are recognisable. The fac becomes pale, the features shrink, the bulk of th whole body is diminished, the skin is shrivelled, the pulse small and irregular, breathing short am anxious, with blueness of the fingers and toes Lastly, eating cold ices, or drinking cold wate while the body is heated, has been said to indue cholera and death ; if so, no doubt by the sudde necremia. But in whatever way a low vitalit is produced preceding cholera, whether by drough and famine, with great heat, as in the epidemic a Delhi in 1861,* or by cold and moisture, with poo diet, great fatigue, watching, grief, fear, anxiety, o by atmospheric insect poison, miasmata, or othe influence, the first impression is undoubtedly a cessa tion or reduction of vital heat in the lungs. 

* See Keport of Dr. D. B. Smith, to Secretary of Government, 



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In the early supervention of the symptoms o collapse, Dr. Watson says,* "At first the patien would have so copious a stool, a consistent dejectio it might be, but so large in quantity as to lead him to conclude that the whole contents of the intestine had been evacuated at once." Here, then, is th first effect on the system of the first blow to it i the lungs, and if the cause continue without inter mission, collapse follows, and the cessation to fabri cate, or abstraction of life-heat, is the only apparen proximate cause, and commences in the imperfec vitalization of the blood in the lungs. Dr. Wm VTeadef makes the following remark, although no applied by him to cholera, — "The process of diges ion is completed in the lungs — first, by the chyle )eing animalised by nitrogen j second, vitalised b; oxygen — thus rendering fit for nutrition this newl] brmed blood." Thus, it may be only a question o degree, how far the interruption of this process )roduces cholera or any other disease. The first effect defecation, nut always, and as the lungs con inue to supply less of vital heat, so is the blooc 

* Page 485, Lect. H* Mcude's Alnnuul 



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drained of its fluid parts, exosmose of the serum, and the rice-water evacuations follow ; then the action of all the organs of vegetative life is sus- Eled, and intense congestion ensues. Without mmation, it is congestion from cessation of vital 

stimulus by the blood, and consequent arrest of function ; the whole arterial system is empty, as proved by post-mortem examination. "If a person were to die in the first twenty-four hours, no visceral morbid change would be found."* This cessation of the manufacture of blood-heat in the lungs, arrests or modifies the peculiar routine of every organ in the body, except the brain, the heart, and muscular contractility. "Another most singular phenomenon was remarked in the dead body, a quarter or half an hour, or even longer, after the breathing had ceased, and all other signs of animation had departed, slight tremulous, spasmodic twitchings and quiverings, and vermicular motions would take place, and even distinct movements of the limbs, in consequence of these spasms."f " I have heard the sounds of the valves of the heart, just before death in cholera, when I am satisfied clots 

* Dr. Billing, " Prin. of Mcd." p. 247. 

I" Watson, p. 487. 



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were forming in the ventricles."* This vital or muscular contractility only proves that death begins in the lungs, and bears out the theory above propropounded. 

I have seen the heart of a shark contract forcibly for hours after it had been cut out of the body when it could receive neither blood nor nerve force consequently, this contractility must be a somethin per se. That some resist the stage of collapse bette than others, is owing to a greater vital contractility or a tenacity of retaining latent heat j and thi adherence of life is strongly exemplified in contras between the hare, kangaroo, &c, which are easily killed by fright; and the cat and jackall, whic resist poisons, cutting, shooting, and disease, wit marvellous astonishment. Instances are on recon of men being shot through the heart, having attempted to draw their swords, although instan taneous death resulted. The idea of a blow demand ing self-protection. A bird shot through the brain towers for some time perpendicularly upwards, and then falls lifeless. In these instances, the heatforming process is the last to desert the body ; its 

* Billing. 



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heat remains for hours after death. In cholera, where death commences in the lungs, the body is cold for hours before the vital spark quits its tene ment, and in every form of death the human bod retains its heat for a considerable time after life i extinct, except cholera, and death from the effect of intense cold and frost. As an instance of th power of enduring cold, while the vitality of the blood is actively kept up by adipose foods, &c, Si Leopold M'Clintock, in his narrative of his Arctic voyage, relates that Esquimaux mothers bared their breasts, and exposed their infants naked, when the thermometer stood at sixty below zero. As a rule, it is generally the ill-clad and ill-fed who suffer most from cholera — bodies in whom the blood is at a lower standard of heat than natural, or minus magnetic force. It will be said that cholera attacks the rich as well as the poor, granted ; for every rich man in perfect or ordinary health, with normal magnetic force, who succumbs, ninety-nine poor and illclad die — extremes meet ; gout attacks the poor as well as the rich, only in the inverse ratio, but the well-fed and well-developed middle classes escape in a greater proportion, where there is a good supply 



31 

of adipose tissue, and the heat-forming process in perfect order, the " mens sana in corpore sano," without the slightest taint of fear, cholera may be safelydefied, it avoids such subjects for its icy attack , dense populations seem to be favourable to cholera Mtations, and the northern more than the southern lisphere. 

Rt the Cape of Good Hope, Australia,* New and, Tasmania, and great part of South ;rica, cholera is unheard of; only at the Mauritius has it been formidable, and there no from the importation of Coolie labour, as was attempted to be proved, but solely from the filthy habits of the place, and entire absence of sanitary regulations, as shown by Dr. Ralph Moore in the columns of the Calcutta Englishman. Why this immunity in the south half of the globe ? Is it in the peculiarity of its fauna and flora, which latter consists chiefly of the Eucalyptus, Mimosa, &c, at least in Australia, Tasmania, and New Zealand, or in its geological formation? That the character o 

* It is also remarkable that hydrophobia is unknown in Australia, where the heat often registers 160 deg. Farh. in the sun, and where the dingo runs wild. 



32 

the locality influences health is undoubted, for as Professor Tyndall has shown by the deflexions obtained by cubes of bark, and rock crystal — the former is 12 deg., the latter 90 deg. j indeed he says, (Lect. 7), " Two bodies so diverse, where they cover any considerable portion of the earth's surface, must affect the climate differently. There are the strongest experimental grounds for believing that rock crystal possesses a higher conductive power than some of the metals ;" he also shows that nature has done her best to guard our bodies against sudden changes of temperature, such changes being more prejudicial to animal and vegetable health than almost any other cause; " while rock crystal produces a deflexion of 90 deg., all the animal and vegetable substances operated on by him gave 0 deg., showing the extreme imperviousness of every one of them (Lect. 7), " therefore the materials chosen by nature are precisely those which are best calculated to avert such changes." I am inclined to regard telluric influence having as much to do with these epidemics as the more generally received notion atmospheric. The northern hemisphere, so far as our 



33 

peopled, for ages, from a time beyond the historic, back, far back into geological periods of catalysis,* and that the Earth may become completely worked out, or so unhealthy to live in, from its deadly effects on animal life, as to make it a perpetual desolation is illustrated by the present condition of the Holy Land.f The deadly effects of telluric radiation in some parts of South America and Africa are well known. 

