SKETCHES OF THE MOST PREVALENT DISEASES OF INDIA. 



LONDON: 

TRINTED By J. MOVES, BOUVEIUE STREET. 





I* 



SKETCHES OF THE MOST PREVALENT DISEASES OF INDIA: 

COMPRISING, 

A TREATISE 

ON THE 

EPIDEMIC CHOLERA OF THE EAST; 

STATISTICAL AND TOPOGRAPHICAL REPORTS OF THE DISEASES IN THE DIFFERENT DIVISIONS OF THE ARMY 

UNDER THE MADRAS PRESIDENCY; EMBRACING ALSO THE ANNUAL RATE OF MORTALITY, &C. OF 

EUROPEAN TROOPS: 

AND 

PRACTICAL OBSERVATIONS 

ON THE EFFECTS OF CALOMEL ON THE ALIMENTARY CANAL AND ON THE DISEASES MOST PREVALENT IN INDIA. 

ILLUSTRATED BY TABLES AND PLATES. 

By JAMES ANNESLEY, Esq. MADRAS MEDICAL ESTABLISHMENT ,* 

LATELY IN CHARGE OF THE GENERAL HOSPITAL, MADRAS, AND GARRISON $<{#GEON OF FORT ST. GEORGE. 

4 31 EM* 

LONDON: 

PRINTED FOR THOMAS AND GEORGE UNDERWOOD, 32 FLEET STREET. 

1825. 





SKETO H I : S 

j ii j 

MOST PREVALENT 

DISEASES OF IN 1)1 A: 

O.MI'KISI.M, 

V TKEATISK 

EPIDEMIC CHOLERA OF THE EAST; 

STATISTICAL AND TOPOGRAPHICAL REPORTS THE DISEASES IN THE DIFFERENT DIVISIONS OF THE ARM\ 

NDEK THE MADRAS PRESIDENCY; EMBRACING ALSO THE ANNUAL RATE OF MORTALITY, &c. OF 

EUROPEAN TROOPS: 

PRACTICAL OBSERVATIONS 

THE EFFECTS OF CALOMEL ON THE ALIMENTARY CANAI AND ON THE DISEASES MOST PREVALENT IN INDIA 

ILLUSTRATED CV TABLES AND PI. ATI 

MADRAS MEDICAL ESTABLISHMENT 

VIELY I L \ CHARGE OF THE GENERAL lloslTl' \l.. MADRAS, \ 

(iAKIUSON -stTicrCON OK I-'o»T ST. UEOIKiI 

1,0,\ DON 

IUMEP HHI THOMAS AM) CiEORGE W( x H) 

VI FLEET STREET 

IM2O 







\W° 



TO 

SIR JAMES MACGRIGOR, Knt., M. D., F.R.S. 

¦•* 

FELLOW OF THE BOYAL COLLEGES OF PHYSICIANS OF LONDON AND EDINBURGH; PHYSICIAN EXTRAORDINARY TO HIS-. 

MAJESTY; DIRECTOR-GENERAL OF THE ARMY 

MEDICAL DEPARTMENT, &c &c. &c. 

MY DEAR SIR, 

inscribing this Volume 

to you, I gratify a desire of publishing my sense of your zealous and well-directed efforts to promote the general arid professional science of the members of the public service over ivhich you preside, and to state my belief that I only share hi this sentiment in common with the whole Medical Service of India. Your endeavours to promote the advancement of science, by encouraging inquiry among the members of the medical department of His Majesty 's Army abroad, as well as at home, and your exertions to advance their respectability and interests as a scientific and learned body, have been 

b 



reflected upon the Medical Service of India, and upon the Profession generally. 

Anxious that my Volume should appear under the patronage of your distinguished merit, I am happy in thinking that it will be thus honoured by a Physician who has had extensive experience of the country, and of the diseases to which it relates, and whose Writings respecting them are so justly esteemed by every competent judge. 

I have the honour to be, 

My dear Sir, 

Your very obedient Servant, 

J. ANNESLEY. 

London, Bth September, 1825. 

vi 

DEDICATION. 



CONTENTS. 

PAGE 

Dedication xiii 

Preface xv 

PART I. 

TREATISE ON THE EPIDEMIC CHOLERA OF INDIA. 

CHAPTER I. 

Introductory Remarks 3 

CHAPTER 11. 

Of the Symptoms and Progress of the Epidemic Cholera 16 

Section I. 

Description of the Symptoms of Epidemic Cholera. . 17 

Section 11. 

Of the early Symptoms of the Epidemic Cholera, or the Symptoms of the Stage of Invasion .... 22 

Section 111. 

Symptoms of the Second, or advanced Stage of the Epidemic Cholera 31 

Section IV. 

Of the Pathognomonic, Diagnostic, and Prognostic Symptoms of Epidemic Cholera 36 



PAGE 

CHAPTER 111. 

On the Pathology of Epidemic Cholera 45 

Section I. 

Details of Cases illustrative of the Pathology of the Disease 46 

Section 11. 

Pathological Observations and Inferences, &c 116 

CHAPTER IV. 

Of the Causes of the Epidemic Cholera 129 

Section I. 

Of the Efficient or Proximate Cause of the Disease 130 

Section 11. 

Of the Predisposing, and of the Exciting or Occasional Causes 149 

CHAPTER V. 

Of the Treatment of Epidemic Cholera 164 

Section I. 

General Sketch of the Treatment of the Disease . . 1 65 

Section 11. 

Farther Remarks on the Treatment of Epidemic Cholera, with Details of Cases in Illustration of 

this and the preceding Section 196 

viii 

CONTENTS. 



CONTENTS. 

9 

PAGE 

Section 111. 

Remarks in proof of the Non-contagious Nature of 

the, Disease, and on the Preservative Means which may be adopted in order to escape from 

its Attack 235 

Table of Admissions and Casualties from Epidemic Cholera in the Army of Fort St. George, both 

Europeans and Natives 249 

PART 11. 

REPORTS OF DISEASES OF THE ARMY UNDER THE MADRAS PRESIDENCY. 

Topographical Reports of Diseases of India 251 

General Explanation of the Tables of Disease 256 

Table I. — Extract from the Medical Board's Returns for the Presidency Division, for the Year 

1815 260 

Table II. — Abstract of Diseases of the Presidency Division of the Army, for a period of Six Years, 

from 1815 to 1820, inclusive 261 

Table 111. — Abstract of Diseases of the Southern Division of the Army, for a period of Six Years, 

from 1815 to 1820, inclusive 269 

Table IV. — Abstract of Diseases of the Centre Division of the Army, for a period of Six Years, 

from 1815 to 1820, inclusive 272 



10 

CONTENTS. 

PAGE 

Table V. — Abstract of Diseases of the Northern Division of the Army, for a period of Six Years, from 1815 to 1820, inclusive 281 

Table VI. — Abstract of Diseases of the Travancore Subsidiary Force of the Army, for a period of Six Years, from 1815 to 1820, inclusive 287 

Table VII. — Abstract of Diseases of the Mysore Division of the Army, for a period of Six Years, from 1815 to 1820, inclusive 295 

Table VIII. — Abstract of Diseases of the Ceded Districts, for a period of Six Years, from 1815 to 1820, inclusive 304 

Table IX. — Abstract of Diseases of the Field Forces of the Army, for a period of Six Years, from 1815 to 1820, inclusive 314 

Table X. — Abstract of Diseases of the Hydrabad Subsidiary Force, for a period of Six Years, from 1815 to 1820, inclusive 322 

Table XL — Abstract of Diseases of the Nagpore Subsidiary Force, during a period of Forty-eight Months, in the Years 1816, 1817, 1818, 1819, and 1820 330 

Table XII. — General Returns of the Sick of the Madras Army, for the Year 1821. No. 1. Admissions into Hospitals 340 

Table XIII. — General Returns of the Sick of the Madras Army, for 1821. No. 2. Cures 341 

Table XIV. — General Returns of the Sick of the Madras Army, for 1821. No. 3. Deaths 342 

Table XV. — Abstract, shewing the Per Centage of Deaths in the different Divisions of the Army, for the Year 1821 343 



CONTENTS. 

11 

PAGE 

Table XVI. — General Returns of the Sick of the Madras Army, for 1821. No. 4. Transferred to 

other Hospitals or Stations 344 

Table XVll.— General Returns of the Sick of the Madras Army, for 1821. No. 5. Remaining in 

Hospitals 345 

Table XVIII. — Abstract of Deaths from Diseases included under the general term of " Other Dis- 

eases" in the General Return 346 

Table XIX. — Per Centage of Deaths of the most Destructive Diseases, for 1821 347 

Table XX. — Abstract, from the preceding Table, of Per Centage of Deaths of the most Destructive 

Diseases, for 1821 348 

Table XXI. — Per Centage of the several Diseases in each Division of Madras Army, for the Year 

1821 349 

Table XXlL— Abstract shewing the Total Strength 

of the Army serving under the Presidency of Fort St. George, both Europeans and Natives; the Total Admission of Diseases, and Rate of Cures, calculated both upon the Effective Strength of the Army, arid upon the Actual Admission of Diseases into Hospitals during the 

Year 1821 350 

Remarks on the preceding General Returns 351 

Table XXIII. — General Return of Deaths, Invalids, 

Pensioners, Discharged, and Time-Expired Men, belonging to His Majesty's and the Honourable 

Company's European Service, for the Year 1815 365 



12 

CONTENTS. 

PACE 

Table XXIV. — General Return of Deaths, Invalids, Pensioners, Discharged, and Time-Expired Men, helonging to His Majesty's and the Honourable 

Company's European Service, for the Year 1816 366 

Table XXV. — General Return of Deaths, Invalids, Pensioners, Discharged, and Time-Expired Men, belonging to His Majesty's and the Honourable 

Company's European Service, for the Year 1817 367 

Table XXVI. — General Return of Deaths, Invalids, Pensioners, Discharged, and Time-Expired Men, belonging to His Majesty's and the Honourable 

Company's European Service, for the Year 1818 368 

Table XXVII. — General Return of Deaths, Invalids, Pensioners, Discharged, and Time-Expired Men, belonging to His Majesty's and the Honourable Company's European Service, for the Year 1819 369 

Table XXVIII. — General Return of Deaths, In- 

valids, Pensioners, Discharged, and Time-Expired Men, belonging to His Majesty's and the Honourable Company's European Service, for 

the Year 1820 370 

Table XXIX. — General Return of Deaths, In- 

valids, Pensioners, Discharged, and Time-Expired Men, belonging to His Majesty's and the Honourable Company's European Service, for 

the Year 1821 371 

Table XXX. — Abstract of Annual Loss in the 

Army of European Forces, by Deaths, Discharges, Invalided, Pensioned, and Time-Expired Men, both in His Majesty's and in the Honourable Company's Services, under the Pre- 



CONTENTS. 

13 

PAGE 

sitlency of Fort St. George, for Seven Years, from 1815 to 1821, inclusive 372 Table XXXI. — Abstract of the General Loss of Men belonging to His Majesty's and the Honourable Company's European Troops in Deaths, Discharged from the Service, Invalids, Pensioners, and Time-Expired Men, for a period of Seven Years, from Ist January 1815, to 31st December 1821 373 

PART 111. 

PRACTICAL OBSERVATIONS ON THE EFFECTS OF CALOMEL ON THE MUCOUS SURFACE AND SECRETIONS OF THE ALIMENTARY CANAL ; AND ON ITS USE IN THE DISEASES OF INDIA. 

Section I. 

Introductory Remarks respecting the Doses in which Calomel may be prescribed, &c 377 

Section 11. 

Details of Experiments, shewing the Effects of large 

Doses of Calomel on the Alimentary Canal, &c 389 

Section 111. 

Of the Influence of Calomel on the Secretions of the Intestinal Canal, and on those of the Liver and Pan- 

creas 398 

Section IV. 

General Remarks on the Use of Calomel in Disease . . 405 



14 

CONTENTS. 

PAGE 

Section V. 

Of the Employment of Calomel, in the Treatment of Intermittent, Remittent, and Continued Fevers 409 

Section VI. 

Of the Use of Calomel in the Acute Diseases of the Liver and Gall-bladder 423 

Section VII. 

Of the Use of Calomel in Chronic Disorders of the Biliary Organs 426 

Section VIII. 

Of the Use of Calomel in Acute Dysentery 433 

Section IX. 

Of the Use of Calomel in Chronic Dysentery and Diarrhoea 441 

Section X. 

Of the Employment of Calomel in Cholera 443 

Section XI. 

Of the Use of Calomel in some of the more prevalent Diseases of Children 445 



PREFACE. 

There are few diseases which have excited more interest among medical men, or more terror in the mind of the Indian community at large, than the epidemic cholera. The various and contradictory views entertained at different times respecting it, shew distinctly our ignorance of the real nature of the disease itself, as well as of any successful means of combating it. During such uncertainty it is the duty of every practitioner who has had extensive experience, or who considers that he can add to the stock of information respecting it, to contribute whatever may be in his possession. It is only by such means that sufficient data can be obtained, whence sound views may be deduced respecting its treatment, and the limitation of its ravages. 

The medical charge of the garrison of Fort Saint George, and of the general hospital 



of the Madras Presidency for a period of five years, (from 1819 to 1823,) during which period the spasmodic cholera raged with great violence, gave the Author ample opportunities of observing this malady in all its forms, of treating it, and of making those examinations after death, which should never be omitted where any doubt exists of the real nature of a disease. 

Respecting the cases which are detailed in this part of the work, the Author thinks it necessary to remark, in explanation of a seeming incongruity existing between the treatment of a few of them and the principles he has advocated, that these particular cases were treated in the hospital of which he had charge, by well qualified and very meritorious medical officers, to whom he committed the care of them ; that he was desirous of knowing the result of a method of cure, in behalf of which much might, perhaps, be adduced; and that he was desirous that rational views should not be placed under any restraint which might savour of narrow-mindedness. 

xvi 

PREFACE. 



The result of his observations respecting this formidable disease, the Author now offers with deference to the Profession, and only laments his inability to do more justice to the subject. 

His only object has been, to give an unadorned statement of facts exclusively ; he trusts, therefore, to the indulgence of the Profession, and assures them that they have been derived from close and attentive observation at the bed-side of the patient, made in the daily, and he may say hourly, performance of his duty. If he shall be so far fortunate as to succeed, even in the slightest degree, in throwing any additional light upon this interesting subject, he will feel amply rewarded for the trouble he may have taken, and the anxiety which necessarily arises in the mind of one unaccustomed to give his opinions to the public. But in attempting this, he is endeavouring to discharge a duty which he owes to the service to which he belongs, and which it has a right to expect from him, as a return for the opportunities he has enjoyed. 

xvii 

PREFACE. 



As to the Reports which constitute the second part of the work, he may merely state, that they were undertaken with a view of informing the medical officer, upon his arrival in India, of the climate of the particular stations and districts in which his services may be required, and of the plan of treatment the Author has found most successful in combating the diseases therein prevailing. He publishes these Reports with a view of turning professional attention to communications of a similar nature ; and he thinks it right to inform his readers, that the practical remarks accompanying them, are the result of twenty-five years of active service in India. During this time, he has practised in all the districts and stations embraced by these Reports, and had very extensive experience in the diseases noticed in each of them, whilst successively filling the offices of regimental, staff, and superintending surgeon, — whilst performing the duties of extensive field hospitals, both European and native, — and, during the last five years, whilst in charge of the general hospital at the Madras Presidency. 

xviii 

PREFACE. 



With regard to the third part of this volume, the Author wishes that it may be considered as supplemental to the reports, as it more fully developes the treatment of the prevailing diseases embraced by them, and as it refers to a remedy more generally employed in the disorders of India than any other, and is consequently one to which more attention is directed. 

Having had sufficient reason to believe, from the opposing opinions generally entertained respecting the operation and mode of exhibiting this remedy, that its influence in disease is not always justly appreciated, and that erroneous views are frequently entertained regarding its action, he was led by these circumstances to direct his attention to the subject. Considering that the method of administering this remedy which he adopted, is authorised by extensive experience of its effects, and by as accurate observation as his abilities allowed him to make, he is induced to place before his professional brethren the results, whence they may draw their own conclusions. 

xix 

PREFACE. 



20 

PREFACE. 

If the reader shall consider that particular facts or opinions are too strenuously insisted upon, or that others are oftener referred to than necessary, the Author begs him to consider, that the subjects treated of in the second and third parts of the work, rendered this, and even some degree of repetition, entirely unavoidable ; and expects that he will be pardoned for whatever faults may have proceeded from his desire to impress upon the mind of the inexperienced practitioner in India, what a long residence, and extensive opportunities of observation, have fully convinced him of the importance of. 

Assured that the Author will be judged by his desire of proving serviceable in his vocation, he sends forth his volume to the Profession, desirous that his views and practice may be adopted only as far as a candid and unprejudiced experience may confirm their propriety. 



PART I. 

TREATISE 

ON THE 

EPIDEMIC CHOLERA OF INDIA. 





TREATISE 

ON THE 

EPIDEMIC CHOLERA OF INDIA, 

ETC. ETC. 

CHAPTER I. 

INTRODUCTORY REMARKS. 