Anyone who has been to great depths under ground cannot have failed to observe, besides the re markable warmth felt, that peculiar odour which the earth has, a smell of decomposed mouldy vitality something between a coffin that has had a deac body in and mildewy mouldy earth, or "fresh decomposing potatoes and a fresh dead body," a smell peculiar and easy of recognition, but indescri)able; and since cholera has confined its attacks chiefly to the northern half of the globe, there must )e some reason for it. It is probable enough that some peculiar telluric principle or agent radiates 

* See Troyon's "Lacustrine Abodes of Man," and M. Worsaes " Northern Antiquities ; the Taurian, or Pre-historic People." 

f See Dr. Keith, Lord Lindsay, &c. 

c 



34 

from its depths, and produces not only this disease but others, where great masses of people are congregated together. Byron says, " The dust we tread on was once alive," and Mrs. Somerville calls telluric moisture the " life-blood of the earth."* I the nidus of certain diseases is in the air, then why should it be constantly in the air of one country am not of another ? Why should consumption always be in the air of Great Britain and not in that o Maderia. According to Dr. Graves, the deaths from consumption number 28,000, against sixteen other diseases numbering 26,000. In consumption the tendency is to form tissues of a lower organisation or animalisation, a lower degree of vitality ; and the proof that cold is the cause, or rather an inability to resist cold, is the fact ; that consumptive patient are sent to hot countries, and recover with heat In ague also, when the patient is removed from an infected to a dry and warm locality he usually recovers. The analogy between ague and cholera is so great, that one can scarcely resist the opinion that it is the chronic, and cholera the acute form of one and the same disease, or an inability to resist the dynamic 

* Physical Geography. 



35 

effects of cold in the lungs. Another reason, and I think a very strong one, for the origin of cholera in the lungs, is to be found in the highly scientific facts demonstrated by Professor Tyndall. " Oxygen hydrogen, nitrogen, and air, are elements or mixture of elements, and both as regards their radiation and absorption, their feebleness is declared j they swin in the ether with scarcely any loss of moving force Now, the air we breathe, in its purest state, is thu proved to be the most simple gas that can be taken into the lungs for the due performance of thei functions; radiant heat passes through the air w breathe at will, with perfect free play, without any resistance ; not so the other gases. See wha Tyndall says — " For every individual ray of hea struck down by air, oxygen, hydrogen, or nitrogen ammonia strikes down a brigade of 7*260 rays olifiant gas, a brigade of 7*950 ; while sulphuric acid gas destroys B*Boo, and carbonic oxide 17*500 rays of heat in the inch. Now, suppose any of the above gases generated even in the smallest quantity in the lungs, look at the enormous destruction oi rays of heat that must take place ; sulphurous acid, or carbonic oxide, neutralise B*Boo rays of heat in 

c 2 



36 

every inch of air. It is easy to see that the abstrac tion of smaller quantities of radiant heat from the air we breathe for any given time must gradually undermine the heat force, and thus this antagonis of cohesion is overcome. 

In the absorption or non-absorption of the sun's heat by the earth, and radiation or non-radiation of earth's heat may be found a cause of cholera. In South Africa, Australia, South America, where there is great heat with sand and rock, cholera is unknown and its absence in so many and such large portions of the southern hemisphere militates against cholera being portable, as ships are constantly going backwards and forwards from all parts of India to Por Phillip, and the Cape of Good Hope, without as ye carrying this specific principle to these localities Cholera is equally destructive in the hottest anc coldest countries of the earth, but in the latter, i generally arises in the hot months of the year, and if it remain for months, it must be from the absence of sanitary regulations, or else from a telluric influence, one cannot conceive the air to be in fault for so long a period, or it may be that the inhabitants, from constantly living on one kind of diet (as rice) may 



37 

be more susceptible to decomposing changes in th blood ; and thus, sulphuretted hydrogen retainec in excess in the body, or the slow generation of any other gas, may gradually undermine the integrity o the blood. Decomposing force overcomes heat force and this temperature (98 deg.) once reduced, sucl subjects remain the victims to ague or cholera.* In Jessore, in Bengal, the heat of the day is succeedec by very cold nights — i.c,, about February, the range of the thermometer is frequently from 40 to 50 deg The natives are nearly nude, a light piece of cotton cloth around the waist being their only clothing, the oxygen or ozone being lessened by absence of the sun's rays, and the air being exhausted of this purifying influence, contaminated by the continually decomposing matter of thousands of human beings as well as of animal and vegetable refuse, always the case in densely peopled districts of India. This 

* " Professor Tyndall shows that any such gas, generated in the lungs would offer an impediment to the transmission of radiant heat, (so necessary to life), that the interstitial spaces of such gases are incompetent to allow the etherial undulations free passage, showing that there is something in the constitution of the individual molecules which enables them to destroy the /• ft 1 Al*i fi /» irmrnL 1 " 



38 

deficiency of oxygen in its natural or allotropic state, may be, and most probably is, the first cause of a deficiency of vital heat in the arterialising process of the blood ; and if, as Dr. William Mead says, "digestion is finished in the lungs, then this process, being imperfect, more carbonised elements remain unchanged, and so carbonic acid is generated, difficult respiration succeeds, and the patient first begins to feel ill, and most probably goes out of his little thatched shed for more air, feeling hot and restless ; this is followed by chilliness, and towards daylight cholera symptoms or dysentery. This naked condi tion of the peasants and lower orders, with rice as their only food (they can afford nothing else on one anna, or two-pence a day), together with the con stant habit of smoking,* which practice is begun in 

* Who will deny that the enormous consumption of tobacco, caused by the habitual and now universal practice of smoking, often begun in boyhood, and continued during the change from it to full adolescence, is not the reason for the increasing prevalence of nervous diseases, ending in paralysis and insanity? This cause, smoking, together with the indiscriminate use of opium, especially the black drop, in infancy by nurses, I believe to be one of the best reasons, for the change of type of diseases from the sthenic of forty and thirty years ago, to the asthenic now prevailing. 