The medical practitioner, who has witnessed the ravages of the cholera which has lately prevailed in an epidemic form throughout the Indian territories, is naturally led to propose to himself the following questions: — Ist. Is there any mention made in the Hindoo medical writings, or in the history of the countries which have been visited by the present destructive disease, of its prevalence in any former age in a similar form? — 2d. Does the history of medical science furnish any account of the occurrence of cholera, as an epidemic disease, either in India or in any other part of the globe ? 



4 

INTRODUCTORY REMARKS. 

As respects the first question, I can only state, that I have not been able to obtain any information from those acquainted with the writings of the Hindoos, favouring the inference that cholera has prevailed in former ages as a wide-spreading epidemic. The disease, however, in its sporadic and less malignant form, seems to be noticed in the medical works of the Hindoos ; but in a way that illustrates neither its pathology nor its treatment. Indeed, it could scarcely be expected that a disease essentially dependent upon the climate and intertropical position of the Indian territories should be overlooked by the native writers on the diseases of these countries. But, as far as I am able to judge from the exposition of those who are well acquainted with Hindoo literature, the account given by these writers, although evidently pointing to cholera in its sporadic form, or as it casually occurs in India, has no reference to the epidemic disease of which I am about to treat. 

As regards the second question proposed, medical writings furnish little information, and the little for which we are indebted to them is neither very definite nor instructive, as regards the point at issue. That the sporadic form of cholera is a disease depending upon the 



INTRODUCTORY REMARKS. 

5 

climate of India, is a fact which ought not to be lost sight of in our speculations respecting its origin. It depends as much upon particular climates, upon the nature of particular localities, and upon certain states and changes of the atmosphere, as dysentery, bilious fever, or hepatitis.* From this it must follow, that it will be found endemic in some districts, particularly at certain seasons of the year; and, owing to a combination of the particular atmospherical vicissitudes which are well known to give rise to the disease, with those causes which belong more immediately to the district or locality, it may assume many of the characters of an epidemic malady ; but then, although assuming these characters, it will be found that it entirely depends upon the causes alluded to, namely, those which relate to the district in which it occurs, and the state of the atmosphere observed for some time previous to. and during its occurrence, and that it will disappear with the disappearance of these causes, especially of the latter. But, as we shall see in the sequel, this distinctive character 

* The reader may, perhaps, doubt that hepatitis is dependent upon the circumstances now alluded to, and may consider its endemic character as questionable. The experienced ihtertropical practitioner will have no such doubts. — See some of the Reports in the second Part of the present work. 



6 

INTRODUCTORY REMARKS. 

cannot be applied to the disease which has for several years, and now is ravaging India. It is different, in many respects, from the cholera morbus previously observed and described by authors, and it has not been a partial epidemic, similar to some which I will immediately adduce, and which evidently depended upon the causes I have just now alluded to ; but it has been general throughout one half of Asia, and has had no relation to localities, or the atmospherical changes on which sporadic cholera is generally found to supervene, and sometimes to prevail to a great extent.* 

Of the occurrence of cholera, or rather the prevalence of it, in consequence of the situation 

* It maybe necessary to state more explicitly the meaning which I attach to the word epidemic. The etymology of it merely indicates the general prevalence of any disease. In this sense, almost every disorder may be said to be capable of recurring in an epidemic form. I shall, therefore, — and, I believe, conformably with the general acceptation of the word, — use it in a much more limited sense. I consider that a disease is truly epidemic, when it attacks great numbers at the same time, and when its general prevalence cannot be altogether explained by the common and manifest causes of temperature and season of the year, &c. without recurring to a certain state of the atmosphere, the nature of which state is beyond our means of ascertaining, and which is independent of the known and palpable conditions of this fluid, as 



7 

INTRODUCTORY REMARKS. 

of the district in which it was observed, and of the additional and more efficient cause — the continuance or sudden change of known states of the atmosphere — several instances may be adduced, both as regards India at all periods of the year, and as respects Europe at particular seasons. 

Thus, Dr. Paisley* wrote from Madras, in 1774, " There can be no doubt that their (the troops') situation contributes to the frequency and violence of this dangerous disease, which is, as you have observed, a true cholera morbus, the same which they had at Trincomalee." He afterwards states that the disease is often "epidemic," especially amongst the blacks; but, from the context, he appears to have confounded endemic causes with epidemic influence, and consequently, to have ascribed what was evidently the result of locality, and the peculiarity 

respects its temperature and state of moisture. In this sense, fevers of various kinds, small-pox, dysentery, the cholera of India, scarlet fever, measles, hooping-cough, erysipelas, are epidemic diseases. Dr. Samuel Johnson defines epidemic to be, Ist. " That which falls at once upon great numbers of people, as a plague;" 2d. " Generally prevailing; affecting great numbers ; general ; universal," &c. 

* See Curtis's Diseases of India. 



8 

INTRODUCTORY REMARKS. 

of the season, to some occult epidemic constitution, of which we find no satisfactory proof. 

The accounts respecting cholera, furnished at different times, from the date of Dr. Paisley s letter up to the year 1817, by individuals who have visited India, refer chiefly to the prevalence of the disease in particular districts, in consequence of the peculiarities of these districts, and principally of the atmospherical vicissitudes, to which the occurrence of sporadic cholera is usually attributed. 

M. Sonnerat, in the account of his travels in India between the years 1774 and 1781, mentions that cholera prevailed on the Coromandel coast, and, at one period more particularly, assumed an epidemic and more malignant character : but, in this instance, we find it expressly stated, that " some were attacked with the disease from having slept in the open air ; others in consequence of eating cold rice with curds ; but the greater part for having eaten after they had bathed and washed in cold water. This epidemical disorder happened during the northerly winds in December, January, and February ; when they ceased, the malady disappeared." 



9 

INTRODUCTORY REMARKS. 

Here we find a sufficient reason for the more than usual prevalence of cholera. Cold, dry winds, occurring after a warm and moist state of the atmosphere, are the usual causes of the frequent occurrence of cholera in temperate climates ; and in intertropical countries, where these causes are generally more efficient, both as respects the causes themselves and the predisposition of those subjected to their influence, they could not fail of producing effects of proportionate intensity. 

The accounts given of cholera in Curtis's well-known work, and in Girdleston's Essay on the Spasmodic Affections of India, refer merely to a somewhat more than usual prevalence of the disease, during the years 1781 and 1782, owing to the seasons, state of the climate, and circumstances immediately connected with the individuals who were its subjects; but neither in the work of Curtis, nor in Girdleston's Essay, is any evidence to be found that the disease assumed a true epidemic character, or that it arose from other than manifest causes. 

The information furnished us respecting the cholera which prevailed during the year 1787 in Arcot and Vellore shews, in an equally 



10 

INTRODUCTORY REMARKS. 

satisfactory manner, that it depended upon the state of the season. Mr. Thompson, who was deputed to inquire into the causes of the more than usual prevalence of cholera in the districts now mentioned, expressly states, that " This disease is exactly the same as prevailed at Trincomalee, in the months of April and May 1782, when the season was very hot and chill, the winds blowing from the land, and reaching some leagues to sea. The weather here, at present, is the same as I experienced at Trincomalee." 

If we look farther back than to the middle and end of the eighteenth century, we shall be equally unable to obtain satisfactory information as to the epidemic prevalence of cholera in India. Bontius, our earliest writer on the disorders of this country, although he makes particular mention of cholera, says nothing of its occurrence as an epidemic disease; and, indeed,, the description he gives of it, though sufficiently accurate as respects the slighter cases of the disorder, as it occurs sporadically, by no means applies to the very violent form of disease, constituting the present epidemic. 

From these considerations, and from others which might have been adduced, I think it may 



11 

INTRODUCTORY REMARKS. 

be inferred, — Ist. That we have no proof of the prevalence of cholera in India, as a widespreading epidemic in former times ; and 2dly. That the accounts which have been given of the more than usual prevalence of cholera, in a particular district or country, or at particular seasons, evidently shew, that such prevalence of the disease was owing to the nature of the locality, of the seasons, of the more evident atmospherical vicissitudes, and of the circumstances of those who were seized with the disease ; and that it was not independent of these causes and apparently resulting from others of a more occult nature, which, in the present imperfect state of our knowledge of the matter, have been denominated epidemic causes, or epidemic constitutions of the atmosphere. 

But if it be denied that we have any knowledge of the previous existence of cholera as an epidemic disease in India, it may be asked if we are equally destitute of information as to its epidemic occurrence in any other part of the globe, during former times. On this point, I shall briefly state the result of my inquiries. Sydenham informs us that cholera, " anno 1669, se latius diffuderat guam alio quovis anno, quantum ego observaveram, earn anni partem, quae sestatem fugientem, atque autumnum 



12 

INTRODUCTORY REMARKS. 

imminentem complectitur, unice ac eadem prorsus fide, qua veris primordia hirundines, aut insequentis tempestatis fervorem cuculus, amare consuevit." And in another place he states — " exeunte sestate [anni 1676] cholera morbus epidemice jam sseviebat, et insueto tempestatis calore evectus atrociora cdnvulsionum symptomata, eaque diuturniora, secum trahebat."* But these expressions, when duly weighed and considered in connexion with the context, shew merely, that cholera morbus prevailed more generally than it had been observed usually to have done, owing to the more manifest causes from which the disease arises having existed, at those periods, in greater force than usual. A few years' experience in London, or, indeed, in any district of country, is sufficient to shew that cholera prevails more generally during the summer and autumn of one year than of another, owing to the difference in the character of the seasons ; yet, although it may be said to be epidemic in these years of its more than usual prevalence, in one sense of the word, — viewing the word epidemic with reference to its etymology, — it cannot be considered as being truly epidemic, when the general relations and circumstances of the 

* Opera Universa. Lugd. 1726, pp. 171 and 295. 



13 

INTRODUCTORY REMARKS. 

disease are more fully and generally investigated. 

What has now been remarked, with respect to the observations made by Sydenham, is equally applicable to the very scanty information we possess respecting the more than usual prevalence of cholera at more recent periods, in a few parts of Europe. J. Franck records, in the " Ephemerides of Natural Curiosities," that a disease resembling cholera morbus was prevalent in Ulm, during October 1696; but, although the history of this particular disease has been adduced by some recent writers as appertaining to cholera, it appears to me, on referring to the account given of it by Franck, to have been essentially distinct from the latter malady ; and to have been an instance of the unusual prevalence of colic, which, in many respects, assumed the form of the painters' colic. The following particulars are sufficient to mark the difference between it and cholera morbus : — The disease appeared after the prevalence of cold and rain ; it was attended by constipation, a lacerating pain in the abdomen, and spasms of the loins ; and it attacked chiefly those who were addicted to the use of spirituous liquors, &c. Franck was at a loss whether to attribute it to the use of new wine made from unripe 



14 

INTRODUCTORY REMARKS. 

grapes, and to the variable state of the atmosphere, or to some inexplicable influence which emanated from the bosom of the earth. 

From the time of Franck, medical authors have made very little mention of the unusual prevalence of cholera ; and, from that little, it appears that they have confounded it with colic, which actually seems to have been the more prevalent disease of the two. Thus Augustini, in his account of the diseases predominant in Venice during 1747, Malouin, in his history of the colic prevalent in Paris, in July 1750, and Lentin, in his " Memorabilia Epidemicorum," describe a violent form of colic, but certainly not a true cholera morbus. Each of the descriptions furnished by these authors refers particularly to the existence of obstinate constipation, and to occasional vomiting only. 

I shall not pursue this subject farther, but conclude with the inferences, that we have no satisfactory proof of the previous existence of a disease in all respects the same as that which has recently ravaged India ; that this malady is in many respects different from the cholera morbus of Europe, and, in a few, from the sporadic cholera of India; and, finally, that the cholera morbus of Europe more certainly, and 



15 

INTRODUCTORY REMARKS. 

the common cholera of India, as far as we have the means of judging furnished us, have never assumed features which resemble, in every particular, those possessed by this epidemic. 



CHAPTER 11. 

OF THE SYMPTOMS AND PROGRESS OF THE 

EPIDEMIC CHOLERA. 

Although this disease presents the general characteristic of all epidemics, yet it differs from the majority of them in several subordinate features, which will - appear in the sequel, but more particularly in the rapidity with which it runs its course ; thus putting at defiance all human means of checking its progress. It first made its appearance in Bengal in 1817, and was observed on the Madras side of the Indian Peninsula, at first at Jaulnah in June 1818; and it afterwards continued, without intermission, to spread through all parts of the country until 1821, when its force became considerably diminished ; but, even up to the present time, cases of the disease occasionally occur, but these are generally milder and more manageable than they were during the height of its epidemic prevalence. 

In order that the symptoms and the progress of the disease may be fully and distinctly 

k 



SYMPTOMS, &C. OF EPIDEMIC CHOLERA. 

17 

brought before the reader, and in order that the Indian practitioner may have his attention more particularly directed to these changes, which indicate the commencing invasion of this dreadful malady, I will direct his attention — jirst, to the description of its usual progress ; secondly, to its early symptoms ; thirdly, to the symptoms of the advanced stage of the disease ; and, fourthly, to its Pathognomonic and Prognostic symptoms. 

SECTION I. 

Description of the Symptoms of Epidemic Cholera. 

The progress of the disease is generally as follows : the patient feels, for several hours, or for a greater or shorter period, according to circumstances, a sense of general uneasiness and anxiety about the epigastrium, with a feeling of heat in the same situation. These symptoms increase more or less rapidly ; and the countenance, which at first is merely expressive of uneasiness, soon becomes more and more anxious and distressed. The pulse, at this time, is generally quickened, and always oppressed. This state of the system forms the first stage of the disease— a stage which, from 

c 



18 

SYMPTOMS AND PROGRESS 

its importance in the treatment of the disease, I have called the stage of invasion, and considered more at large in the next section. 

Accompanying these symptoms sometimes, but always supervening immediately to them, the patient complains of sickness at his stomach, and an uneasy sensation which seems to invade the whole track of the digestive tube. To this sense of general disorder, and of derangement more particularly of the alimentary canal, soon succeed a copious evacuation of the stomach and intestines, a sense of exhaustion, of sinking and emptiness, and an irregular spasmodic contraction of the muscles of the lower and upper extremities. The evacuations which take place at this time consist, in a great part, of the matters remaining in the stomach and the rest of the alimentary canal at the period when the patient was seized with the disease ; and, from the abundance of these evacuations, and the sense of emptiness and exhaustion produced by them, it seems as if the contents of the whole tube were completely evacuated at this time. 

The spasms, which generally come on at this period, soon increase ; but, although they are tolerably general, especially in the extremities 



19 

OF THE EPIDEMIC CHOLERA. 

where they commence, they seldom attack the muscles of the back, loins, and face : the abdominal muscles are affected next in succession to the extremities, and lastly the thoracic muscles and diaphragm. With respect to the nature of the spasms, it appears to me that they partake more of the clonic, than of the tonic character ; but the kind of spasm varies very much, even in the same patient, in different stages of the disease; in some cases it partakes somewhat of a tonic character at the commencement, but gradually assumes the clonic form, which, upon the whole, seems to be the predominating kind. 

With the supervention of spasm, and the evacuation of the alimentary canal, deafness, giddiness, noise in the ears, coldness of the extremities and surface of the body, are also present. Great oppression at the praecordia and epigastrium is now generally felt, attended by difficulty of breathing, and general collapse of the system. The pains sometimes felt in the abdomen are of a colicky nature, and these, with the pain accompanying the spasms of the muscles of the abdomen, and of the extremities, are relieved by pressure and friction. The skin becomes colder and colder as the disease advances, and is covered with a cold damp, which 



20 

SYMPTOMS AND PROGRESS 

increases to a copious, cold, raw moisture, which bedews the shrunk, sodden, and cold integuments, especially of the extremities. The countenance now assumes a contracted or collapsed, cadaverous, and anxious appearance. 

The eyes are sunk in their sockets, and are surrounded by a livid circle. The pulse becomes first small, quick, oppressed ; and afterwards, it scarcely can be felt at the wrist. Blood taken at this period is quite black, thick, and oily, and it frequently will not flow from the vein. The arterial blood also presents the characters of that usually circulating in the veins. The patient all the while complains of a burning sensation about the epigastrium and umbilicus, and of an unquenchable thirst. The tongue and mouth are, however, moist, cold, and white. The vomitings and stools are now frequent, and consist entirely of a fluid resembling rice-water, with mucous flocculi and albuminous matter floating in it. Sometimes these matters are muddy, turbid, and somewhat different in colour; but they are always without any admixture of bile. As the disease advances, these evacuations become less and less frequent, and sometimes subside for a considerable time before the death of the patient. The same may be said with respect to the spasms. The urine seems not to be 



21 

OF THE EPIDEMIC CHOLERA. 

secreted, and not only it, but even the saliva, and all the glandular secretions, appear to be completely arrested during the continuance of this dreadful malady. 

As the disorder advances, the eyes and other features become more sunk, and the corneae assume a flaccid appearance. The extremities are perfectly cold, covered with a cold, clammy moisture, and their surfaces sodden and corrugated. The voice becomes feeble, sepulchral, and unnatural ; the respiration more and more oppressed, generally quick, and sometimes slow ; and the air which the patient expires is cold. During this state, restlessness is generally observable, and is sometimes very urgent ; the patient tosses about continually, and evinces the utmost distress. 

Although the patient is listless, impatient of disturbance, averse from speaking, and is altogether physically overwhelmed, still he retains his mental faculties to the last hour of his existence. 

Towards the termination of the attack, the sense of anxiety at the prsecordia and epigastrium seems to increase. The restlessness appears to degenerate into a kind of jactitation ; the vital actions gradually sink, and, at last, 



22 

SYMPTOMS OF INVASION. 

entirely disappear ; and the patient dies, generally, within twelve, fifteen, twenty, or twentysix hours from the invasion of the disease. 

Such is the description of the progress of the epidemic cholera — a disease which can never be forgotten by the practitioner who has even once been called upon to counteract its effects, nor contemplated, whether in idea or in reality, without sentiments of the most anxious and painful nature. 

I shall next proceed to notice those symptoms which mark the different periods of the disease, in order that more precision may be entertained respecting the employment of the means best suited to counteract its disposition to a fatal termination. 

SECTION 11. 

Of the early Symptoms of the Epidemic Cholera, or the Symptoms of the Stage of Invasion. 

It is a matter of the most serious importance, both as respects the reputation of the practitioner, and the lives of those who come under his care, that the symptoms denoting the invasion of the epidemic cholera be familiarly 



23 

SYMPTOMS OF INVASION. 

known to him. From these symptoms, I am fully convinced, that an experienced and an attentive observer may discover the approaching invasion of the disease ; and, by having recourse to suitable treatment, may prevent it from assuming that degree of severity which it inevitably would assume, if it were left uninterfered with even for a very few hours ; and which would lead to a fatal termination, in a great many instances, notwithstanding the employment of the best-adapted and most active means. 

A practitioner possessed of true professional tact, will discover, in the countenance of the patient, the earliest changes which mark the approaching invasion of cholera. The countenance is expressive of something approaching a state of anxiety, although the patient himself may not be aware of his state, or even that he is at all ailing. If the medical attendant inquire how he feels at this time, he generally answers, " Very well :" but if pressed upon the subject, he acknowledges that he experiences feelings which he cannot distinctly describe, though he feels neither pain nor sickness. His spirits are, however, low, and there is a clammy moisture sometimes on the skin, and the pulse, though occasionally full and strong, is evidently oppressed and labouring. It is not, however, 



24 

SYMPTOMS OF INVASION. 

that kind of pulse which would attract particular attention, unless we are upon the alert for this disease ; but being prepared for such a visitation, it is impossible to mistake it : and bleeding at this moment may be, and indeed has been found to be, attended with the happiest consequences. 

I could adduce many instances, wherein a close attention, paid with the express purpose of discovering and observing this stage of the disease, has led to the adoption of measures which have had the best effects, as respects both its subsequent severity and the recovery of the patient ; but this is unnecessary : the necessity of closely watching for, and of paying unremitting attention to, this stage of the malady, being sufficiently obvious. 

During this stage of the disease, I may farther add, that the patient feels considerable nausea, and has his bowels more freely moved than usual ; but the stools then generally consist of such matters as have been lodged in the large intestines, and consequently they present various appearances, according to the state of the digestive organs at the time of invasion. The patient, however, often complains of no actual pain, even on pressure made upon the abdomen, either in this, or in the subsequent stage, but what is the result of the spasm in the latter. 



25 

SYMPTOMS OF INVASION. 

He feels chiefly a great degree of exhaustion, and inability to make the least exertion. Colicky pains are frequently felt in the belly ; but they often pass off, or are relieved by pressure and the free evacuations which take place in this stage. The urine, in the period of invasion, is often in small quantity, and seldom voided. 

The following extract of a letter, from an intelligent and zealous medical officer, bears so fully upon this subject, that I shall take the liberty of quoting it, as it shews, in the clearest manner, the strong impression made upon his mind as to the advantages that arose to the men under his charge from closely and vigilantly watching this stage of the disease. Mr. Colledge,* surgeon of the Honourable Company's ship General Harris, writes to me in the following terms :—¦ " From the kind manner in which you have received a part of the sick belonging to the ship General Harris, under your charge, into the Madras Hospital, perhaps a statement of the primary symptoms, or mode of attack of upwards of seventy cases, 

* As the symptoms of invasion of the cholera have been so very little insisted upon by those writers whose works on cholera I have had an opportunity of seeing, and even, I believe, altogether overlooked by most of them, I here insert the whole of Mr. Colledge's letter, in support of my observations; adding merely a few corrections, which by no means affect the general purport of his remarks. 



26 

SYMPTOMS OF INVASION. 

may not be altogether devoid of interest, as, in my opinion, they partake much of the nature of the epidemic which has prevailed in India, more or less, since the year 1817. I must acknowledge, however, that some of these cases wanted the usual characteristics of this disease ; but if it be taken into consideration, that the early period of their application for medical aid, or what is termed amongst seamen, going to the doctor on a refusal to work, we shall not be at a loss for symptoms, which obviously mark the disease, previously to the supervention of purging, vomiting, or spasms. 

" I am so thoroughly convinced that these symptoms are only secondary, that, were the following marks present, I should not hesitate to pronounce the case to be one of epidemic cholera. 

" As the patient is approached, an appearance of overpowering lassitude is at once perceived, with a pallid, anxious, and sorrowful cast of countenance ; and in more advanced stages the countenance is dejected and sunk. Here allow me to remark, that this peculiarity of countenance was so very obvious to every intelligent person, that many of the officers deserve my best thanks, for bringing to my notice those who assumed this oppressed appearance. 



27 

SYMPTOMS OF INVASION. 

" My object being merely to point out early symptoms, you will grant me the use of the patient's own words : —'I must knock off work ; I feel unable to do more, but don't know what is the matter : I have only a little pain in stomach, and rumbling in the guts.' These are the patient's own words. Sighing, peevishness, and uneasiness, accompanied these complaints : are not these symptoms of congestion, to a considerable degree, in some vital organ ? 

"July 4th, 1821, 10 o'clock, a.m. Robert Smy came in the manner above described ; I purposely neglected him, but I kept an attentive eye upon him, often passing his birth, and asking him how he was ; feeling confident that cholera would be the result. One experiment of this kind was quite sufficient, and it was a sufficient warning to my assistant and myself to attend to the early symptoms. The patient was saved, but with much difficulty. At eight o'clock, p.m. I was sent for, and found him vomiting, and affected with spasms. His pulse was feeble and his spirits low. He considered himself as having been neglected, and refused to take medicines. Nine hours had elapsed, from the appearance of the premonitory symptoms, until purging, vomiting, and spasm appeared. 



28 

SYMPTOMS OF INVASION. 

" George Smith, Henry Sankin, Robert Hart, John Miller, George M'Alpin,* were in similar cases; but they were allowed to go without treatment at this early stage of the disease, in consequence of their own obstinacy in refusing to submit to it. The appearance of the countenance and other symptoms, marking the early stage of the disease, were best shewn in the cases of Webber, Lindigreen, Anderson, and Fabin.* From the continuance of pain, and protracted disposition to a state of collapse, in each of these cases, I am warranted in concluding that an unfavourable termination would most probably have supervened, had I deferred the treatment until the more direct and diagnostic symptoms of the disease had manifested themselves. 

" An extract from my journal will shew the healthy state of the ship's company, previous to the appearance of this dreadful malady, the rapidity of attack, violence of symptoms, and the success derived from copious bleeding, &c. " Madras, June 27th. The Honourable Company's ship General Harris dropped anchor in these roads on the 20th current. Her crew, 

* The names of some of the patients who were landed and admitted into the Madras Hospital. 



29 

SYMPTOMS OF INVASION. 

consisting of 140 men, 198 Honourable Company's recruits, and sixty passengers, all in good health, and free from epidemic disease during the whole passage from England. This day (27th) cholera spasmodica attacked one of our seamen whilst in bed, and three other cases have occurred up to July sth ; one of which appeared under the aggravated form of collapse, and died in ten hours. The disease is now raging violently throughout the ship's company, cases hourly coming before us, some of which have the well-marked symptoms of cholera ; others, on their application, have neither purging nor vomiting, but they are marked by an anxious and depressed countenance, general lassitude, and inability to exertion ; pain across the diaphragm, with sense of constriction about the thorax. A few complain of pain on deep inspiration, and of headach and vertigo. Pulse regular, but quickened or oppressed, and differing as the constitution is feeble or robust. Tongue furred, with a clamminess of the mouth, and insatiable desire for cold water; they finding nothing to be relishing but this fluid. Skin cold and clammy. When blood was drawn under these circumstances, it was dark, and the patient then invariably vomited, expressed himself wonderfully relieved, and always recovered." 



30 

SYMPTOMS OF INVASION. 

The sentiments contained in the above extract correspond so precisely with my own observation, and corroborate so fully the views, on this topic, which I had adopted, that I make no apology for having given them thus at length. The cases which Mr. Colledge particularly alludes to, were all landed at Madras, and they all recovered. John Miller, after having been discharged from the hospital, quite recovered, had a severe attack of dysentery, and was left at the general hospital when the ship sailed to China ; but he recovered his health perfectly. 

The detailed cases are likewise to be found in the hospital journals for July 1821.* 

* Since this treatise was ready for the press, I have had an opportunity of seeing the " Report on the Epidemic Cholera," drawn up by Mr. William Scott, surgeon, and secretary to the Medical Board at Madras. In that report, I find the following statement, which must either proceed from an imperfect experience of the disease, or from a deficient attention to its early stages. 

" This most formidable disease," Mr. Scott states, " does not appear to be attended by any premonitory symptoms, which can be regarded as being at all peculiar to it ; on the contrary, we may safely assert, that it is of sudden invasion ; for, although a slight nausea, a laxity of the bowels, and a general feeling of indisposition are often found to precede cholera, yet these symptoms are evidently common to many 



31 

SECTION 111. 

Symptoms of the Second, or advanced Stage of the Epidemic Cholera. 

The symptoms usually looked for, as marking the advanced stage of this disease, are vomit- 

acute diseases ; and they are especially frequent in this climate, without being followed by any graver ailment. When such symptoms are found to precede cholera, they might with more truth be regarded as indicating merely a certain deranged state of the alimentary organs ; a condition of the body which certainly predisposes a person to an attack of cholera." 

I have adduced sufficient evidence that there are premonitory symptoms, and those of a pathognomonic kind. I would not have noticed this statement, but, proceeding from authority, it is calculated to mislead, if it be allowed to go uncontradicted. The sudden invasion, as it is called in this quotation, with slight nausea and laxity of the bowels, is, in fact, the approach of the disorder to the second stage — the transition of the symptoms of invasion into those of the perfectly formed disease, when it is approaching its height, and when the patients are more generally brought to receive medical aid. When the premonitory or invading symptoms are not understood, and particularly when they are not looked after, the medical attendant is quite unprepared to check the disease in its early progress, when it is most manageable. 



32 

SYMPTOMS OF THE ADVANCED STAGE. 

ing and purging of a thin watery fluid, similar to rice-water, with white flocculent matter floating in it. Cramps supervene in the legs, arms, and muscles of the abdomen, and in many cases become even more general. The eyes are sunk, and the features sharp and collapsed. The skin is generally cold, and covered with a cold, clammy dew. There is scarcely any pulse at the wrist, and, if it be at all perceptible, it is small and thready, and generally quick ; but it sometimes gives the sensation to the finger of oppression. The extremities are cold, livid, and shrunk. Sometimes there is considerable heat about the chest and epigastrium, and the head is in general hot. The tongue is not particularly foul, though, at times, it is covered with a thin coat of glairy mucus ; and, at other times, it is dry and white, having the appearance of being without blood ; but it is not furred. The lips are cold and blue. The fluid stools are generally discharged from the bowels with a considerable degree of force, as if they were ejected from a syringe ; but they are generally not accompanied by any pain. 

During this stage the patient voids no urine ; and, judging from the phenomena of the disease, and the appearances observed on 



33 

SYMPTOMS OF THE ADVANCED STAGE. 

the dissection of fatal cases, I believe that the functions of the kidneys are entirely suspended ; the watery part of the circulating fluid usually secreted by the kidneys being completely drained off, by the diseased action of the mucous surface of the digestive canal. 

The appearance of the extremities is peculiar, particularly of the superior extremities : the hands and ringers are shrivelled, as if they had been soaking in warm water for a considerable time. The nails are blue, and sometimes there is a blue cast over the whole skin. The prostration of strength becomes now excessive, and the thirst insatiable, evidently owing to the defect of the aqueous part of the blood, from the number of watery stools. Accompanying this insatiable thirst, the patient generally complains of an inward heat, and of a burning sensation about the umbilicus. 

These are the symptoms which are generally observed when patients are first brought for assistance, both in natives and Europeans ; they differ only in degree, and are merely modified according as the strength and vigour of the patient may have given rise to some degree of re-action of the vital energies of the system. 

n 



34 

SYMPTOMS OF THE ADVANCED STAGE. 

In this stage the spasms may become tolerably general ; but the muscles of the back and of the face are uniformly exempt from them. Notwithstanding the urgency of the vomiting and purging, the patient complains of little or no pain on pressure being made upon the abdomen : indeed he generally makes but little mention of any other painful sensation than of that of a colicky nature, and what accompanies the spasm, and the burning sensation in the abdomen to which I have already referred. 

With respect to the appearance of the stools, and of the matters thrown off the stomach in this stage of the disease, I may remark that, when the bowels have not been fully emptied during the previous stage, the stools which are the first evacuated generally vary in appearance, according as the matters lodged in the intestines may modify their character; but they generally assume the appearance of congee-water, with flocculent matter floating in them, or matter of a still more albuminous character. But almost in no case of the disease do we find, in this stage, any appearance of bile in the stools ; nor does bile ever appear in them until the violence of the malady has received a check, and until 



35 

SYMPTOMS OF THE ADVANCED STAGE. 

it is allowed to flow into the duodenum, from this circumstance, and from the operation of the remedies employed. As to the appearance of the matters thrown from the stomach, it may be generally stated, that they consist, at first, of such ingesta as may have remained in this viscus at the time of attack, and that they are afterwards in every respect similar to the matters which come away from the bowels.* When the disease draws to a termination, the violence of the retching and purging 

* In Mr. Scott's Report on Epidemic Cholera, formerly alluded to, I observe the following statement : — 

" Spasm may be generally present in one instance of invasion ; in another it may not be distinguishable. A frequent variety, the worst of all, is that which is noted for the very slight commotion in the system ; in which there is no vomiting; hardly any purging; perhaps only one or two loose stools ; no perceptible spasm ; no pain of any kind ; a mortal coldness, with arrest of the circulation, comes on from the beginning ; and the patient dies without a struggle." 

This is a type of the disease which I have never seen. Deaths may take place in this manner and suddenly in the disease, and when no person can give information as to how long the patient had been complaining, or as to the nature of his complaints, before he was brought for medical aid; but in every case in which I had an opportunity of marking the progress of the disease, 1 have seldom found it to terminate in a shorter period than that of ten or twelve hours, or without much more marked symptoms than those 



36 

THE PATHOGNOMONTC SYMPTOMS. 

often ceases ; but still a watery, and sometimes an ichorous fluid continues to flow both from the mouth and anus until the death of the patient. 

SECTION IV. 

Of the Pathognomonic, Diagnostic, and Prognostic Symptoms of Epidemic Cholera. 

The symptom which I have always looked for as particularly marking this disease — and I have never seen a case of the epidemic wherein it did not exist — was a burning sensation between the scrobiculus cordis and umbilicus, precisely over that spot where the vermilion blush was invariably found on examination after death.* This is one of the first symptoms the patient is sensible of, and it is generally felt before vomiting or purging takes place. Whenever this painful sensation is 

referred to in this quotation. I have certainly seen patients die in the state described by Mr. Scott, and a great many have died as described by him ; but, in all these instances, the symptoms indicating a more violent commotion of the system have passed off, and the fatal collapse had proceeded before they were brought for treatment. 

* See the Section on the details of cases illustrating the pathology of the disease. 



37 

THE PATHOGNOMONIC SYMPTOMS. 

accompanied with an anxious look, and a general feeling of weakness or oppression, even without vomiting or purging, we may be certain that the disease is at hand ; and at this stage it is generally manageable, if boldly and decidedly treated. 

The vermilion blush over the small intestines — which blush exactly resembles the colour which they assume when injected to shew the villi* — I conceive to be peculiar to this disease, and belonging to its pathological character, because it is the only appearance that is not observable in many other diseases : for instance, congestion of the brain is found in an equal degree in apoplexy ; and in various visceral affections, we find occasionally congestion to a great extent in the liver, spleen, lungs, &c. &c, but the peculiar vermilion appearance observed in cholera, I do not recollect to have seen, by any means, so generally in my examination of those who have died of other diseases of the abdominal viscera. I am, however, fully aware that this appearance may sometimes be found in cases of sudden death; but I am anxious to draw attention to this particular symptom, and to 

* See the dissections in Chapter 111. Sect. I. 



38 

THE PATHOGNOMONIC SYMPTOMS. 

connect it with this particular appearance of the small intestines, which appearance will always be found on examination after death. This symptom, therefore, I consider as particularly characteristic of the epidemic cholera ; and this morbid appearance, which is related to it, I conceive to be the particular lesion which is uniformly to be met with on dissection of cases of the disease. 