39 

almost infancy, and continued through life, no doubt engenders a feeble habit of body, and makes cholera so destructive in this climate. It is said, that o three men lying close together, the two outside one were seized with cholera, while the middle one escaped. If so, the extra warmth enabled the middle man to resist action of the cold; anc what more favourable instance for contagion ; am yet the middle man escaped ! That the inhabitant of one side of a river shall be attacked, and not thos on the opposite side, might arise from peculiarity of vegetation, or composition of the soil. It is we] known that certain plants will destroy miasm, a proved by Lieut. Maury at the Washington Observa tory, where, by sowing sun-flower seed, he destroyec the marsh vegetation, which annually, in the montl of August, brought its malarious fever.* 

Of all the causes advanced, negative as well a3 positive, accounting for cholera visitations, not one is satisfactory. I cannot see that the fungoid, or the animalcula, are to be regarded with greater favour than the changes in the condition of the elements of the blood, by the theory of Tyndall poisonous gas or 

* See Courier dcs Etats Univer., No. 20, 1859* 



40 

of Briiecke electro magnetism. That the M nervous system is in some way primarily affected " is altogether too vague. Schultz declares that many of the effects now regarded primary or direct, are in reality secondary or indirect. " Narcotics paralyze the blood corpuscles, and through these the nervous system." According to this, cholera is a paralysis of the blood. Whatever nervous power may be, we know not ; and here I quote the following scientific opinions : — " Nervous force is the resultant of an acid and a mineral, as galvanism is ; the brain is the organ or vehicle containing iron, sulphur, phosphorous, &c. ; the subtle commingling of these indefinite proportions causes incessant discharges or explosions, thus mental emotions originate, to be controlled, altered, or acted upon by external physical agents ; and this mode, though conceivable by our senses, but not capable of mathematical proof, s no doubt the mechanical manner in which sensations arise, in decomposing water by a continuous current of galvanism, the water ultimately disapiears, and its components separated. There is a change of form by an inappreciable physical agent, nobody sees the electricity, nor can they feel it, 



41 

simply because its ultimate molecules are so inconceivably minute as to be beyond the reach of our senses."* 

Dr. Holland says of nerves of sensation and motion, "Yet are the functions themselves so utterly unlike to our comprehension, that we can in no way conceive the same physical agent, however modified, to be capable of fulfilling both."f The blood is the same in all, and its heat the same alike in the old man and in the infant — no matte what the climate or the race, the blood is the same. Compare nervous power or foree — take a thin intellectual and highly sensitive nervous temperament, and a dull, stolid, ignorant, anima brute ; the latter fellow will allow his toenail to be wrenched off without moving a muscle, as I once witnessed in a patient at the London Hospital, unde Mr. Luke, who asked the man if it did not hurt ? He coolly answered, "No." The prick of a pin will throw the former into convulsions, yet the blood is the same in both. Then we have the law of the Hebrews — " Of the blood thou shalt not partake for therein is life." In the capillaries inter- 

* Sir B. Brodie. f Page 601. 



42 

posed between the external branches of the pulmonary artery and the roots of the pulmonary veins, the conversion of venous into arterial bloo( takes place : during this conversion animal heat o heat-force is developed ; respiration is mechanics chemical, and vital, the function is to subject th venous blood mixed with the chyle, to the air in the lungs, and form arterial blood, on which lif depends. If, as Briiecke contends that each eletnen tary unit has a mechanism and motion peculiar to itself, here is the idea of Grove, Tindall Joule and Mayer, demonstrated— viz., that the vital fore differs in nothing from the mechanical nature o heat or motion — i.e., just as heat is produced on th melting of ice into water, or by the boring of a cannon,* or the falling of a body from a height to the surface of the earth, its motion is arrested, anc heat is developed, in all these instances by a change in the molecules of matter j the mighty force o; such molecular motion can be only faintly imaginec by the immense masses of rocks and mountains Cup by the united energies of the infusoria, 00,000 of which go to form a square inch of 





43 

therock. # " Thus, the compound molecules of elementary organisms which build up the forms of living beings are to be conceived of only as the equally wonderful changes produced in the physical world by light and motion," &c. Tyndall says, the sun separates the oxygen from its beloved carbon, and thus grass grows, upon which animals feed ; of course the grass has a matrix upon which to develop itself: so in the human body oxygen is separated from carbon, and blood corpuscles are formed." The amazing quantity of three hundred ounces of blood passes through the lungs of man in each minute ; at each inspiration watery vapour escapes with carbonic acid gas. In the proper adjustment of this function consists life. "The constituents of the blood from a diminished temperature (less than 98 deg.) fail to absorb the quantity of oxygen necessary to healthy metamorphosis ; this failure from cole causes a greater evolution of carbonic acid."f "As the temperature of the blood falls, more carbonic acic is evolved."! Here is a confirmation of the theory above stafed ; it simply remains to be found out 

f Mueller. 

* Ekrenbe.rg. 

\ Dr. E. Smith 



44 

what produces the first degree of cooling ? Nutrition could not go on unless the histological elements conveyed to the nervous system by the thoracic duct, and converted into arterial blood in the lungs was consummated. 

Any cause which stops healthy respiration mus equally arrest healthy nutrition, but the convers of this does not follow; the nutrition of one o more organs may be impaired or destroyed with out danger to life. Therefore, I hold the theor above given to be less objectionable than that nutri tion and absorption are first destroyed, throug some " unknown primary affection of the nervou system ;" then the brain remains unaffected to th [ast. Why should one part of the nervous system and not the other be impaired ? Why lesion of the nerves of vegetative life, and freedom from injury of the cerebro-spinal axis? We do not know what electricity is, and physiologists suppose tha nutrition is dependent on the electric current always )assing along the nerves j but whether this " uncnown primary affection of the nerves " consists in a smaller or greater quantity of electricity, we are not informed. Of the blood we have a better knowledge; 



45 

blood corpuscles possess a real organisation ; they have a beginning, a development, and an end. By any alteration in its quantity or quality we can be guided. Therefore, the opinion that the first blow to the system in cholera is in the alteration of vital heat, or heat-force of the blood, is to my mind clear. " For the blood travels with railroad speed, and like it generates force ; put out the fire, the water cools, and the train stops ; lessen the velocity of the blood corpuscles, caused by the friction of these against each other, and the force is impeded, the blood cools ; and thus the chemical and mechanical conditions for life, which demand a temperature of 98 degrees are destroyed."* In like manner we may say in cholera, a the chemical force which maintains life ceases; the vital force being unsupported, changes its direction, and becomes decomposing force. This continuing, the spring which maintained the balance, snaps, and the clock of life runs down — this spring is force and chemical action combining to produce a temperature of 98 degrees — anything which disturbs this vital union, impairs the integrity of this vital 





46 

I do not think it necessary to go into the different theories of Lavoisier, Davy, Majendie, Lagrange, or Magnus, all admit that the source of vital heat is in the capillaries, and inspired air in the lungs. The blood in the first circulation nourishes or carries life stimulus to every organ in the body and nervous system. If this life stimulus be impaired or destroyed, then the nutrition and proper function of every organ or part fails, but impair or destroy nervous influence and the blood remains healthy. Goltz concludes that circulation, change of arterial into venous blood, nflammation, all these processes occur in a limb in which every connection with the nervous centres las been completely severed. To prove still further that the nerves are inferior to the blood in point of vital derangement, Dr. O'Shaughnessy (now Sir O'Shaughnessy Brooke) states, insensibility may be produced by the gungah, or Indian hemp, during which the patient retains any position in which he may be placed, in fact, a cataleptic, yet the )lood remains the same, for he says : " there is no increased heat or frequency of circulation, nor any appearance of inflammation or congestion." 