Cold skin, colliquative sweats, and collapsed countenance, are symptoms which I have frequently seen in cases where worms were the cause of disease ; and which symptoms were completely removed on their discharge. But, in treating cholera, I have always been particularly careful to ascertain, in its early stage, whether the patient complained of a burning sensation about the umbilicus or not ; and whether it was mild or otherwise : when this symptom was felt, and more particularly when it was attended with sighing and anxious respiration, I considered the case to be a well-marked one of epidemic cholera, and acted accordingly. 

It is seldom, indeed, that patients are seen before all the symptoms are fully developed, and then the pulse at the wrist generally cannot 



39 

DIAGNOSTIC SYMPTOMS. 

be felt. There is little to be expected from human art at this period of the disease ; yet I have seen such cases recover frequently, but still I consider recovery to be quite a chance, and to be, perhaps, owing more to the constitutional strength of the patient than to the remedies employed, or to the knowledge and judgment of the practitioner. I am, however, quite satisfied that the disease will prove perfectly manageable if the treatment be commenced in its early stage, and before the symptoms of congestion have arrived at the utmost. 

Diagnostic Symptoms. — There is no symptom of the disease more uniform than the black, thick, and ropy condition of the blood taken from a patient in the epidemic cholera, particularly when the disease is fully formed. This condition of the blood, of which the arterial blood also partakes, is, even of itself, and still more particularly when viewed in connexion with the other symptoms, sufficient to distinguish the disease from the cases of sporadic cholera formerly occurring in India, and from the cholera usually observed in warm climates, or in temperate ones during the autumnal season. The low and exhausted state of all the vital actions, the depression of the patient's 



40 

DIAGNOSTIC SYMPTOMS. 

spirits, the unnatural appearance, and cold, dewy condition of the surface of the body ; the withered and cold state of the extremities, the extension of the spasms, so early in the disease, to the muscles of the superior extremities and chest ; the entire absence of bile from the stools and the matters vomited, the suppression or interruption put to the secretion of urine, and to all the other natural secretions ; the early depression of the action of the heart and of the pulse ; the coldness of mouth, tongue, and respired air, — are phenomena which we find not similarly congregated in any other disease, and which are sufficient to distinguish it from the other species of spasmodic diseases in general, and from the bilious cholera, and even from the mort de ckien, or more violent form of the cholera commonly observed in India, in particular. 

The clonic nature of the spasms, the manner in which they attack the extremities and abdominal muscles, and their uniform absence from the muscles of the back, loins, and face, are circumstances sufficiently serving to distinguish epidemic cholera from tetanus and trismus. The copious evacuation of the bowels and stomach, the state of the pulse and surface of the body, and the sensation felt, so early in the 



41 

DIAGNOSTIC SYMPTOMS. 

disease, at the epigastrium, serve to shew that it cannot be confounded with colic. As bile is seldom if ever met with in the severer cases of the common cholera of India, until the violence of the disease is diminished, or medicines procure the flow of it into the intestines ; and as the general phenomena of the disorder are so nearly allied, —it may be proper to allude, at this place, to the points of dissimilarity existing between it and the epidemic form of disease. But here I may also admit, that a number of the phenomena characterising both, differ chiefly in the greater malignity of those appertaining to the latter malady, and in the rapidity of their progress to a fatal termination. The absence of bile, however, from the matters voided in both forms of disease cannot be assumed as grounds of identity between them, more than the existence of spasm in both can be considered as such. In the latter form of malady, besides the more malignant nature of many of the phenomena common to both, we find that the state of the blood, the burning sensation complained of at the epigastrium, the low, weak, small, and undeveloped state of the pulse from the commencement of the attack; the cold tongue and mouth, the coldness of the respired air, the great derangement 



42 

PROGNOSTIC SYMPTOMS. 

of the respiratory function, the shrivelled state of the extremities, the cerebral congestion, the clonic nature of the spasms, the suppression of the urine and other secretions, the wide diffusion of the disease throughout southern Asia, its violence, and fatal effects, — are circumstances which authorise the inference, that the epidemic cholera is different from the common cholera of India, as observed previous to 1817, not in degree alone, but that it is also different in kind. These circumstances cannot be explained by a reference to a mere difference of intensity in the causes immediately producing both forms of disease, but must be referred to the existence of some superadded cause, whose presence and extension has been as general as the epidemic disease which it has been mainly efficient in producing. 

Prognostic Symptoms. — The symptoms by which the practitioner may with propriety be led to hope that the disease will terminate favourably, are, an increase of the strength and fulness of the pulse, a return of warmth to the extremities, and an increase of heat on the surface of the trunk ; less frequent calls for drink, and a diminution of the burning sensation in the epigastric and umbilical regions ; 



43 

PROGNOSTIC SYMPTOMS. 

diminished urgency, or cessation of the spasms, vomiting, and purging ; the appearance of bile in the motions, and an inclination to void the urine, and still more particularly, if any quantity be voided ; an improvement of the countenance, and a return towards the healthy appearance and functions of the skin ; a more natural respiration, and an increased warmth of the air which is expired by the patient ; an inclination to tranquil sleep, or a more lively aspect of the eyes ; a ruddier or livelier appearance of the lips, tongue, and mouth ; and less general uneasiness and restlessness. If, on the contrary, the symptoms mentioned in the description of the disease increase rapidly, notwithstanding the means of relief which have been adopted, and the functions of respiration become either very unusually slow and oppressed, or very quick and laborious, as if the patient were gasping for breath ; and if the action of the heart be so greatly diminished as not to occasion pulsation in the extremities ; when the features are sunk and collapsed, and the tongue and mouth become cold, and the breath occasions a cold and raw impression ; and when the cornea begins to sink, and jactitation to be constant, the spasms, vomitings, and purging, at the same time to cease, we cannot hope for the recovery of the patient. 



44 

PROGNOSTIC SYMPTOMS. 

The vital energy has then sunk so low, owing to the impression of the cause of disease, and to the more immediate effects produced thereby upon the nervous system, and upon the blood through the medium of the lungs, that it seems beyond the influence of medicine to restore it. 



45 

CHAPTER 111. 

ON THE PATHOLOGY OF EPIDEMIC CHOLERA. 

Before I proceed to consider the causes of the disease, I will first detail the history of some of the cases which came under my care, and the appearances which were observed upon a post mortem examination of them. lam induced to adopt this arrangement, because these cases not only illustrate the description I have now given of the disorder, but they furnish, in addition to what I remarked in other cases which came before me, the data on which I rest some observations respecting its pathology. These cases will also be found to convey much useful information, which may be made available when I come to speak of the causes and treatment of the epidemic cholera ; and the details of these cases will not, it is hoped, appear the less interesting, that they enable the pathologist to trace the relation which he may consider to have existed between the signs of disease observed during the life of the patient, and the lesions remarked after death had taken place. 



46 

CASES OF EPIDEMIC CHOLERA. 

SECTION I. 

Details of Cases illustrative of the Pathology of the Disease. 

I had no opportunity of treating the epidemic cholera in 1818, the year when it first appeared at Madras; but in 1819, on taking charge of the general hospital, at this presidency, opportunities of doing so were ample. Having formed no notion of the nature of this disease till my own observations enabled me, I entered upon the treatment of it perfectly unbiassed in my practice. The following cases were the first that came under my charge ; and, as they furnished the grounds on which I founded my opinions respecting the nature of the disease, and of the treatment which I considered the most suitable to it, according to the ideas I formed of its pathology, I shall proceed to detail them faithfully to the reader, and as they stand in the journals of the hospital. 

CASE I, 

James Lynch, private H. M. 84th regiment, aged 30 years, a strong, healthy man, seldom in the sick report, but much given to the drinking of spirits. The party of the regiment to which this man belonged was encamped upon the south beach, ready for embarkation 



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to Europe. Strong southerly winds were at this time blowing, and the men, owing to their situation, were exposed to cold blasts and clouds of sand. It appeared that Lynch had taken a hearty dinner at two o'clock, p.m. on the 23d May, 1819. That about three o'clock the same afternoon, he accompanied some of his companions to bathe in the surf close to the tents. While in the water, he was attacked with sickness at the stomach, and he vomited a quantity of green, bitter matter. This was almost immediately followed by a violent purging ; and the stomach and bowels, from this time, were emptied alternately, till their natural contents were completely removed, after which, the discharges from both became watery. In this state he was brought to the general hospital, between the hours of six and seven o'clock, p.m., accompanied by Dr. Walker, surgeon of H.M. 73d regiment, who had been appointed to the medical charge of that division of the 84th regiment which was about to embark for Europe. 

I am unacquainted with what had been done for this man previous to his admission into the general hospital, nor did I see him on his arrival, having been at the time engaged with a very difficult case of midwifery ; but Dr. Walker, and Mr. Conwell, who was also present, gave stimulants with opium, used friction, applied warm bricks to the extremities, and opened three veins in the arm. When I saw him there was no pulse at the wrist ; he was covered with a profuse, cold, clammy dew ; the nails were blue ; fingers and palms of the hand shrivelled ; eyes sunk deep in the orbits, and the features collapsed and sharp ; thirst excessive, the patient continually calling for cold water ; breathing exceedingly 



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CASES OF EPIDEMIC CHOLERA. 

oppressed and difficult. No heat about any part of the body, except the chest, which was considerably above the natural temperature. Tongue white, and covered with a clammy mucus. Spasms in the extremities and body extremely distressing. Blood could not be procured from the arm; the little which oozed out was thick, black, and ropy. 

Warm, stimulating applications were applied to the extremities and body; he was put into a warm-bath, brandy and water were given him to drink, which he took with avidity, and after he was removed from the bath, he was well dried in warm crunlies ;• a stimulating injection was given, and sinapisms were applied to the legs. About forty minutes past seven o'clock his breathing became short, quick, and laborious ; and he died about eight o'clock, p.m., five hours from the first attack. 

Examination of the Body. 

On laying open the abdomen, the arch of the colon was found considerably contracted ; the stomach greatly distended, and completely covering the liver, leaving a very small portion visible, which was of a pale brovm colour. The omentum was very fat, and covered the whole of the small intestines. 

Intestines. — After the removal of the omentum, the small intestines exhibited a very singular and unusual appearance : their coats were much thickened, and they had a doughy feel, as if filled with pultaceous 

* An Indian blanket. 



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CASES OF EPIDEMIC CHOLERA. 

matter. The duodenum and jejunum were of a pale vermilion colour ; the ileum was of a darker hue, and its calibre much contracted. About two feet of this intestine, near its entrance into the caecum, had a dark blue colour, and the veins upon its surface were beautifully injected. 

The small intestines were laid open throughout their course ; their coats were generally much thickened, and they contained a quantity of thick, viscid, and tenacious matter, of a yellowish cream colour. It is remarkable that, although there were considerable congestion and vascularity in the external coat of the small intestines, there was not the least appearance of congestion or vascularity in the internal surface of either the duodenum or jejunum ; but upon that part of the ileum which I have already noticed as having a dark blue cast, the mucous coat was quite purple, and we distinctly traced this to be owing to the venous congestion. 

The external coat of the colon had the same colour which I have already described, and, on laying that gut open from the caecum to the rectum, I could not observe any change of structure ; but from the commencement of the transverse arch to the rectum, the whole internal coat was of a dark red colour, which increased in brilliancy as it approached the rectum. No faeces were found in the intestinal canal. 

Stomach. — The stomach was next examined and laid open. Near the pyloric orifice it was much corrugated, of a dirty and darker colour than natural, with some bruised bloody spots between the coats. The 

r<: 



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CASES OF EPIDEMIC CHOLERA. 

pylorus had a bright red, gelatinous appearance, compared with the part above described. 

Liver. — The liver was not enlarged, but the superior convex part of the right lobe was of a purple and mottled hue ; and the inferior concave surface of the same lobe was of a dark blue colour ; this part, on being cut into, emitted freely, thick, black-coloured blood. 

The gall-bladder contained about three ounces of bile, of a dark green colour, but not so thick as I have sometimes seen it. There appeared to me to be a stricture of the mouth of the common duct, which prevented the bile from passing without very considerable pressure upon the gall-bladder ; but after this stricture was once forced, the bile then flowed with ease. 

Lungs. — I found some adhesions between the lungs and the pleura costalis, and the vessels filled with blood; but the whole posterior portion of the lungs presented precisely the appearance of a solid mass of bruised, bloody flesh ; and, when cut into, had a fleshlike structure ; it gave out profusely, a black, thick blood, and seemed to have completely lost the character and structure of lung. 

Heart. — Very little water in the pericardium, but the blood-vessels were turgid. The heart itself was collapsed, particularly the right ventricle, and contained no blood. ....... 

Head. — The dura mater was transparent, and the vessels were in a very turgid condition. 



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CASES OF EPIDEMIC CHOLERA. 

Between the tunica arachnoides and the pia mater, on the middle lobe of the right hemisphere, I observed a considerable effusion of dark-coloured, gelatinous, bloody lymph, as if a severe blow had been inflicted on that part ; and on the left side also, the same appearance existed in a less degree. The vessels of the pia mater were very turgid, and of a darker colour than I have ever seen them before. The appearances, generally, were precisely the same as are found in some apoplectic subjects. 

On removing the pia mater, the brain was found soft and pulpy. There was very little water in the lateral ventricles. The vessels of the choroid plexus were very turgid, giving it a dark, reddish brown appearance, very different from its natural and healthy state. The vessels of the cerebellum were precisely in the same state of congestion as those I have already described ; the pons varolii and medulla oblongata were likewise highly injected, and a small quantity of water was found lying in the cerebellic cavity and top of the spine. 

CASE 11. 

Chowery Mooto, Sepoy, 2d br. sixth regiment N. infantry, a strong, healthy man, about forty-three years of age, and had lost his leg at the battle of Mahidpoor, 21st Dec, 1817. He was perfectly well, to all appearance, at seven o'clock in the morning of the 25th May, 1819, when I was going my rounds through the general hospital. At ten o'clock he was reported as having been attacked with vomiting and purging; I went to 



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him immediately, and found a wonderful change in his general aspect : his features were sharp and shrunk ; pulse scarcely perceptible, small, thin, and struggling ; skin cold, and covered with clammy dew ; burning sensation above the navel ; countenance expressive of great anxiety and distress, but not of a feeling of actual pain. When I inquired where he felt pain, he drew his ringer round the navel, and said, " Here." As the Medical Board at Madras had recommended the application of nitric acid, as a quick and effectual blister in these cases, the umbilicus, scrobiculus cordis, and chest, were well rubbed over with the following :—: — 

R Acid. Nitr. fort. 3iij. Aq. purse giss. M. 

It produced considerable smarting, but did not in any degree produce blistering; a large mustard cataplasm, mixed with vinegar, was, therefore, laid over the whole abdomen, and the following draught given : — 

ft Sp. iEtheris Sulph. 3J. Opii g tt . 1. 

Aq. Cinnam. 

Aq. purse Jj. M. ft. haustus 

Warm frictions, and hot bricks were applied to his extremities. 

Eleven o'clock, a.m. — Passed a large evacuation of pure yellow fluid, unmixed with faeces, and which I considered at the time to be pure hepatic bile. He 



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CASES OF EPIDEMIC CHOLERA. 

retained the draught upon the stomach, but the pulse could not be felt at the wrist, and the whole surface of the body was covered with a clammy, cold dew. Thirst very urgent ; spasms extending from the hip to the foot, and extremely distressing. 

Warm brandy and water was given to him occasionally, but in small quantities at a time. The vapour-bath was used, and friction, with spirits of turpentine, applied to the extremities, with evident relief of the spasms ; and as the thirst was most distressing, a person was constantly at his side supplying his wants, but preventing his taking too much at one time, lest it should make him sick. 

He was sensible of the heat of the vapour-bath, and moved about a good deal while it was in use ; but it appeared to me rather to distress than relieve him, and it made no alteration whatever in the temperature of the skin. 

At twelve o'clock he became perfectly indifferent to external objects, would not speak, but made signs that he was easier. No warmth could be produced on the skin, either by friction or the vapour-bath. The surface was still covered with a cold, clammy dew, and his eyes were much sunk in their orbits, and drawn upwards, so that the white of the eye can alone be seen. He made no complaint ; but the anxiety expressed in his countenance was distressing. No pulsation was felt at the heart or wrist, and he breathed with great difficulty. 

The draught was repeated, and an anodyne injection was given. The former remained on his stomach, but the latter was immediately returned. He called 



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CASES OF EPIDEMIC CHOLERA. 

anxiously for rice-water, with brandy, which was given to him; and the spirituous frictions and vapour-bath were continued. 

At one o'clock, the skin still continued cold, and he seemed not so sensible to heat as he formerly was. He made a slight effort to vomit, but did not throw any thing off his stomach. He was quite indifferent to every thing around him, and disliked being questioned. There appeared, at this visit, to be some uneasiness and confusion in his head, for which a few leeches were applied to the temples. As they would not bite, a vein was opened in the arm, but no blood followed the operation. In this state he continued till three o'clock, p.m., when he fancied himself much better, and called for mallagatawney. I could not see any favourable change, and he died before the pepper-water could be prepared, about five hours from the period of attack. 

Examination after death. 

Abdomen. — Small Intestines. — After removing the parietes of the abdomen, the jejunum appeared much inflated, rising considerably above the other intestines, and throwing back the omentum and colon, so as to leave itself completely uncovered. There was much congestion in this intestine, and several spots of a dark-red and bruised-like appearance. Near the commencement of the ileum this intestine had a thickened feel, and was of a dark vermilion colour, which extended some distance along the ileum ; but the lower part of this latter intestine, on being removed from the 



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pelvis, exhibited a more natural state of its coats, with less of the pulpy matter than was found in the upper part of the canal ; but it was of the same hue as described above, only of a lighter vermilion, or flesh colour. 

The duodenum was laid open, with a view to examine the biliary ducts. The mouth of the ductus communis choledochus was sufficiently open to admit the point of a probe ; but the bile did not flow from the gall-bladder until considerable pressure was made upon it. The whole of the small intestines was removed and laid open from the duodenum to the caecum. In the duodenum and jejunum, there was, both externally and internally, considerable congestion, which appeared to exist in the cellular substance connecting the muscular and mucous coats. Blue and red-coloured spots were observed in various parts of these intestines, corresponding precisely with the place where he complained most of pain, when he was first attacked with the disease. 

There was not much congestion in the ileum, but a dusky vermilion blush pervaded the whole of that gut, similar to the external appearance of the gut when injected to shew the villi. 

Colon. — The colon was partially contracted throughout its course, and on laying it open, there was not observed the slightest appearance of congestion, either on the external or internal surface. 

Stomach. — The stomach was distended by a watery fluid. The general appearance of the peritoneal coat was natural ; but on the internal surface there was considerable congestion, particularly about the cardia and large 



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CASES OF EPIDEMIC CHOLERA. 

curvature ; and this congestion appeared, evidently, to be confined to the vessels of the cellular tissue, connecting the muscular with the mucous coats. 

Liver. — The liver was not much enlarged, but it was in a high state of congestion, of a dark blue colour, and it bled freely when cut into. The gall-bladder was not unusually full of bile, and what was found there was healthy. 

Lungs. — The lungs were much collapsed, of a very dark colour. Both lobes were like a mass of bruised flesh, and, when cut into, had a fleshy structure, and poured out, very profusely, thick, black blood. 

Heart. — The right auricle and ventricle were full of blood, and both the vena cava superior, and inferior, were gorged with the same fluid. A small quantity of black blood was found in the left auricle and ventricle. 

Head. — The dura mater was transparent, and the meningeal arteries and veins exceedingly turgid, both in their trunks and branches. On separating and removing the dura mater, about six ounces of serum were found between that membrane and the tunica arachnoides. 

The anterior portion of both hemispheres of the cerebrum had the appearance of having been the seat of considerable arterial action ; the arterial branches were highly injected with red blood; and the large veins spread over the posterior portion of the cerebrum, were gorged with black blood. Upon the middle lobe of 



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CASES OF EPIDEMIC CHOLERA. 

both right and left hemispheres, there was a red, gelatinous extravasation, as if some injury had been sustained in that situation. 

The vessels of the pia mater in general, were exceedingly turgid, and infinitely more dense than in a healthy state, uniting the hemispheres so firmly, as to require some force to separate them to expose the corpus callosum. Very little water was found in the lateral ventricles, and the choroid plexus, though very turgid, still retained its beautiful appearance. Some effusion was found in the cerebellic cavity and top of the spine, and a very great turgescence of the vessels surrounding the whole of the cerebellum, the pons varolii, the medulla oblongata, and all the nerves which rise there. 

CASE 111. 

James D'Arcey, private H.M. 84th regiment, aged thirty-six years, was attacked in the tents on the south beach, about twelve o'clock at night, 27th May, 1819, with purging and vomiting, and pain in the belly and side. Dr. Walker, who was upon the spot, gave him the following draught : — 

R Tinct. Opii, 

Tinct. Valerianse, aa. g". 1. 

Aquse purse M. ft. haustus. 

And in half an hour afterwards, the same quantity of tinct. opii, and ninety drops of tinct. valerianae was repeated ; a vein was opened, but no blood would flow. At one o'clock, a.m., the patient took several drops more 



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of tinct. opii, being in all 170 drops, and was sent to the general hospital, where he arrived at a quarter past two o'clock, on the 28th May. 

Quarter past two o'clock. — Has just now had one evacuation from his bowels, of a watery consistence, and brown, muddy colour ; does not complain of sickness, but says he has a severe pain in his side. The skin is quite cold, and is covered with a cold, clammy dew ; his hands and feet are pale, bloodless, black, and wrinkled, and as if they had been soaking in water for some time. No pulse at the wrist, nor in the temporal artery ; feels no pain in his head, but says there is a noise in his ears and head, like the roaring of the surf. This, however, he did not express till I inquired whether he had pain. I therefore conclude it does not distress him. 

The medicated vapour-bath was immediately used, and appeared to act extremely well. It produced considerable heat over the body, but it did not, in the most remote degree, change the nature of the perspiration, which still continued to be a deadly-cold, greasy, moisture. The following draught was given :—: — 

R Tinct. Opii, 

Sp. JEtheris Sulph. aa^j. Mist. Camph. Jiss. Ft. haustus. 

Warm brandy and water was given frequently, and he took it with great satisfaction ; I opened a vein in the arm, but a few drops only of black, sizy blood came away ; leeches were applied to the base of the head, and 



CASES OF EPIDEMIC CHOLERA. 

59 

to his side, where he complained of pain ; but only two would fasten upon him. I could not trace the jugular vein, or I should have opened it. The scarificator was used, with the intention of cupping ; but there was not a drop of blood on the surface, and no pulsation any where but in the carotid artery. 

At half past two o'clock the draught was repeated, and congee-water, with brandy, was given. The extremities were well rubbed with spirituous embrocations. 

Three o'clock. — He has retained every thing he has taken upon his stomach ; has had two watery motions. He feels at present cramps in his legs. Let the legs be well rubbed with sp. terebinth. This was attended with the best effects — with a complete cessation of spasms ; but he says, " the pain in his side is shifting higher up towards the chest," and his breathing has become oppressed and difficult. 

The nitric-acid blister was applied over the epigastric region, and at half past three it was repeated, but with very little effect. It appears to me to do no more than to make the patient smart, without producing any thing like vesication. He says he suffers no very acute pain, and only feels weak. The spasms are not severe in any part ; but his breathing bespeaks great distress and oppression. He is desirous, however, of having something to eat. Give him arrow-root and brandy, in preference to wine. The pain in his left side increases, and he says it is gradually rising upwards to the lungs. Repeat the vapour-bath. 



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Thirty-Jive minutes past three o'clock. — Complains, for the first time, of pain about the heart. The pulsations of the carotid artery are 120 in a minute, but becoming very languid. 

Fifty minutes past three. — Pain on the left side very severe. Neither of the nitrous applications have yet had any effect upon the skin. Let the nitrous blister be repeated, of the following strength :—: — 

R Acid. Nitric, fort. 3J. Aquse puree 3SS. M. 

This produced great smarting, much worse, he says, than a blister. Breathing more oppressed, and very laborious ; excessive restlessness. The two leeches which fastened on the side have fallen off, but not one drop of blood has flowed from their bites. He has no spasms, but he is evidently sinking; his skin is quite cold, yet his mind appears quite collected : he asks for arrow-root and brandy, which are given to him. 

Five minutes past four . — Takes thirty-eight inspirations in a minute ; says he feels quite easy, though he is evidently very much oppressed. 

Repeat the draught and the vapour-bath. 

Half past four. — Still complains of a noise in his ears, like the roaring of the surf, and says he begins to feel distress and oppression about his head. He continued in this state, without any visible change, till a quarter past five o'clock, when he became quite insensible. 



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He died about six o'clock, a.m., four hours after his admission, and six from the time of attack. 

He appeared to suffer more during the last ten minutes of his life, than at any time from his first coming into hospital. 

Examination post mortem. — The appearances were precisely similar to those I have already described in the cases of Lynch and Mooto, with this exception, that there was not so much congestion in the liver of D'Arcey as in the former cases ; but the right side of the heart, the large veins leading to it, and the pulmonary arteries, were all completely gorged with blood. The left auricle and ventricle were much contracted, and contained but a very small quantity of blood, and that was of a very dark colour. The state of the brain was likewise similar to what was observed in the former 

cases. 

CASE IV. 

Serjeant Henry Halding, H. M. 84th regiment, was taken ill in Fort St. George, about ten o'clock, a.m., and went to the garrison assistant-surgeon, who gave him two draughts, which were rejected immediately. He was sent to the general hospital at three o'clock, p.m., on the 28th May, 1819, five hours after he had been attacked. 

When he arrived at the hospital the pulse was quite gone at the wrist, his skin was quite cold, and without perspiration. Complained of pain in his head, and immediately under the ensiform cartilage, but not until 



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inquiry was made as to these symptoms. Eyes clear and natural. Spasms of his extremities very distressing. He is purged frequently ; the stools are quite watery, and not discoloured ; tongue white, dry, and excited. 

Two veins were immediately opened in both arms, and about eight ounces of blood were drawn ; but it was thick, black, and sizy, and oosed out in drops. He thinks the pain in his head is relieved, but the cramps are as bad as ever. Let the medicated vapour-bath be used, and the following draught be taken immediately :—: — 

R Sp. iEther. Sulph. 

Tinct. Opii, aa SJ. 

Mist. Camph. Jiss, M. ft. haustus. 

Let the extremities be well rubbed with sp. terebinthinse, and give him warm congee-water, with brandy, to drink. 

Four o'clock, p.m. — No pulse to be felt. The draught remained upon his stomach. The pain at the epigastric region removed, and there is less uneasiness in his head. Has only occasional attacks of spasms in the extremities. There is a slight degree of warmth in his feet, and at the back of the head ; eyes quite natural ; face cold, and covered with a cold, clammy dew. 

Rept. haust.; injiciatur enema anodynum statim. Contin. ut antea, et frictio et balneum vaporosum. 

Half past four o'clock. — No change for the better. — Pergat. 



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Five o'clock. — Spasms removed; pain at the epigastrium gone. No pulse at the wrist. The pulsations of the carotid arteries are 120 in a minute, but very irregular ; no pulsation to be observed in any after-part of the body. Continue as before. 

Half past Jive o'clock. — Exceedingly restless, and complains of great heat in his feet ; I think I can feel the pulse, but it is so very weak I cannot be certain . — Cont. omnia. 

Six o'clock. — No change for the better. — Pergat. 

Seven o'clock. — The heat has certainly increased over his whole body, and there is less of the cold, clammy dew ; but he has no pulse at all at the wrist, and the tongue is white, and perfectly dry. He is very restless, and very anxious to sleep. He longs for coffee. Let him have coffee, and continue the treatment as before. 

Half past seven o'clock. — Spasms have quite left him. He. has no pain ; wishes for sleep. 

He lay perfectly quiet till eight o'clock, when his breathing became exceedingly oppressed and difficult; but he made no complaint. He sunk rapidly from this time, and died at ten minutes past nine o'clock, 

— six hours from his admission into hospital, and twelve from the time of the attack. 

Examination of the Body. — Appearances are generally the same as those I have already described. The 



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jejunum is considerably inflated, and there are several dark-red and purple spots on it. 

Great congestion in the lungs and brain, with some serum in the cerebellic cavity. 

The right side of the heart is loaded with blood, which, with a smaller quantity contained in the left auricle and ventricle, is quite black and thick. 

CASE V. 

Serjeant Gardiner Wilson, H. M. 84th regiment, was attacked with epidemic cholera, between nine and ten o'clock, p.m., of the 28th May, 1819, and was bled, but I was not informed of the quantity taken. On his admission into the general hospital, at one o'clock, a.m., of the 29th May, he had no pulse at the wrist ; the skin was cold, and covered with cold, clammy dew ; his feet and hands were shrivelled, and of a blue colour ; he had severe spasms in his legs and thighs, and was excessively restless. The tongue, at present, is dry and white, and the only pulsation to be felt any where is in the carotid arteries, which beat about one hundred and twenty times in a minute. His eyes are fixed and glassy ; no sickness at stomach, but is purged frequently. The motions are watery and flocculent, like rice-water. 

R Tinct. Opii, 

Sp. iEther. Vit. aa 3J. Mist. Camphor. Jj. M. Ft. haustus, statim sumendus. 



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Let an anodyne enema be administered immediately, and his limbs be. well rubbed with spirits of turpentine. The vapour medicated bath. 

Two o'clock, a. m. — Is excessively restless, and constantly calling to the coolies to rub his legs. He says that he had been drinking very hard previous to his attack. Does not complain of pain in his belly, but says he has great oppression at the chest, and every inspiration is made with an effort, as if there were not space for the lungs to act in. 

Repeat the draught. 

Blistering plaster to be rubbed up with the oil of turpentine, and applied over the chest, and a large cataplasm of mustard placed over the whole. 

Repeat the enema, and continue the vapour-bath . 

Three o'clock, a.m. — Complains, for the first time, of pain in his chest and heart. Head much confused with the sensation of a noise similar to that of the firing of guns ; skin cold, and not a drop of blood near the surface ; eyes fixed, but not suffused ; the pupils are contracted ; has not derived the least benefit from what has been done. He appears to be sinking very fast. 

Died at a quarter past four o'clock, three hours after admission, and between six or seven hours from the time of attack. 

Examination of the Body. — The same appearances of the abdominal viscera are observed as have been already described, and the same degree of congestion also in the lungs and head. The only marked difference is, that in this case there is a greater quantity of blood 

!¦' 



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CASES OF EPIDEMIC CHOLERA. 

in both ventricles of the heart than was found in any of those cases already described ; but the blood in both ventricles is of precisely the same colour as it was in all those —it is very black and thick. 

CASE VI. 

John Belsh, private H. M. 13th Light Dragoons.* — Received into the general hospital on the 19th of June, 1819, at seven o'clock in the morning. It appears that he had been attacked about six o'clock the preceding evening, and had been very ill in the barracks during the whole night. 

Cramps in his legs, arms, and stomach, were very severe ; pupils of the eyes much dilated ; countenance ghastly, and expressive of great general uneasiness ; pulse labouring and fluttering ; skin cold, and covered with a profuse, cold, clammy dew ; eyes very much sunk in their orbits, and drawn up, shewing only the white part. 

A vein was opened immediately, and the blood, which dribbled down the arm in thick, sizy drops, was as black as ink. The opening into the vein was tolerably large, and more blood was abstracted in this advanced stage of the disease than I have before seen, though the depletion was not attended with the advantage I have sometimes witnessed. 

He complains of excessive pain, and of a burning sensation at the umbilicus ; pulse intermitting every third stroke, and exceedingly languid and hurried. Let 

* The 13th Dragoons had not landed at Madras many days before they were attacked with cholera. 



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him take the following* draught immediately, and apply twenty leeches to the umbilicus :—: — 

R Tinct. Opii, 

Sp. .Ether. Vit. aa 3J. 

Mist. Camph. f jss. M. ft. haust. 

Let an opiate enema, with camphor, be exhibited as soon as possible, the extremities be well rubbed with spirits of turpentine, bottles of hot water be applied to the feet, and small quantities of warm congee-water with brandy, be given occasionally. 

Half past eight, a.m. — The spasms are relieved; pulse one hundred and four in a minute, but very thready; there is some warmth upon the skin. The leeches on his belly appear to be drawing very well ; he has slept for ten minutes, during which time the pulse became fuller and stronger, and was reduced to ninety-four in a minute, but the instant he awoke I could not feel it at all. 

Repeat the frictions and draught. Continue the warm congee-water with brandy. 

Half past ten, a. m. — He continued to sleep without interruption from a quarter past eight till twenty-five minutes past ten o'clock, and the pulse again improved : it is now fuller and more regular, and one hundred and three in a minute; more warmth upon the skin, eyes half open, the white part only to be seen. The leeches at the umbilicus have dropped off, and only shew two ounces of blood, which is thick and 



68 

CASES OF EPIDEMIC CHOLERA. 

black, like tar. The pain and burning heat at the umbilicus are removed. He has no spasms ; but he has shewn frequent inclination to retch, though he has neither had vomiting or purging since his admission into hospital. Says that he feels great oppression in his head, but he does not complain much. 

Let ten leeches be applied to each temple, and ten to the occiput and cervical spine. Give the following draught every fifteen minutes :— 

R Aq. Ammon. g". xxx. 

Tinct. Opii g". 1. 

Mist. Camph. 

Aq. puree, aa 31J. 

M. ft. haust. 

Half past eleven. — Has been asleep for some time, and appears perfectly easy, but the pulse is very small and thready, and his strength is decreasing. Leeches quite inactive. 

Twelve o'clock. — Sinking rapidly — no pulse — great oppression in the chest, and difficulty of breathing. He is quite insensible. Died at one o'clock. His breathing, for half an hour before death, was excessively laborious. 

lnspectio Cadaveris. — The same general appearances are evident in the abdominal viscera as were remarked in former cases ; i. c. the vermilion blush, and thick, doughy feel of the small intestines. 

The liver is healthy, and of a much paler colour than usual, and the gall-bladder is full of healthy bile. 