47 

Then the celebrated experiment of cutting through the artery and vein of a limb and inserting a quill, through which the blood could pass and keep uj life, all surrounding parts being cut through, bu the nerves would not keep up its vitality if treatec in the same manner 1* "It is now generally admittec that the blood is the source from which the vita power of all the solid parts are derived, to acknow ledge anything else would be to disbelieve Hunter' great doctrine of the life of the blood." Briiecke contends that in the elementary organisms or units (ultimate particles of Schwann), the minute being which are the elements of the larger ones, does each vital action depend upon special organs, he instances a saliva corpuscle, in which so called molecular motion is seen, compress it slightly so as to flatten it, and the molecular motion will cease for ever — does not this prove that the organic mechanism which produced the motion has been destroyed? He contends that the elementary organisms, of which the whole superstructure (body) is built, may differ from each other as widely as one animal from another, and there is 

* Majendie. 



48 

every reason to believe their intimate structure to be of the most complicated kind.* 

Treatment. — It is too well known to need comment, that a uniform plan of treatment has not bee yet discovered, by which the profession can be guidec this being so, it is not astonishing to find a numbe of specifics pronounced infallible. If some of thes were carried out, I fear the profession would gain little credit ; and who will be bold enough to deny that many have not been hurried into eternity by treatment which has prevented nature from recover ing by her unaided efforts from the mysterious col lapse which so appals us ! To show the difficulty i no ordinary one, take twelve of the leading Britisl authorities for the last twenty-five years. What do we find ? Every one opposed to the other in theory and practice ; one asserting, and the other denying with all the ability of their vast talents, that each is wrong. Ido not mention names, the comparison might appear invidious ; but simply to show that, in the diversity of remedies and theories on which 

* Year book of New Sydenham Society. 



49 

such treatment was based, the lamentable fact tha in the absolute chaos of conflicting evidence, w must still confess ourselves innocent of the mean by which a patient is to be revivified from im pending death — that Asiatic Cholera has yet t find its terrors averted in the genesis of a second Jenner. 

The period that cholera selects for its invasion is generally after sunset, during the night, or early morning, when the magnetic force of the oxygen of the air is diminished, and when the absorbing powers of the cutaneous exhaling vessels are more active, as they always are during fasting.* Faraday states, that " oxygen is magnetic, and that it is effected by heat."f Now, any deficiency of oxygen in the lungs must lessen the magnetism the blood receives, and which probably is the origin of " Nerve Force." Nerve force and electricity are said to be identical; the blood corpuscles must be endowed 

* In Calcutta and other large Indian oities, after sunset, which is sudden, a dense mist rises from the earth above 3 or 10 'eet in height. The cold atmosphere above keeps it from rising. n this night pall, loaded with miasmatic abominations, many an European, from imprudence, finds his winding sheet. 

f See Med. Gazette, Nov. 29, 1850. 

D 



50 

with the magnetism of the oxygen of the air at eacl inspiration. Here is a constant source of electricity and the nerve elementary corpuscles undoubtedly appropriate it to themselves, abstracting every par tide of it from the blood in its course through the body ; nerve matter is the proper recipient and pro pagator of nerve force, or electricity ; the compo nents of the blood are held together by affinity o cohesion ; lessen this in any way, as by excess o deficiency of ozone, or as above shown, by poison ous gases, absorbing or neutralising radiant heat and the perfect blood is impaired, and some of it components suffer ; and in this manner, no doubt most diseases originate. In " one case the serum corpuscles are disunited and thrown out of the system, as in cholera ; in another case, fibrin is cas out, as in tumours ; in a third, albumen, as in dropsy ; in a fourth, hermatin, as in scurvy ;" in a fifth, the glands only are affected and suppurate, a in plague ; in a sixth, the cuticular texture shall be only affected, as icthyosis. About three or fou o'clock in the morning, when the system is at its greatest depression and the pulse at its lowest in the twenty-four hours, cholera generally attacks the 



51 

patient — at least this is my experience, and that of many medical friends in the East Indies — just that period of the day when it is rawest and coldest ; and this is also the case in a form of disease similar to cholera in hot climates — viz., that attack in which all the choleraic symptoms present themselves, except the rice-water stools, chiefly affecting sailors after a run on shore, and which usually ends in death. 

Let it be borne in mind that the vital action is at its lowest ebb when cholera attacks. And now or the vaunted remedies, " always remembering that in the present state of our knowledge the endosmotic action of powerful medicines, in modify ng or altering nutrition and absorption, does not nform us of the precise share which this action has n the production of effects."* It behoves us seriously to reflect before giving large doses of therapeutic agents, as narcotics, hydragogues, &c, how uch remedies indirectly physically alter the condiion of the blood corpuscles ; and young practitioners should diligently bear in mind the judicious advice of Dr. Billing, — " Before a decided step is 

* Pereira. 





52 

taken, the physician ought to have made up his mind, as to what is the nature of the disease." 