The internal coat of the stomach has a dark, bloody 



CASES OF EPIDEMIC CHOLERA. 

69 

appearance, as if blood were extravasated between the coats. 

The lungs are full of blood, as in the former cases. 

The left side of the heart is much contracted, and empty, but the right is full of blood, and a considerable mass of coagulable lymph fills the right ventricle. 

The vessels of the brain have precisely the same appearance as I have previously described, and there is a good deal of water in the ventricles of the brain. The veins of the choroid plexus are very turgid, but the arteries are bleached and empty. The cerebellum and vessels which envelope the medulla oblongata and pons varolii are minutely injected. 

CASE VII. 

James Brown, private H. M. 13th Light Dragoons, was received into the general hospital on the 24th June, 1819, at seven o'clock, a. m. Says he was first taken ill at twelve o'clock the preceding night, and that nothing had been done for him till five o'clock this morning, when fourteen ounces of blood were taken from the arm. 

When he arrived at the hospital, the pulse was nearly gone. I could, however, feel it, and although I could not number it distinctly, yet I fancied I could count ninety strokes in a minute. 

He complains of confusion and giddiness in his head ; no spasms ; but there are pains and burning heat in the epigastric region and umbilicus. Let twenty-six leeches be applied immediately to the epigastrium and umbilicus, and twenty-four to the occiput and neck. Give the following draught : — 



70 

CvVSES OF EPIDEMIC CHOLERA. 

R Tinct. Opii, 

Sp. iEther. Vit. aa gj 

Mist. Camphor. 3jj M. ft. haust. 

Let an anodyne enema, with camphor, be exhibited as soon as possible. 

Half past seven, a. m. — Vomited the draught, which was repeated and retained. 

Eight o'clock. — No spasms at all; the skin is moist and cold ; pulse sinking ; eyes sunk, and half open ; has constant inclination to vomit, but does not throw any thing from his stomach ; complains of excessive thirst, and has the sensation of excessive and burning heat in the body, though he is quite cold to the touch, and covered with a cold, clammy dew. 

Let him take the following pills immediately :—: — 

R Calomel, gr. xx. 

Opii pur. gr. ij. Ft. pilulee iv. 

Nine. — No vomiting or retching since the pills, and he has been dosing : pulse quite gone ; skin of the hands and fingers shrivelled and wrinkled ; a cold, clammy dew over the whole body, though he has still the sensation of excessive heat and oppression. 

Let cataplasms of mustard and spirits of turpentine be applied to the legs and spine. 

Half past nine. — No pain, no spasms, but no improvement. 

Repeat the calomel and opium 



71 

CASES OF EPIDEMIC CHOLERA. 

Ten, a. m. — Has vomited a little watery fluid, had some sleep, and is now free from pain of any kind ; no pulse ; skin still cold. 

Let the medicated vapour-bath be used. 

Half past eleven. — The sinapisms on his legs are very painful ; those upon the spine are not felt ; the pulse is returning, but is still very languid; has no internal pain. 

Repeat the calomel and opium as before. Apply sinapisms to the inside of the thighs ; and let him have a small quantity of brandy and water occasionally. 

Half past twelve o'clock. — The pulse is certainly stronger, and the skin is not so deadly cold. He thinks himself better, and imputes it to the brandy and water ; lie has no pain or spasms ; calls for warm water to drink, which is given to him. Continue the treatment as before. 

Three o'clock, p. m. — No visible change for the better ; vomited a little at half past two o'clock ; will not drink any thing but warm water; speaks as if he were quite strong, and calls for an emetic. 

The pulse left him again at half past three o'clock ; and he died at four o'clock, p. m., nine hours from admission into the hospital, and sixteen from the time of attack. 

Dissection. — I think there is more appearance of general congestion in the omentum and small intestines, than in any of the preceding cases. There are no marks of arterial excitement in the small intestines; 



72 

CASES OF EPIDEMIC CHOLERA. 

but there are the same thickened appearance and pulpy feel which I have already described, as if the gut were glued together. 

The stomach is very much contracted, and the veins spreading over the external and internal surface gorged with blood : this viscus contains some sero-sanguineous fluid. 

The colon is much distended throughout with flatus. The liver is in a high state of congestion, and the gall-bladder distended with dark-yellow bile. 

The contents of the chest differ in no degree, in appearance, from the cases already noticed. The lungs and right side of the heart are gorged with blood, but the left side of the heart is empty. 

The brain has precisely the same appearance as has already been described ; the only difference is, that there is more water in the lateral ventricles than was found in any of the former cases. 

CASE VIII. 

Thomas Kershaw, a recruit belonging to the Honourable Company, and lately arrived from Europe, was received into the general hospital at a quarter past five o'clock, p. m., on the 9th August, 1819, and from the account given of him, it would appear that he had been seized with cholera about one o'clock, p. m. 

The symptoms are violent: vomiting and purging of watery matter, like congee-water, with small pieces of rice floating in it ; severe spasms of the extremities, abdomen, and epigastric region, with burning heat about the navel ; skin quite cold and clammy, but not livid ; pulse not perceptible at the wrist ; countenance 



73 

CASES OF EPIDEMIC CHOLERA. 

sunk; hands shrivelled, like a washerwoman's; eyes dull, heavy, and depressed in their orbit, and half open. He complains not of thirst, nor is he very restless. 

A vein was opened in both arms, and eight ounces of black, thick blood were abstracted with much difficulty, but without visible advantage. The blood flowed from the vein in a languid stream, and was much thicker than oil. Let him have the following draught immediately :—: — 

R Aq. Ammon. gss. 

Tinct. Opii 3J. 

Mist. Camph. 3 iss. 

M. ft. haust. 

Six, p. m. — No alteration for the better. Has taken one ounce of the drogue amere* in the same quantity of camphor mixture. Tobacco-smoke was thrown up the rectum, and the medicated vapour-bath used, but without any effect. He died at twenty minutes past six o'clock ; one hour after admission, and five from the invasion of the disease. 

* The following is the drogue umere, as given by a Jesuit : — 

R Aloes Socot. Jbj. 

Gum. Myrrh. -. Mastich. f ... v, aa sviij. Benzoes, L Rad. Columbse, 3 

Crocus Angelic. 

Rad. Gentianae, aa Jiv. Eau de Vie, Ifexxxvj. 

Genievre, Ibxij. M. 

To stand forty days, then filter through paper for use. 



74 

CASES OF EPIDEMIC CHOLERA. 

Examination of the Body. 

Abdomen. — The peculiar vermilion colour of the intestines, which has all along been considered as characteristic of epidemic cholera, was singularly striking in this case. The jejunum was considerably inflated, and the veins upon its surface beautifully injected. The thickened, pulpy appearance of the other small intestines, usually observed in this disease, extended throughout their whole canal. Very little, if any, change was observed in the colon. 

The veins on the external coat of the stomach were highly injected ; the internal surface was considerably corrugated, and its veins greatly congested: in some spots of the surface there appeared to have been considerable arterial action. 

The liver, as usual in cases of this disease, was loaded with blood of a black colour, and had much of the appearance of bruised flesh. The gall-bladder contained no unusual quantity of bile, and there appeared to be bile in both the cystic and hepatic ducts, but there was none in the ductus communis choledochus. This duct evidently appeared to be obstructed,* but on making a smart pressure on the gall-bladder, the bile flowed freely into the duodenum, and on closer examination there was no difficulty in introducing a probe through the ducts. 

No morbid change could be detected in the kidneys.f The spleen also appeared to be quite natural. 

* Possibly from spasm during the disease. 

f The kidneys were carefully examined, as it was observed that the secretion of urine was arrested in this and in the cases already detailed. 



75 

CASES OF EPIDEMIC CHOLERA. 

Thorax. —In order to ascertain the precise appearance of the blood in both ventricles of the heart, and in the aorta itself, I tied the aorta and vena cava immediately above the bifurcation of the iliac vessels, and removed the heart and lungs from the body ; the carotid and cervical arteries, with the veins, having been also previously secured. The following appearances were observed. 

The right auricle, ventricle, and pulmonary arteries were, as usual, filled with black blood ; and the left auricle, ventricle, and aorta descendens, were likewise filled with black blood. Upon opening the pulmonary artery, the blood seemed to flow with bubbles, as if it contained air. 

The carotid artery I found quite empty, but pressure having been made on the lower part of the artery, immediately above the arch of the aorta, some blood was forced into it ; and, although the blood was not of a florid, arterial colour, it was certainly brighter than that found in the aorta descendens. The same appearance was likewise observed in the iliac vessels, /'. c. the blood in them was of a brighter colour than that found in the aorta itself. 

Head. —In the brain there was, as usual, considerable congestion, and the arteries of both hemispheres had the appearance of having been the seat of considerable action. Upon cutting into the brain, points of blood were observed all over the divided surface. There was some water in the lateral ventricles, and the veins of the choroid plexus were highly injected. 

A little water was found at the base of the skull, and the arteries of the pons varolii and those of the 



76 

CASES OF EPIDEMIC CHOLERA. 

medulla oblongata, surrounding the seventh, eighth, and ninth pairs of nerves, were very turgid. There was a considerable degree of congestion in the membranes of the cerebellum. 

I shall next detail some cases which illustrate the less severe appearance of the disease, and which occurred at the time when its epidemic violence had considerably abated. 

CASE IX. 

Josiah Reader, astatis 23, Serjeant C.C. artificers, of a sanguineous temperament, was admitted at five o'clock of the afternoon of the sth of October, 1823, complaining, since yesterday, of vomiting and purging, which supervened after drinking cold water, whilst he was warm. 

Was first seen at half past five, p.m., when his eyes were sunk ; his senses perfect. Has frequent vomiting and purging. Stools watery, flocculent. Severe cramp of the lower extremities. Considerable burning pain in the epigastrium and head. Pulse very small, thready, and extremely quick ; great restlessness ; skin hot ; tongue white, moist, clean. The following medicines were at this time administered to him : — 

R Calomel, gr. xx. 

Opii gr. ij. M. ft. pilul. s.s. 

Admov. hirud. xv. part. dol. abdom. et v. utrique tempori. 

Cataplasmata sinapeos ad totam spinse longit. ad suras et ad epigastrium. 



77 

CASES OF EPIDEMIC CHOLERA. 

Seven, p. m . — I first saw him. Pain in the epigastrium was very severe. Spasms of the superior and inferior extremities, and of the abdominal muscles, violent ; pulse small, very quick, thready, almost imperceptible at the wrist. Passes thin, watery, flocculent stools involuntarily. Skin of extremities cold, and covered with a clammy sweat. Eyes sunk, features collapsed ; is very restless ; breathing natural ; senses perfect. No passage of urine. 

Habt. statim Calom. gr. xv. Opii gr. ij R Mist. Camph. 

Drog. Amari, aa J ss. Sing, semihoris repetend. 

Habt. cyath. brandy, subinde. 

Bibat pro potu communi aquam cum succo citrorum. Fricentur crura brachiaque linim. camphorae. 

Fifteen minutes past seven, p. m. — Vomited almost immediately after taking the pill. Spasm still violent ; has great thirst ; other symptoms the same. Four men are constantly employed in rubbing his extremities. The friction evidently relieves him. 

Rept. Bolus Calomel, et Opii. 

Calomel, gr. xv. Opii gr. ij. R Mist. Camph. Jj. 

Tinct. Opii 31J. ./Ether. Sulph. 31J. Sp. Ammon. 3J. 

M. ft. enema. Contin. alia. 



78 

CASES OF EPIDEMIC CHOLERA. 

Thirty minutes past seven, p. m. — Did not retain the glister; pulse quite imperceptible; other symptoms increased. Vomited shortly after taking the pill. 

A glass of brandy 

Rept. Calomel, gr. xv Opii gr. ij. 

Forty-jive minutes past seven, p.m. — Pulse rising, fluttering, hardly to be counted. Did not reject the pill. Symptoms continue violent, with occasional remissions. Continues to take the lime-juice as common drink. Complains much of thirst. 

Contin. brandy et alia. Lime-juice. 

Eight, P.M. — Pulse rising, though still extremely small and thready. Cramps and pains continue violent ; very restless and thirsty. 

Contin. mistura, frictiones, et potus acidus. 

Fifteen minutes past eight. — For the last quarter of an hour has been rather easier; pulse rising; skin cold. 

Bottles of hot water and hot flannels to be applied to the extremities. 

Contin. alia. 

Ni/ie, p.m. — Vomited during the last half hour. Cramps more violent ; pulse fuller ; skin of extremities cold ; that of trunk natural ; clammy perspiration ; restlessness. 



79 

CASES OF EPIDEMIC CHOLERA. 

Contin. excitantia omnia. Frictio. 

Thirty minutes past nine. —No alteration ; spasms occasionally occur ; breathing is hurried ; great oppression at the chest ; pulse perceptible at the wrist, small, thready ; countenance sunk ; continual tossing in his cot ; tears the bandage from his breast ; calls out to the men to rub hard. Voice is hollow; stools frequent, flocculent, involuntary ; no urine ; deafness and noise in the head. 

R Calomel, gr. xx. 

Opii gr. ij. 

Contin. omnia alia. Frictiones assidufe. 

Oct. sth, ten, p.m. — Pulse much more perceptible at the wrist; about 130 or 140 beats in a minute; small, thready; eyes sunk, and half open; restlessness. 

Contin. omnia. Frictiones. 

Fifteen minutes past ten.— For the last quarter of an hour has been extremely restless; cramps frequently recurred; he complains of great oppression and difficulty of breathing. The cramps are now more violent; lips livid ; eyes fixed, and half open ; great pain of abdomen ; a blister applied to it. Great thirst. 

Admov. empl. vesicat. abdomini. Contin. alia ut antea. 

Forty minutes past ten. — The pulse became more perceptible ; the other symptoms nearly the same as 



80 

CASES OF EPIDEMIC CHOLERA. 

in last report. A vein was opened in the arm, and about eight ounces of dark, thin blood were, with considerable difficulty, abstracted. During the bleeding, no perceptible change was produced. 

Contin. excitantia, frictiones, &c. 

He became more feeble afterwards; the cramp recurred with less violence and less frequency. He complained, however, of great difficulty of breathing, and oppression at the chest. In this state he lingered on till twelve o'clock ; when he died, seemingly from mere exhaustion.* 

Sectio Corporis, ten hours after death. 

Abdomen. — Ist, In situ. — Peritoneum and omentum were natural. The small intestines had a peculiar, deep, florid, lake-coloured blush, resembling their appearance in injected preparations. The vessels were enlarged, and the capillaries rilled with red blood. When the coats were handled, they communicated to the fingers a sensation of thickness, and doughy softness. 

The colon, as far as it could be seen in situ, was contracted throughout. The contraction, however, was greatest at the transverse and descending portions. 

* In this case 88 grains of calomel were given, in order to try its effects upon the secreted matter covering- the intestines, and already alluded to. The calomel was employed here in illustration of the experiments which had been previously performed with this medicine ; for which see the chapter on the treatment of cholera, and the paper on calomel at the end of the volume. 



81 

CASES OF EPIDEMIC CHOLERA. 

The caput cacum, and sigmoid flexure, were of nearly natural size. 

The stomach was considerably distended. 

The liver appeared of natural colour. A few white patches were observed here and there on its convex surface, but the substance beneath was healthy. The gall-bladder was nearly full of healthy bile. The ductus cysticus was contracted. 

2d, Ex situ. — The stomach and intestines were removed for the purpose of a closer examination of them. Throughout they had the same lake-coloured blush, which, in the ileum, assumed a purplish hue, from the greater degree of venous turgescence. 

On being cut into, the following appearances were observed : — The duodenum, jejunum, and the upper part of the ileum, were filled with a greyish-white, slightly viscid matter, which, especially in the ileum, much resembled cream. The inner coat of the ileum was encrusted with the same matter, but it was much more viscid and tenacious.* That in the duodenum was of a darker colour, and became more so when exposed to the air. A small quantity of cystic bile had flown into the upper part of it, and given it a slight yellow tinge. The whole of the inner surface of the intestines seemed softer and more glistening than in the healthy subject, as if they had been steeped some time in hot water, and then glazed over. 

In the colon a small quantity of the white feculent matter was observed, but more fluid and transparent, 

* From this I infer that the calomel, in this instance, had no effect upon this peculiar secretion. 

c; 



82 

CASES OF EPIDEMIC CHOLERA. 

resembling, in appearance, thin congee-water. In the lower part of it, and upper part of the rectum, a gelatinous, somewhat viscid, matter, was found lining the inner coat. 

The stomach contained about two pints of a dirty, greenish, muddy fluid, in which floated a few portions of more solid matter. The inner coat shewed nothingremarkable. It was encrusted with a viscid, greyishgreen matter. The calomel which the patient had taken lay near the pylorus, slightly altered, and tinged of a grey colour. 

The liver was sound. The portal vessels were rather flaccid. The vena cava inferior was much distended, and a considerable quantity of black, venous blood issued from an incision made into the aorta. 

The spleen and pancreas were healthy, though the former appeared a little darker than natural. 

The kidneys were gorged with blood. 

The urinary bladder was perfectly collapsed. 

11. Thorax. — Pleura healthy; lungs much collapsed, more loaded than natural at the back part. 

Heart, externally, of natural appearance. The right auricle was full of dark, venous blood, in a state of coagulation, with some portions of coagulated lymph. The right ventricle was nearly empty. The left auricle and ventricle were nearly as in the healthy state. In the latter, a little dark blood, and polypi of coagulated lymph, were observed. The aorta and pulmonary veins carried also dark, venous blood. (The thymus gland was very large.) 

111. Encephalon. — The dura mater was thick and shining. The veins were turgid, and several extravasations 



83 

CASES OF EPIDEMIC CHOLERA. 

of blood had taken place. There was, likewise, a very small quantity of water found beneath it. The vessels of the pia mater were enlarged, and the membrane itself had an. inflamed appearance. The ventricles contained about three drachms of serum. The substance of the brain was softer than common. 

CASE X. 

James Taylor, Oct. 27, recruit M. E. R., entered Bth Sept. 1823. Seven o'clock vespere. — Was attacked with symptoms of cholera this morning. At present, skin cold ; tongue excited, but moist ; pulse very frequent and small ; eyes much sunk ; a considerable degree of restlessness ; thirst urgent ; complains of deafness, and dull pain in the head; has not been troubled with cramps during the last two or three hours, except in the upper extremities. Has passed no urine since the accession of the disease. 

V. S. ad |xxx. 

R Hydrarg. Submur. gr. xx. 

Opii puri, gr. ij. atatim. R Mist. Camph. gj. 

Drog. amari Jss. Ft. haust. 

Enema purgans. 

Empl. lyttse sterno et abdomini. 

Eight o'clock. — The cramps in the lower extremities returned ; skin cold ; tongue as before. The restlessness continues ; eyes sunk ; pulse very small, but frequent ; thirst very urgent ; the deafness and pain of head no better. His fingers cramped ;no urine passed ; 



84 

CASES OF EPIDEMIC CHOLERA. 

one stool from the enema, of a light colour, and viscidlike mucus. 

Nine o'clock. — No alteration. 

Ten o'clock. — The same. 

Eleven o'clock. — As before. No cramps since last report; skin of a more natural temperament; tongue excited, but moist; pulse small, 80; eyes less sunk. The restlessness not so great; thirst urgent. The deafness and pain of head much relieved; had one motion similar to the former, and has passed a little urine. 

A little hot brandy and water occasionally. 

Sept. 9th, seven, a.m. — Feels better this morning ; has only had one stool since last, watery, with portions of yellow viscid matter floating in it, and has vomited two or three times, and thrown up a dark green fluid, similar to the green watery stools sometimes passed from the bowels. Pulse 120, small, and soft ; tongue much furred, and rather dry ; skin hot ; some cramps in the legs, but none at the epigastrium. Has great thirst, and burning sensation at the stomach ; no headach, or increased sensibility to light. 

Pulv. Jalap. Compos. 3J. ex. aq. Menthse statim. Potus Acidi Citrici. 

Ten, a.m.— Pulse 120, and not so soft; skin temperate ; no vomiting or stools since last report ; expresses himself easy, and free from pain; no cramps; still thirsty. 

Enema Purgans. 



85 

CASES OF EPIDEMIC CHOLERA. 

Eleven, a.m. — Pulse small and frequent, but soft ; skin warm ; tongue furred and dry ; no vomiting nor purging since last report; voided a little urine this morning ; free from pain ; no cramps ; eyes less sunk ; still feels a slight deafness ; thirst urgent. 

Pulv. Jalap, ut antea Cont. potus Acidus. Rep. Enema. 

Hora merid. — No alteration. 

One, p.m. — No motions since last report; pulse small, but firm ; skin warm and dry ; tongue furred and moist ; no cramps ; eyes less sunk. The deafness continues; thirst unabated. 

Rep. Enema. 

Cont. potus Acidus. 

Three, p.m. — Has had one viscid, mucous stool, since last report, of a yellow colour ; pulse soft, but quick; skin warm and dry; tongue furred, moist; thirst urgent; feels weak; eyes less sunk; still complains of the deafness. 

Cont. Med. 

Arrow Root with brandy. 

Six, p.m. — One more stool, the same in appearance as before ; pulse the same ; skin moist ; tongue furred ; thirst urgent. The deafness better ; no pain of head, nor cramps in the extremities. 



86 

CASES OF EPIDEMIC CHOLERA. 

R Hydrarg. Submur. gr. xx. Opii puri, gr. ij. 

M. ft. pil. ij. h. s. Cont. csetera. 

Rep. Enema. 

Sept. \Oth, seven, a.m. — Pulse 108, and full; skin warm ; tongue cleaner ; no cramps ; no pain in the abdomen or chest ; stools watery and bilious ; has had but little vomiting ; no headach or deafness, but complains of a singing in his ears. Had but little sleep in the night; countenance looks better, and eyes not so sunk. 

Cont. potus Acidus. Capiat Pulv. Jalap. C. 3J. Habt. Enema Purg. stat. 

R Mist. Camph. Jj. 

iEther. Sulph. g tt . xx. 2dis horis. A little arrow-root with brandy, occasionally. 

Three, p.m. — Pulse 100, full, and moist; skin good and moist ; tongue foul ; no cramps any where ; no singing in the ears; no headach; stools feculent, loose, of a green colour. Has vomited, several times, a green watery fluid, with a mucous sediment ; countenance 

good. 

Calomel cum Opio. Rep. ceetera omnia. 

Sumat Tine. Opii, g u . xx. c. singulis dosibus mist, camph. 

Sept, Wth, half past six, a.m. — Pulse 120, full, and 



87 

CASES OF EPIDEMIC CHOLERA. 

soft ; stools bilious, soft, and offensive ; has vomited a quantity of grass-green, and very bitter fluid ; skin temperate ; tongue cleaner ; slept but little ; no cramps ; no headach ; still very thirsty. 

R Pulv. Jalap. Comp. 3J. 

Cont. csetera omnia ut heri prses. 

Half past Jive, p.m. — Pulse as before; stools green and watery ; not so much vomiting ; skin rather hot ; tongue cleaner ; no cramps ; no headach ; still very thirsty. 

Rep. Calomel, &c. h. ss. et csetera. Omitt. brandy. 

\2th, seven, a.m. — Stools green and watery, not very copious ; skin cold and clammy ; pulse imperceptible ; tongue foul ; says he feels light-headed ; breathing oppressed ; no vomiting ; thirst continues. He died at nine o'clock. 

Upon inquiry, it appeared that he had got up from his bed, and spent nearly the whole night in perambulating the wards, with no other clothing but his shirt. There is little doubt, therefore, that the favourable reaction which had taken place in the system, was, by this imprudence, at once arrested, and that a state of collapse suddenly supervened, from which he so rapidly sunk. 

On examining the body, the appearances were — a great degree of congestion in the venous system of the 



88 

CASES OF EPIDEMIC CHOLERA. 

brain, and still greater in that of the lungs, which were loaded with purple blood, so as to present the appearance of having been bruised. The right auricle and ventricle of the heart were distended with venous blood. In the abdomen, the appearances were such as fully to justify us in supposing, that, had it not been for this ill-timed exertion on the part of the patient, the disease would have proceeded to a favourable termination. The liver appeared healthy, the gall-bladder was empty, and there was no vestige of the peculiar, lightcoloured, viscid secretion, which is so constantly found lining the internal coat of the small intestines, (the duodenum and jejunum, particularly), obstructing their calibre, and preventing the operation of the remedies administered. No newly secreted or hepatic bile was present, but, on the contrary, the intestines were loaded with dark, green-coloured contents, of a soft consistence, which, most probably, consisted of the above mentioned viscid secretion, removed by, and intimately mixed with, the proper purgative cystic bile. 

CASE XI. 

James Johnson, seaman on board H. M. S. Liftey, aged about 40. — Was suddenly seized on the morning of the third instant with severe spasms in both extre-* mities ; pulse perceptible ; eight ounces of blood were immediately taken from his arm, and he was afterwards put into the hot-bath. His countenance soon became dejected, features shrunk, and his fingers and nails blue and livid, and the whole body cold. Brandy, with tinct. opii, was frequently given him, and a single dose of calomel, with two grains of hard opium. 



89 

CASES OF EPIDEMIC CHOLERA. 

Considerable stupor from the opium ; hot-bath was repeated during the day; the spasms began to abate about nine o'clock, a.m., but his skin remained cold, and his pulse nearly imperceptible all day. He had violent and severe vomiting during this day. 

Fourth. — Very restless all night, pulse being about 60, and extremely feeble ; frequent vomiting and purging of white and watery stools; tongue loaded. Wine and water, and brandy and water, were given him frequently. 

Fifth. — Has been more quiet all night; at present, four o'clock, p.m., vomited a little to-day; pulse pretty good ; skin and extremities cold : complains of a griping pain in his bowels. This man has had frequent bowel and hepatic attacks since arriving in this country. As it is probable he will not recover speedily, on that account he is sent to the hospital. 

Sept. sth, six, p.m. — Was admitted into the Madras general hospital.* His countenance was pale and shrunk, lips livid, and eyes rather sunk, and turned upwards ; pulse small and quick ; skin rather cold. He seemed very much inclined to dose, and was with difficulty prevailed on to answer any question. Expressed himself free from pain. At times he vomited small quantities of green fluid, and his stools were loose, and of a brown colour. 

* For the previous part of this report, I am indebted to Mr. Small, assistant- surgeon of the Liffey. 



90 

CASES OF EPIDEMIC CHOLERA. 

Sumat statim Hydrarg. Submur. 9j. Opii, gr. ii. R Mist. Camphoree, |j. 

Sp. Ammon. gj. 

./Ether. Sulph. 3SS. 2dis horis. 

Brandy and water occasionally. His breathing at this time was rather hurried, but he seemed to pass the night as comfortably as his state would allow him. Towards morning he became very restless, and his breathing still more hurried. At six, a. m. these symptoms had greatly increased, and he was so restless, as to be unable to lie on the same side for the space of a minute, and could scarcely be roused sufficiently to answer any question. Still he expressed himself free from pain, either in the head or chest. About eighteen leeches, however, were applied — some to the nucha, some to the right side of the chest, in the direction of the intermediate space between the sixth and seventh ribs, and he took sj. of pulv. jalap, comp. in aq. menth. pip. This was not rejected by the stomach. A large blister was applied to the chest. From this time, however, he sunk rapidly. His countenance became more shrunk, his eyes sunk and immoveable, their brilliancy gradually declining; his pulse became imperceptible, extremities cold, and, notwithstanding the frequent exhibition of strong brandy and water, with spirit of ammonia, and the application of hot bricks, &c, he expired about eight o'clock. 

This was one of the most instructive cases I have seen ; it was clearly a case of epidemic cholera, and one in which the treatment seemed for a time to be beneficial. The pulse was 



91 

CASES OF EPIDEMIC CHOLERA. 

restored to the wrist ; the skin had not that coliquative dew upon it, and coldness, that is usual in the last stage of cholera : and, to all appearance, the case was manageable on his coming into the hospital. In the morning there was a sullenness and dislike to answer questions, excessive oppression in breathing, and restlessness ; and, although the pulse was quite distinct, there was something indescribable in his general state that led us to fear danger. Supposing that the oppression arose from congestion in the lungs, leeches were applied, but they had not been on more than a few minutes, when the pulse at once sunk : and he died soon afterwards. The quantity of blood taken by the leeches, was too insignificant to lead us to suppose that he sank under their operation. The mulled wine, camphor, ammonia, and opium that was afterwards given, had no effect whatever ; the blister that had been applied was discharging, but not freely. From all these circumstances I was particular in the examination, and the result is truly satisfactory. 

Dissection.* 

" On opening the abdomen, the stomach presented itself very much distended. The liver was apparently 

* The account of the dissection was drawn up by one of my hospital assistants. I insert it in his own words. 



92 

CASES OF EPIDEMIC CHOLERA, 

healthy, and its size natural; and the gall-bladder empty and contracted. The small intestines presented a pale appearance, but with a great deal of venous congestion; and, when held between the thumb and fingers, they occasioned a peculiar thickened feel, as if the internal coat were lined throughout with some deposition. On laying them open, the duodenum contained a quantity of bile, of a light-green colour; the jejunum presented the same appearance, but with numerous patches of a dark-green, viscid substance, lying loose on its internal surface. The ileum was rather contracted, and loaded with the above-mentioned dark-green, viscid matter. The colon was found distended at the caecum, but contracted in the course of the transverse arch ; which contraction continued, though in a smaller degree, to its termination. On examining its internal surface, the villous coat, from the caecum to about the sigmoid flexure, was much thickened, and exhibited a great degree of congestion, which, at the commencement of the gut, was so great, as to give the appearance of extravasation of blood. In the situation of the transverse arch, the mucous coat was of a brighter red, and the ramification of the vessels was distinct on its surface, though with occasional spots of a darker aspect. Towards the left side, there was another large portion of the above dark colour, which again changed to the red, and this last gradually declined towards the rectum. There were no ulcerated spots observable. 

" The examination of the chest presented the lungs in a collapsed state, with considerable venous congestion. The pericardium contained no fluid. The right auricle of the heart was distended with fluid, venous blood. Both the ventricles likewise contained unoxygenised 



93 

CASES OF EPIDEMIC CHOLERA. 

(or undecarbonised) fluid blood. The veins of the brain were preternaturally distended with blood, and the ventricles contained a small quantity of serous fluid." 

From this examination it is evident, that a very important change had taken place in the intestinal canal. I may farther add some of my own notes, made at the time when this interesting examination took place. 

In general, the jejunum and upper part of the ileum have a flesh-coloured blush in the external coat. There was a great difference between this part of the gut and other parts, but the blush did not exist in the same degree. The pulpy feel and thickening of the coat of this portion of this canal existed, but there was not so much contraction of that part of the gut, as is usual when death is more sudden. 

The whole of the small and large intestines were removed and laid open ; and here the important change was evident. The upper part of the duodenum was clear of every thing except its natural secretion, with here and there a speck of green viscid matter. 

The internal coat of the jejunum was covered with green viscid matter, in greater 



94 

CASES OF EPIDEMIC CHOLERA. 

quantity than in the duodenum ; but evidently merely what remained after the greater part of this matter had been removed, either by the flow of bile, or the medicine. 

The ileum was full of a mass of this green, viscid, tenacious matter, almost from its commencement to the caecum. In the caecum and colon were found a brownish fluid, like the colour of chocolate ; and this fluid, though not in considerable quantity, was found throughout the large intestines. 

This fluid was very distinct from what was contained in the small intestines, and appeared to be the secretion of the bowel, tinged with a mixture of blood, perhaps from those portions of it where there appeared so much extravasation. 

This fluid was not unlike what is often passed jin cases of dysentery, where sloughing of the villous coat has taken place, and what should be called dysenteric stools. 

From these observations, and from the gallbladder being completely empty, the following reflections must arise : that the bile, having flowed into the duodenum, separated the white, 



95 

CASES OF EPIDEMIC CHOLERA. 

viscid, and tenacious matter that was contained in the duodenum and jejunum, and was actually carrying it down to the large gut, changing its nature from an adhesive white viscid substance to a green gelatinous matter, easily carried off by purgatives. I conclude it was the bile, and not the medicine, which had detached this particular substance : first, from the colour ; second, from the gall-bladder being empty ; and third, from its being impossible that any medicine could have given it a green colour, and more particularly the medicine he had taken, viz. pulv. jalap, comp. If the powers of life, therefore, had held out till this matter was removed, re-action might have taken place, and the patient might have been saved ; but, from the singular collapsed state of the lungs, from their congestion, and from the congestion of the brain, it would appear that the powers of life were oppressed, and that no known human art could, in this stage of the disease, have proved successful. 

CASE XII. 

Conrad Kingsburgh, seaman, aged 27, was seized suddenly on the second instant, about two o'clock in the morning, with cramps in his toes and fingers, and a coldness all over the body. Pulse extremely feeble. At first the spasms were confined to his feet. 



96 

CASES OF EPIDEMIC CHOLERA. 

A draught of tinct. opii, 3SS. with Jij. of peppermint water, was ordered for him. 

About six o'clock the spasms became more severe. He was put into the hot-bath, the opiate draught was frequently repeated with brandy, but severe vomiting came on, and frequent stools of a white, watery appearance. His pulse was nearly imperceptible at the wrist, and his fingers and toes assumed a cold and livid appearance. Countenance anxious. 

About seven o'clock the bath was repeated. His pulse rose a little, and the sickness at stomach began to leave him. A few ounces of blood were taken from the arm, and stimulating draughts continued all day. 

On the morning of the third he appeared much better; his extremities were not so cold, no vomiting or spasms. He became gradually better, and yesterday convalescent. At present (three o'clock, p.m.) pulse good ; skin cool ; tongue foul in the centre ; bowels loose ; no pain or appetite. 

Sept. sth, six o'clock, p.m. — Was admitted* into the Madras general hospital at the same time with the foregoing case, (Johnson). At this time he had frequent retching, and occasional vomiting of yellow bilious matter ; pain at the pit of the stomach, and his stools were scanty and watery. Pulse about 100, rather small, 

* For the foregoing details I am indebted to Mr. Small, the assistant-surgeon of H. M. S. Liffey. 