The principal remedies recommended, then, ar calomel, lead, opium, nitrate of silver, turpentine creasote, sumbul, chloric sether, chloroform, quinine strychnia, and phosphorous. Some have recom mended bleeding and tartar emetic. Sydenham reliec solely on chicken broth. Dr. Marshall Hall honestl admits that he would not venture to give an opinion as to treatment. Majendie's punch was admitted t be most successful ! Calomel, castor oil, and purga ;ives have been boldly pronounced to have arrestec ;he stage of collapse from supervening. Ido no Dretend to deny this ; but was it certain that col apse would have resulted ? I feel sure that I have seen cholera confirmed by purgatives being given a )ed time, so as to act at early dawn, and thus the two causes combined period of greatest depression lave hurried on the fatal collapse. Transfusion is a remedy which demands notice. Injecting human )lood into the veins has proved successful in uterine icemorrhage. Majendie bled an animal until respiraion was suspended, and all muscular action, volunary as well as involuntary, ceased, until no externa 



53 

signs of life were manifested — apparent death. H then injected a similar quantity of blood to tha taken away ; vitality was restored and the anima recovered; but Majendie proved, if the blood injectec was deprived of any of its constituents, then th animal would die. The remarkable effects produced by transfusion with saline fluids I shall never forget. My brother, Mr. John Story, performed this many times in 1832, without permanent success. Had a fluid of the sp. gr. of 1030 been used, as suggested by Drs. Taylor and Rees, insteac of Dr. Latta's of 1004, no doubt the result would have been more satisfactory.* Dr. Kennetl M'Kinnon says, " On public health and prevailing diseases of India." " Transfusion approaches more nearly to an immortal discovery than anything of late years." Inhaling oxygen gas as recommended by the late Sir Henry Marsh, of Dublin, and others since, is no doubt, a valuable therapeutic agent. Dr. Blacklock states, " stimulation by electricity is more required than oxygen." Faraday contends, " oxygen is made magnetic by heat, (< so that inhaling heated oxygen ought to be the right thing. Twenty cases 





54 

so treated are reported to have recovered in the Howrah Hospital. Dr. Thomas O'Brien gave the following mixture : — Rj. Spt, vini camph., creosote brandy, soda water. Oxygen ga& was generated by mixing chlorate of potash with one-sixth its weigh of black oxide of manganese, and throwing the mix ture on a heated iron shovel.* In fact, any one o all of the above remedies are valuable to a certain degree, but to assert that either of them is a cure for cholera is fallacious and to be deprecated. Cholera, like other diseases, has its stages and degrees, of severity, and from not observing these attentively, has no doubt arisen much of the discrepancy of opinion that exists — first, the suddenly fatal case in from four to twelve hours ; here heat force, the antagonist of cohesion, is overcome so thoroughly by decomposing force, that all treatment is unavailing. 

Case I. — Illustration of the first, or suddenly fatal form, in four hours. 

When I was in Bengal as private surgeon to the Jessore Indigo planters, I was called to a case of cholera by Mr., now 

* Ed. Dublin Hospital Gazette, Feb. 1, 1854. 



55 

Dr. R. Moore. His salutation was most emphatic, and ended by saying, " My Dhobee will be dead in four Lours if you don't do something directly." Of course I went, and found the man cole livid, and pulseless, and all but insensible ; neither vomiting no purging. The man was of good caste. After some doubts as t the offence likely to be given by my treatment, Mr. Moore con suited with the natives, and it was decided I was to do wha I pleased. Frictions of turpentine were at once commenced, anc blankets substituted for his calico covering, small doses of tinct opii and spt. ammonia were given. Half an hour, then thre quarters passed, and no apparent change. I now decided upon a turpentine enema, it acted, yet the man kept cold, pulseles and insensible. The frictions were continued, and heat pro moted by bottles of hot water. The medicine was administerec every fifteen minutes. At the end of three hours a gradua change was perceptible, this continued, and directly the man could swallow well, some hot brandy and water was given Reaction now set in rapidly, which was held in check by saline and five grain doses of calomel. The man made a good recovery with infusion of chiretta, and remained a valuable servant of Dr. Moore. But for the prompt action in this case, the patient must certainly have been dead in four hours, I was not equally successful in many similar attacks. This was a rare case of recovery. 

The next degree is from twenty-four to fortyeight hours. Here we have the vox cholerica — cold tongue, spasms, rice-water stools, and blood heat lowered ; this may be recovered from or end in death, according to the extent the cutaneous system is involved. 



56 

Case II. — Usual termination in from twenty-four to forty-eight hours. 

This happened in Bromley in 1848. J. C — , a journeyman carpenter. Called at 10 p.m. Found this man in the stage of collapse, 'and looked upon it as hopeless. The vomiting and purging had been incessant ; however, the turpentine frictions were commenced, and the mixture recommended under " Treatment," given every ten minutes. After staying with him two hours without any change, I left my assistant to continue the remedies, with heat to be constantly applied, and the turpentine to be rubbed along the spine, and acetic acid and water with syrup for a drink was given to satisfy the usual thirst-craving demand. Visited at 2 a.m. Not the slightest change. My assistant and myself were both tired out from hard work. "We left the wife and friends to continue the treatment. At 8 a.m. I was informed that the man was no worse ; saw him, and perceived an improvement in the feel of the skin, which was wrinkled and cold. The pupil which had been steadily small, began to vary. This I considered a good sign. The remedies were continued until 12 at noon when I again saw him, and found a slight warmth returning, the spasms not so violent, the sickness and ejections stopped. Five grains of calomel were now given and continued for four doses at intervals of four hours. Sensation returned to the skin, and broth could be taken. The friction along the spine was discontinued, having been conducted too severely by the relatives. An improvement in every way now took place, yet the patient was perfectly helpless and afraid to move for fear of producing cramps. Salines were continued, but the reaction was very gradual; the bladder acted, and I considered the man safe. On the third day of the attack lie was still a frightful looking object, and now commenced a sloughing of the whole skin of the back from the neck downwards, such 



57 

and ammonia, with good beef tea, this man ultimately recovered and always maintained in the neighbourhood that I had brough the dead to life. My assistant was highly delighted with this case, from the fact, that a physician, a friend of mine, had seen it, and told us we might rub till doomsday, the man would die. 

The next degree is the severe English cholera threatening to go into the second form, if no promptly relieved by appropriate treatment. In this form the sunken eyes and liquid stools, wit] perhaps cramps, lead many to believe it to be th true Asiatic Cholera. The same appearances ar frequently observed in infants from teething. Anc this is the cholera in which so many remedie have been found successful, the blood never having been below its normal standard. 

Case 111. is an illustration of the severe English Cholera. 

This occurred last summer in the person of a gentleman connected with the city and living in the suburbs. He had beeD actively engaged the whole of the previous day in a cricket match. The attack commenced at 4 a.m. I was sent for a little before 8 a.m. and found him with rapid and almost imperceptible pulse, vomiting and purging of rice water stools, sunken eyes, small pupils and violent cramps ; in fact, all the appearances of the worst form of cholera. I soon perceived that although the voice was altered, it was not the vox cholerica, and I discerned by feeling the skin over the body, the coldness was not general. The ejection that 



58 

took place after my arrival was tried, and registered 96 degrees farh. The above mixture, turpentine frictions, blankets and heat were persevered in for eight hours, during which time I never left him. Eeaction was noticed in two hours and a half, and steadily continued. The calomel and salines were given with final recovery. The convalescence was long. 

The above are given as types of the respective degrees of the severity of the disease, and selected from notes taken at the time. Of course, like every other man who has seen much of cholera, I have had many fatal cases of each class, but on the whole, my success has been such as not to induce me to alter my treatment until I can find a better. I can scarcely understand how it is some gentlemen positively declare they have never lost a case ou of hundreds treated by them, especially when their treatment ha been tried by other hands and uniformly failed. I can onl conceive that the severe English form of the disease, withou loss of blood heat, has been mistaken for the more severe on with the blood several degrees below the normal standard, anc which usually terminates in death, else how is it, as in Copenhagen 4,000, out of 8,000 die ! Surely, it is not. the fault of the medical men ! 

Lastly, the common diarrhoea of summer, more or less severe, and in weak subjects, with low vital powers, often proves troublesome, leaving the )atient liable to a return from very slight causes. n vast multitudes of people there must be thouands who are naturally anaemic and strumous, with others whose systems are shattered by a vicious node of life. In these classes cholera reaps the larvest — persons in whom the magnetic force of 



59 

the blood is minus the healthy standard. We ma also assume, that as nearly every article of food i adulterated by poisonous compounds, as shown b the Lancet Analytical Commission, with the un known quantity of diseased meat consumed, tha these have their share in helping the dreaded enemy In Copenhagen, in 1853, 7,219 cases occurred, wit 4,737 deaths, and the disease was not severest in those parts of the town whose sanitary condition was the worst.* Last year, in India, 10,000 death were recorded, and at this time cholera is, in Egyp and the Mediterranean, sweeping off its hundred daily, and most probably will appear in this countr) in the course of the summer. But the diseas alters in its features according to the nature of th climate and soil, and the physical condition of th inhabitants. Thus it will be very different in Rome or Vienna to Constantinople, and may change its character still more widely should it come to London. The treatment of cholera ought to be chemical, mechanical, and hygienic; by administering those foods and medicines in which the "elements of respiration" are abundant — as acetic acid, starch, gum, sugar, &c. " Alcohol tends to 

* Year Book, N. S. S. 



60 

produce depletion of organs to the gain of the sanguineous mass,* cold water, which acts by producing the strongest current by endosmose of th solution, besides being a powerful radiant, in keepin and maintaining heat in the body by external ap pliances, and for these remedies to be successful i centres of disease, the patient's removal from th specific cause is imperative. I think lam not fa wrong in stating that nine-tenths of the professio commence the treatment of this disease by astringents and stimulants. Such appears to be the almost universal practice ; and Dr. Ayre states, that the calomel treatment failed only in those cases where opium and stimulants had been given. 

Dr. Stevens declares the saline treatment was successful in these and in all other cases. f My own practice has been, at the commencement of a cholera attack, to give one tablespoonful of the bllowing mixture, viz. : — 

Spirits of Camphor, twenty-four minims. Aromatic Spirits of Ammonia, two drachms. Tincture of Opium, forty-eight minims. 

Compound Tincture of Cardamoms, one ounce and a half. 

Simple Syrup, two ounces. 

Cinnamon Water, enough to make sis ounces. 

* Poiseuille. 

f Braithwaite, 1849. 



61 

every five, ten, or fifteen minutes, until a reaction sets in ; at the same time, external heat must be diligently applied and persevered in. A return of warmth to the body is the first indication of success, and more to be desired than any other apparent amendment.* The exception is where repeated doses of brandy or spirits have been taken to allay the vomiting, until gastric irritation has become excessive, and the stomach rejects everything ; this irritable condition must be first allayed by perfect rest, the acid drink and counter irritation over the stomach. After a time the remedy will be tolerated. Drunkards, and those in whom exhaustion has been produced by excessive smoking and venery previous to an attack of cholera, are always the worst and most fatal cases, in such, the following mixture may prove beneficial : — 

Tincture of Sumbul, one drachm ; Tincture of Opium, one drachm ; Chloric (Ether, one drachm ; Syrup, two ounces ; Water to make six ounces, of which one tablespoonful may he 

* The Board of Health recommended the following mixture during the prevalence of cholera: Aromatic powder, 3 drms. Tincture of catechu, 10 drms. Compound tincture of cardamoms, 6 drms. Tincture of opium, 1 drm. Chalk mixture to make 



62 

given every five, ten or fifteen minutes, according to the urgency of the case — or at longer intervals in mild attacks. 

As in bodies restored from drowning, how gradua is the return of heat, and how little of it saves life First, one beat of the heart, distinguished at lon intervals, yet by perseverance in the remedies, fina and complete restoration. In the worst cases o collapse, I am satisfied that the practitioner who perseveres most in the application of external heat with his other remedies, will obtain a greater measure of success than he who does without it. The cure of a cholera patient is a long and tedious undertaking. I have been eight and ten hours at the bedside without leaving the patient. The medical man's presence is everything in this disease, in fact, could every cholera case have the constant supervision of a doctor, the death rate would be much diminished. In all diseases some cases will be fatal ones, therefore it is not right to say that this or that plan failed because it was improper; persevere in a course which reason and common sense direct, and you have done your duty ; if not eminently successful, there is this comforting satis- 



63 

M 'Tis not in mortals to command success, But we'll do more, Horatio, we'll deserve it." 

With external heat, frictions of turpentine are most beneficial in allaying cramps, and here I mus say, I do not agree with those who assert th diarrhoea to be the immediate cause of cramp (spasm), and collapse. The latter are the effects o a cause, and that cause originates the disruption and death of the liquor sanguinis — heat force anc cohesion being overcome, decomposing force takes possession of the body for the generation of new existences. " The pathology of spasm, " Dr. Radcliffe remarks, " is connected with a deficient mani festation of vital power in general, the great functions of circulation, respiration, and in nervation being depressed ; the treatment is stimulating food and medicine."* The stimulating plan must not be carried too far; but should be suspended the moment a reaction is perceptible, either by the medical attendant, or by the patient expressing himself better, by the slightest improvement in the voice, the feel of the skin, or pupils altering instead of being fixed ! Although vomiting and 





64 

purging may not have ceased, then give five grains of calomel ; if reaction still goes on, then commence the salines, so as to check inordinate force. Continue the calomel at intervals of four hours, for three or four closes, still persevering with the frictions of turpentine if the spasms have not entirely left. With the above, the incessant thirst at the commencement may be allayed with acetic acid and water, sweetened as a drink, or with sulphuric acid and water, I have found both beneficial ; good beef tea or nutritious broth, in small and frequent quantities, completes the plan I have relied upon for years. Of course, it must be understood the acids are not given with the salines. In many cases, I have found it better to continue the acid drinks with the calomel, the stimulant being left off. [n others, I have found the salines preferable without the calomel, the moment reaction is perceived, [n bad cases, the anxiety to produce reaction, often cads to great mistakes ; thus, I have heard suggested, nitrate of silver, preparations of lead and ron, with salines, as well as preparations of silver, lead, iron, and zinc, with opium. This umbling together of remedial agents should be 



65 

sedulously avoided, except where the mutual decomposition, forms a valuable agent, as acetate of lead and opium. 

In those cases which do not appear to yield to treatment, and in which it is considered necessary to do something more, the practitioner may take his choice of the remedies above given ; they have each their extollers, only avoid decomposition in the stomach, or death may take place from the sequelae. Inhaling oxygen gas I hold to b advantageous. I should also strongly recommem injecting the bladder, before proceeding to trans fusion, with the saline solution, as given by Drs Taylor and Rees.* The temperature ought to be 98 degrees farh. The bladder, in my opinion is more fitted for this solution from the nature of its structure than the veins. The tempe rature is that of the blood, and it would pas through this viscus by osmosis and dialysis, the surrounding tissues would take up the salin particles so necessary to health, and the kidney might be stimulated to a compensatory action by the bladder. One of the elastic bottles with a 

* Pereira's Mat. Med. 

E 



66 

tube at each end, now so common in the druggists shops, with a catheter properly fitted would answer the purpose, a gradual and continued stream could be injected with the greatest ease.* 

Turpentine as a remedy is especially valuable, both externally and internally ; it quickly absorbs ozone from the atmosphere. "It acts on the general system as a stimulant, it excites the vascular system, especially of the abdominal and pelvic viscera; its influence is principally directed to the secreting organs during the circulation of the terebinthinate particles ; they exercise a local influence over the capillaries and secerning vessels, in the vital activity of which they effect a change ; in certain morbid conditions this change is most salutary."f " Turpentine reproduces the urinary secretion when other powerful diuretics fail."{ I believe large quantities of sugar or syrup valuable, not only for exhibiting turpentine, camphor, sumbul, and other remedies, but also for its " osmotic powers, which lessens the drain of serum 

* Injecting the bladder with water was tried by M. Piorri, but Griesinger states not sufficiently to test its value. 

• T> n __*_ 4. tv.; j 



67 

from the blood ; it absorbs the water of the tissues with which it comes into contact ; it has antiseptic properties by arresting development of organised beings; it excites the flow of gastric juice."* 

As I have elsewhere stated,f it would be a nice point to know what is the lowest blood heat at which life can be maintained, and capable of resisting pathological change. Can infusoria, the result of decomposition, exist in the blood prior to actual death? "Alcohol lessens the waste of heat and therefore of food. Alcohol is fitted for changes in which it is desirous to increase the force of the heart, and to lessen the dispersion of heat by the skin."J I think the above good reasons, and to be depended upon, although " the specific effects of Eiedicines cannot be satisfactorily accounted for, nd must be referred to peculiarities in the vital ndowments of particular parts." 

The convalescence from cholera is tedious ; the tongue remains obstinately dirty ; iron and quinine if commenced too soon, will have to be left off. I have found infusion of gentian or orange peel 

fL. Mandl., Y. B. New S. S. 1860. Lancet, Feb. 18th, 1865. 

J Dr. E, Smith. E 2 



68 

with salines, most beneficial until the tongue cleans. Cold by radiation and contact of air, should be counteracted by warm clothing. If the decomposition of the tissues, and their constant renewal is life, under a given temperature, say 98 deg. farh. blood heat, then any cause which destroys this balance, must go in favour of decomposition or death (change of force), and the more rapid this " change of force," the more speedy the change of form; therefore, stimulants internally and externally, by tending to restore the force heat, of the blood, which keeps it fluid and more capable of absorbing radiant heat, and activity o functions, in the first instance, appear to be the proper plan in the treatment of cholera; if so much brandy or wine in health causes an increase of force, which we know by the muscular contraction and excitement produced, Why should it not do so when the force is departing? This it does, always supposing the equilibrium has not been so far destroyed as to produce congelation in the vessels of the entire cutaneous surface of the body. 

Without looking for causes "impossible and 



69 

inconceivable to our senses," I believe it to be more philosophical to look for the origin of cholera and other diseases in the changes that arise within the body itself, from the incessant death and decay of the worn out elements of the superstructure, and non-ejectment and decomposition, generating different deleterious gases, and contaminating the newly formed products ; hence arises congestion of one or more organs anc temporary arrest of function, alteration of blood mental emotions, depraved habits, excessive sexua indulgence, excess of food, or want of food ; these and various other causes are quite sufficient to originate disease without looking for " fungous atmosphere," or "inconceivable animal life." 

The treatment of cholera by cold, both inter nally and applied to the skin, appears incompre hensible. Cold is a depressing agent. It lessens preternatural heat. It reduces vascular action constringes the living tissues, coagulates the blood and lessens the volume of the body. One wouk scarcely apply cold on theoretical grounds in the stage of collapse, either for its effects by radiation, evaporation, or conduction. " The only 



70 

agent which in all cases reduces animal heat is cold. It abstracts heat, lowers the intensity o the- vital movements, diminishes vascular action and reduces the calorific functions."* 

Let those who attempt the cure of cholera by cold explain its rationale ! 

* Pereira. 



CONCLUDING REMARKS. 

In the treatment of cholera, and its sequelae, i must not be forgotten that one or more disease may exist together in the body during an epidemic Scarcely a medical man of any experience i disease, but must have met with cases which hay confounded his judgment; thus, who has not seen the duad nature of scarlatina and measles, anc been utterly unable to the end of the case to pronounce satisfactorily the nature of the attack especially when told that the child has ha( measles before, or scarlatina previously. Dr Kennedy says, # "Books speak of a number o distinguishing features between the two, as the premonitory symptoms, the nature of the erup tion, the presence or absence of desquamation but cases are ever occurring (and some of them came under my notice during the late epidemic) 

* Kennedy on Scarlet Fever. 



72 

where these distinctions were of no avail. Cynanche and diptheria have led to similar confusion, and I have seen a case in which all four of the above have co-existed. Typhus, cholera, cerebro-spinal meningitis, and relapsing fever. Only lately have most accurate observers been unable to distinguish the exact nature of the epidemic raging about Dantzic and in Russia. 

Scarlatina and cholera, as in Dr. Egan's case, and confirmed by Dr. Kennedy, clearly unite. The latter author says, in his work on " Scarlet Fever, " It may appear strange that there could be any possibility of mistaking the two diseases, and yet I have been brought to see cases where, from any examination of the patient, it was not possible to distinguish. I found such patients with livid extremities and pulseless, and these symptoms accompanied by vomiting and purging, and had there been no history of the case, it might as well have been called cholera as scarla tina."* Ague and poisoning by arsenic may simulate cholera, and with such fidelity, as to make the diagnosis one of extreme difficulty in the 





73 

absence of any history of the case.* In a simple case of cholera, without any complication, we should bring to our aid all such agents, designated by Mtiller vivifying stimuli, and which are essential to life, as well as the "homogeneous stimuli" which " exert a vivifying influence when their action on the organic matter favours the production of the natural composition of the parts."f I have never seen a case of cholera, pur et simple, in which bleeding was necessary, but in the complicated cases, the treatment will depenc entirely on its nature, according as the bowels the lungs, the liver, the skin, the cerebrum, am spinal chord are implicated, and each medical man must rely upon his own intuitive tact and judgment in carrying his patient through this most difficult and trying after part of the disease. Authors and very able ones have laid down rules for guidance in most of the systematic works on medicine, and I should advise all who are desirous of obtaining the fullest knowledge of this disease to consult the "Indian Annals of Medicine," in 

* See Taylor's Med. Juris. f Elements of Physiology, by Baly. 



74 

the library of the College of Surgeons, and to master all points of interest communicated to the various medical periodicals by accurate and observing professional brethren, not only in our 

own Colonies, but wherever cholera has appeared ; but the practitioner must not rely implicitly on the opinions of others. Cholera is an ever vary ing disease, and he should reflect and conside how much of the after mischief pertains to any one cause : thus, How far did the decomposition o the blood extend ? How much can be attributed t other diseases co-existing? and, How much t effects of remedies administered during the vio lence of the attack? Bearing in mind these points, there will be no doubt about the line o conduct he should adopt in the treatment o (;he sequelae of cholera. Guided by a steady houghtful judgment, and persevering in a plan which reason and common sense acknowledge to ?e right, and carried out with such skill as the >resent medical education imperatively demands Eiembers, he need not fear of obtaining that b of success, to which a conscientious perce of his inviolable duties entitle him. 



75 

The cause of cholera is not yet known. Mr. 

Grainger describes it as an affection of the blood. 

" That the best results which have been attained by the German Pathologists, particularly those of Berlin, is that the first impression is serial, acting on the blood, and thus the blood became poisoned." Dr. Wells in a short sentence on cholera, says, " a loss of vitality of the blood." In these opinions I coincide, and the manner in which the blood loses its vitality, I have endeavoured to point out in the foregoing remarks. As I believe in time Meteorology will become a tolerably exact science, so soon as the laws which regulate the changes in the conditions of our serial envelope shall become known, and that every shower will be foretold with exactness, so do I conceive a time will come when the law which regulates vital force will be more fully comprehended. Life is maintained and carried on, not miraculously as too commonly supposed, but just in the same way as trees grow, as E) seasons change, just the same as if water owed to stagnate will engender animal life, all m a Physical Force which at present man has 



76 

not mastered. Every part or parts of Nature that our intellect has conquered and shown the law, appears simple enough, it is only those parts of natural laws that we do not fully comprehend that appear miraculous. The human mind wi] ultimately know the laws of the Physical Forces and then we shall attain to a more perfect know ledge of First Principles. Physical force is the parent of vital force; this law once known, then anything which disturbs this law, will produce derangement of bodily health and disease. Our inquiries must therefore be directed to the laws of Physical Force, to which the law of vital force is co-ordinate. It is gratifying to know that minds of the highest order are at work, that Tyndall,* Grove,f Joule,| Mayer,§ and others have pointed out the path for the scientific observer of disease to travel; at present we can only indulge in the belief that this century will not close without the birth of a man, who, in the words o 

* On Heat as a Mode of Motion. 

f On the Correlation of the Physical Forces. \ Dr. Joule, Philosophical Magazine. 

§ Quoted by Tyndall. 



77 

Sir Charles Lyall,* "By a higher capacity of reason, and a greater power of concentration, will approach nearer to" the comprehension of this difficult subject." 

Let us hope that effects will soon be distinguished from causes. I can only repeat my con viction that some one or more of the physica forces undergo a change ; this change alters vita force, thus oxygen supplies magnetism to the blood, magnetism originates nerve force, men in health have a standard or even plus amount o: magnetic force ; others have minus magnetic force The quantity of radiant heat necessary to main tain healthy life, is from some cause at present unknown, diminished. The man who has the healthy standard, or plus magnetic force, wil resist the altered condition of the physical force, which disturbs the vital force, better than the man whose life was carried on minus magnetic force. Therefore, in the violation of the laws of health, anc defective sanitary arrangements must in a great measure exist the cause of Epidemic Cholera. 

Should another epidemic unfortunately visit us, 

* On the Antiquity of Man. 



78 

I conceive the fullest trial ought to be given to the inhalation of medicated atomized steam. Dr. Siegle's apparatus is perfection for this purpose, and I believe an instrument can be made applicable, at a cost to come within the reach of the poor. The constant supply of atomised steam in the mouth would relieve the intense thirst, and certainly tend to warm the cold mucous membrane. The specific and latent heat contained in steam coming into immediate contact with the extensive surface of the air passages, would most likely restore the loss so sadly deficient in the black and thickened blood. Any of the remedies recommended by Dr. J. Rose Cormack,* could be used. The effect of this method on the patient's mind would be of immense advantage, tending to allay the fear so common by keeping his attention fixed to his cure. The steam jet could be used as a rubefaciant along the spine, and its action easily localized ; lastly, by this means, the air of the room could be purified, the latent heat and moisture being dispersed through it. Dr. Beigle, of Finsbury Square, has recently called the atten- 

* In the Association Med. Journal. 



79 

tion of the Profession to the value of Atomized Fluids in the columns of the Lancet. He is not aware that this method has ever been tried in cholera or rheumatism on my suggesting its use in these maladies.* 

In addition to all previously-known treatment, the three systems of constant irrigation of the E Madder, inhalation of oxygen gas, and inhalation f medicated atomized fluids, merit an extensive rial, the results should be faithfully recorded, and the Profession be guided by the success or non-success of either plan. 

* Dr. Paris was in the constant habit of using steam and warm vapour, and Mudge's Inhaler is well-known. 

Upfikld Green, Printer, Joiners Hall Buildings, 79, Upper Thames Street.