97 

CASES OF EPIDEMIC CHOLERA. 

skin cold and clammy, countenance collapsed, and eyes turned upwards. His breathing was free, and he had no restlessness ; but lay quietly on his back, and was with some difficulty roused, so as to be prevailed on to answer questions. A large blister was applied to the epigastrium ; twenty grains of calomel with two of opium were administered, and he was ordered to take, every two hours, the camphor mixture, with spirit of ammonia and aether, and occasionally some hot brandy and water. 

At six o'clock in the morning, I found, on inquiry, he had passed the night in the state above described. His pulse was nearly imperceptible, and he was evidently sinking. One drachm of pulv. jalap, comp. was given, which his stomach did not reject, and the same treatment was continued. He died about ten o'clock, A. M. 

On examination, the head and chest presented the same appearances as in Johnson's case. The lungs were in such a state of congestion, as to present here and there the appearance of having been bruised. The blood found in the heart was fluid and venous, and the right auricle, with the two ventricles, were filled with blood possessed of a similar character. The appearances observed in the abdomen were very interesting. The gall-bladder was distended with dark green coloured bile. The duodenum and jejunum were lined throughout their villous surface with the peculiar white and viscid deposition or secretion observable in all recent cases of cholera. In the duodenum this deposition had been displaced, and mixed with a quantity of hepatic bile, and 

v 



98 

CASES OF EPIDEMIC CHOLERA. 

presented a bright orange colour, (which, from the result of a subsequent experiment, was supposed to be caused, or at least rendered more intense, by the brandy which had been exhibited). — In the jejunum, the deposition was more viscid, tenacious, in larger quantity, and adhered pretty firmly to the surface of the intestine. Its colour was not influenced by the admixture of the yellow bile, but resembled that of cream. The ileum was empty, and contracted in several places, and its external or peritoneal coat was not in so great a state of venous congestion, nor did it offer the thick, pulpy feel, as the jejunum and the duodenum. The internal surface of the colon did not appear to have suffered under much organic disease, and towards the rectum was contained a small quantity of thin, watery faeces, of a dark colour. 

These two cases are individually very interesting, but when considered in connexion, and contrasted with each other, they become exceedingly valuable and instructive. It is pretty evident, that their conveyance to the hospital was too long deferred to offer anyreasonable hope of recovery in either case. 

In Johnson's case, however, nature had done infinitely more towards the cure of the disease than in the other. The gall-bladder had disbursed its contents into the small intestines, and the cystic bile had displaced from its adhesions to the surface of the intestines, 



99 

CASKS OF EPIDEMIC CHOLERA. 

and nearly entirely dissolved the viscid secretion which is peculiar to the disease, and which, in this case, was found floating in flakes among the contents of the intestine. We may reasonably infer, that, if the previous effects of this disease had not been so debilitating, the bowels would have got rid of their contents, and the patient might ultimately have rallied. There is one question, however, to be asked in this case : — Whether the application of the leeches to the chest had any effect in hastening the patient's death ? I should think not ; for he sunk so suddenly and rapidly, and the time was so short from their application to their removal, that the quantity of blood drawn must have been very insignificant indeed. 

In Kingsburgh's case, the gall-bladder had got rid of none of its contents ; * hepatic bile alone had found its way into the intestines, and the morbid deposition peculiar to this disease remained adherent to their villous coat, and obstructing their calibre. The disease, therefore, had evidently not advanced so far in 

* In an experiment made subsequently to the occurrence of this case, cystic bile was found to be the only effectual solvent of this peculiar viscid secretion, whereas, from the appearances in Kingsburgh's dissection, the hepatic bile was supposed not to possess that power in any degree. 



100 

CASES OF EPIDEMIC CHOLERA. 

its course; and it is not wonderful that the patient sunk eventually, when we consider that apparently the vis medicatrix natures, (on his admission into the hospital) was not nearly so great as in Johnson's case. 

CASE XIII.* 

_ T- , Esq. was attacked, about three o'clock, a. m. 10th October, 1821, with frequent vomiting and purging of a watery fluid ; he had severe pain at the scrobiculus cordis, excessive cramps in his limbs, and constant thirst. I saw him at half past nine o'clock, and I found the cramps in his legs, feet, arms, and hands, most distressing and severe : the pains continued at the scrobiculus cordis; thirst excessive ; pulse small, and 130 in a minute ; skin cold, with considerable moisture; countenance rather collapsed, and a great degree of anxiety in his look. He was constantly vomiting a colourless fluid, and his motions, which were frequent and distressing, were water, with some flocculent matter floating in it. At thirty-five minutes past nine o'clock, a. m., the following was given. 

* 1 add this case, as its history, and its progress towards perfect recovery, seem to me to illustrate both the nature of the disease, and several of the points of difference existing between it and the severer cases of common cholera. 



101 

CASES OF EPIDEMIC CHOLERA. 

R Calomel, gr. xx. Opii, gr. ij. Conf. Aromat. q. s. 

Ft. pilul. statim sumend R Mist, Camph. Jjijv 

Sp. .Ether. Vit. g tt . xxx. Aq. Ammon. g tt . xl. 

M. ft. haust. stat. sumend. 

Palankeen boys were immediately set to work to shampoo, and to rub the legs, feet, arms, hands, and epigastrium, &c. with spiritus terebinthinse. 

This was continued without intermission, and at forty-five minutes past nine o'clock, he thought the spasms in his legs relieved, though they continued severe in his hands and arms. Complains very much of thirst. 

Continue friction, with terebinthinum, to the legs, arms, epigastrium, &c. &c. 

Ten o'clock. — The pains at his stomach increased, and are very distressing ; feels very sick, but does not vomit; cramps returned with severity in his legs, and they continue in his arms and hands ; pulse very languid and thready. I can hardly number the pulsations, they are more than 130. Made an effort to be sick, but did not vomit; frequent retching. , 

R Infus. Amar. 

Sennse, Tinct. Jalapii, £ss. 

Cardam. Jss. 

M. ft. haust. stat. sumend. 

Continue friction without intermission. 



102 

CASES OF EPIDEMIC CHOLERA. 

Fifteen minutes past ten, a. m. — Feels great oppression at his stomach, and constant desire to be sick, but has not vomited or purged since he took the calomel. Has occasional relief from the cramps, but it is of short duration. The pulse is, I think, rather improved, though still exceedingly weak and frequent. 

Continue the friction. 

Thirty-Jive minutes past ten o'clock. — Vomited the last draught, and says his stomach is much relieved. I examined with attention what was thrown off his stomach, and was glad to see that there was no appearance of calomel, nor did the fluid smell of camphor; but I thought I could observe a slight tinge of green bile ; this, however, was so slight, that I am not certain whether it was not a tinge given to the fluid by the brass basin. Pulse labouring very much ; cramps continue severe. 

Rep. haust. Camph. v. a 

Forty -Jive minutes past ten. — He insisted on smoking a cheroot, and he is now smoking one. He feels rather easier, and the skin is certainly warmer. 

Continue friction without intermission. 

Eleven o'clock. —At this moment I was desirous of taking blood from his arms, but he declines it, as he feels satisfied he has no blood to spare. The pulse is quick and rather labouring, and this is the time when bleeding would be useful, in order to relieve the circulation, and it therefore ought to be resorted to ; but he will not listen to it. The skin is warm, and 



103 

CASES OF EPIDEMIC CHOLERA. 

there is no unpleasant moisture upon it ; but the cramps continue more in his legs than arms. 

Enema purgans stat. 

Five minutes past eleven. — He passed a few drops of very high-coloured urine, which occasioned a very unpleasant sensation at the neck of the bladder, which lasted some time. 

Fifteen minutes past eleven o'clock. — Retained the enema till now, when he passed it exactly as when thrown up. He felt much exhausted after it; but his skin is certainly warmer, and the pulse, though still 120 in a minute, is firmer than it was, and the cramps are somewhat less severe. 

Continue the friction. 

Thirty-Jive minutes past eleven o'clock, a. m. — Had another stool rather copious, watery, with floccula : he feels a singular degree of exhaustion after every attempt to relieve his bowels ; but lam glad to find that his skin still retains its warmth, and that the pulse, though weak, is very distinct, and 120 in a minute : thirst distressing. 

Sent for acid drink, and for some doses of the compound powder of jalap. 

Fifteen minutes before twelve o'clock, a. m. — Cramp still continues, and he feels more uneasiness and pain at the stomach, but he does not complain of the burning heat at the prsecordia. 

Continue the friction. 



104 

CASES OF EPIDEMIC CHOLERA. 

R Drog. amari Jss. Aq. purse |j. 

M. ft. haust. statim. 

Five minutes past twelve. — Vomited the drog. amarus. The cramps in his legs continue. 

Apply mustard poultices to both legs. 

Continue to rub the whole belly and stomach with sp. 

terebinth, and prepare sinapisms for the belly. Rept. haust. Camph. v. a. 

Half past one, p. m. — Pulse much improved, fuller, and stronger, but intermits at every ten or twelve strokes. The skin is warm, but the spasms in his legs continue. Bleeding was again urged by Dr. Harris and myself; but he still positively refused to have any taken from him. 

Enema purgans 

This remained with him near an hour, and brought away much glairy mucus and watery fluid. There is an amazing quantity of glairy, white mucus in this motion, and he feels exceedingly exhausted. 

Half past two, p. m. — Feels an excessive degree of general irritation about him, and the cramps have returned with more severity ; his pulse has become weaker than it was, and his skin is covered with a profuse, cold perspiration. Complains again of nausea and sickness at stomach, but does not vomit. The 



105 

CASES OF EPIDEMIC CHOLERA. 

sinapisms are so painful that he will not allow them to remain upon him. 

Cont. frictiones. 

Refuses to take the camphor draught. 

Forty minutes past two, I prevailed on him to take the following draught : — 

R Pulv. Jalapii comp. 3J. 

Aq. Minth. pip. M. ft. haust. 

This remained upon his stomach, and at a quarter past three o'clock he was fast asleep, and slept with very little interruption till four o'clock, p.m., when his pulse again became full and soft; skin warm, though the cramps continue, but they are not so frequent or severe ; and he has less sickness. 

Cont. frictiones. 

Quarter to Jive, p. m. — Had another motion, very small in quantity, and precisely like the last ; but he was not so much exhausted as he previously has been after each motion. His skin continues warm, and his pulse, though quick, is full and strong. He has had a very profuse perspiration, and I think him much relieved by it ; the cramps do not come on so frequently, nor are they so severe 5 and he has less sickness at stomach. 

01. Ricini, Jj 

Quarter past eight, p. m. — Rept. enema, v. a. 



106 

CASES OF EPIDEMIC CHOLERA. 

He slept a good deal, and perspired freely, between six and eight o'clock; retained the enema till nine o'clock, when he passed a very offensive motion, of a pale, muddy colour, watery, and without the appearance of faeces. 

Quarter before ten, p. m. — Felt sick, and vomited part of the oil ; cramps not so severe ; pulse quick, but soft and full ; skin of the natural temperature. Tongue excited ; says he feels great uneasiness and sickness at the stomach, and a griping sensation in his bowels. 

Ten o'clock. — Fast asleep, and he breathes freely and distinctly. 

Quarter to eleven. — Has only just now awoke ; he feels sick, and has drank largely of warm water, and has vomited ; but nothing came from his stomach except the pure water which he had drank. His mind has been wandering much in his sleep, and has been desirous to know whether the cholera is under the direction of the supreme court, or the Sudder Adawlut ; he thinks it ought not to have remained so long upon him. 

Twelve o'clock at night. — Fast asleep, and slept tolerably sound, and without any kind of disturbance, till ten minutes past three o'clock, a. m. He awoke with a desire to relieve his bowels, and passed a motion, watery, and with flocculent matter ; but nothing at all like faeces. His pulse is more regular and less frequent, full, and strong ; no pain in his belly or head ; cramps 



107 

CASES OF EPIDEMIC CHOLERA. 

much less frequent, and, on the whole, I consider him greatly better. 

R Pil. Colocynth, gr. iij. Cal. gr. iij. 

Pulv. Antim. gr. ij 

Syr. q. s. 

Ut fiat pilul. to be taken immediately, and repeated every two hours. 

Half past Jive, a.m., Wth October. — Has slept till this time, and has taken another pill ; feels some cramps still in his legs, but feels perfectly easy in his belly ; pulse full and soft — 88 in a minute; skin of a natural heat ; no feculent, stools as yet ; his tongue is clean, but he complains of great thirst. 

Six, a. m. — Repet. enema purgans. 

Seven, a. m. — The enema has just now come away, with some glairy mucus, similar to what has been already noticed, and small pieces of broken fseces. 

Rept. pilula. 

Nine, a. m. — Has felt a good deal of sickness at stomach, and has drank a considerable quantity of warm water, which has produced vomiting, but only of the water he has drank, and he feels relieved by it. 

Twenty minutes past nine o'clock, — Rept. haust. Jalapii, v. a. 



108 

CASES OF EPIDEMIC CHOLERA. 

He went to sleep immediately after taking the draught, and slept till half past ten, when he awoke, and felt refreshed. The draught has not occasioned any disturbance in his stomach ; he feels quite easy. 

Quarter before twelve. — Had a motion from the medicine, of curdled, feculent matter, exceedingly offensive, and slightly marked with bile. Feels sickness at stomach, but no vomiting ; pulse good ; the cramps occasionally attack his legs and arms, and the palankeen boys are constantly shampooing him; and his limbs are occasionally rubbed with sp» terebinthinse. 

Rept. enema, v. a. 

Twelve o'clock, noon. — Purged by the enema ; motions feculent, morbid, and offensive ; there is bile, but it does not seem to flow freely. The cramps still continue. 

Apply a large blister over the epigastric region. 

[This was not applied to remove pain, but to remove spasm from the biliary ducts, and to promote a free flow of bile.] 

Cont. pil. v. a. 

He slept from this time till one o'clock, p.m., when he awoke, complaining much of sickness at stomach, which he imputed to the pills, and will not take any more. Has drank a good deal of warm water, and has vomited nothing, however, but water; cramps severe in his legs ; no effect, as yet, from the blister. 



109 

CASES OF EPIDEMIC CHOLERA. 

Quarter before two o'clock, p. m. — Pulse 86, firm, regular, and full ; complains of being sick at stomach. There is a warm moisture on his skin ; he feels griping pains in the lower part of his belly — probably the effect of medicine. 

He will not take an enema, which I am anxious to give him, nor any more medicine. 

Three o'clock'?, m. — Had a motion of dissolved faeces, with more bile than usual, and in tolerable quantity, after which he slept till four o'clock. He now complains of nausea and sickness at stomach ; drinks warm water, and makes himself sick : this is done in defiance of all my objections. He will not take medicine to aid the operation of what he has already taken, because he thinks he has taken enough. Fancies there is a stricture in the gut, and that whatever he takes does more harm than good ; in short, he has such singular notions of his disorder, of his own medical knowledge, and of the effects of medicine on his peculiar constitution, that all my persuasion is perfectly useless. He is now, certainly, out of all danger ; but should he continue to abstain from taking such medicines as may be required, or such nourishment as may be essential to his recovery, it is quite impossible that I should be answerable for the consequences. — The blister is doing its duty well. 

Ten minutes before five, p. m. — Has had another motion, of precisely the same appearance as the last. 

Half past six, p. m. — Has taken a very small quantity of congee-water, which is the only thing like 



110 

CASES OF EPIDEMIC CHOLERA. 

nourishment he has taken for the last forty hours. The sickness at stomach, of which he has complained so much lately, is considerably diminished — a circumstance which proves satisfactorily, that its continuance depended on the want of food. 

Quarter past eight. — Had another motion, of the same kind as the last ; has less sickness and cramps ; skin warm and comfortable; pulse good; slept from half past eight till half past nine o'clock ; he awoke exceedingly thirsty, and drank some toast and water, complaining, for the first time, of feeling weak. He will not take his broth, as he promised to do ; feels less sickness and spasm. Slept from a quarter to ten, to a quarter past eleven o'clock ; his pulse is 88 in a minute, full, distinct, and regular ; natural temperature, with a good moisture ; has not been moved in his bowels since eight o'clock, p..m. The blister has risen well, and is dressed ; feels very weak ; took a glass of soda-water, which he found exceedingly agreeable, and went to sleep again. 

Twenty-Jive minutes past one, a. m. — Has slept soundly till this time ; pulse continues good ; skin natural and moist; great thirst; less sickness at stomach; has occasional cramps in both legs and arms. Drank a glass of soda-water. 

\2th October, half past Jive, a.m. — Has passed an excellent night. His pulse, this morning, is very good ; skin natural, and tongue clean ; no cramps ; feels some uneasiness, and confusion in his head, but can bear the light of a candle, or any other strong light ; has sickness 



111 

CASES OF EPIDEMIC CHOLERA. 

at stomach, and bitter taste in his mouth ; had a small fluid, bilious motion; is very drowsy, though he thinks himself stronger. Probably these symptoms may arise from some bile having regurgitated into the stomach, from the constant vomiting he has kept up by drinking hot water. 

Half past six o'clock. — Dressed the blister, which discharges freely. Let him have an enema every four hours. 

Seven o'clock. — He took a cup of tea, and sat up in a chair till eight o'clock, without inconvenience or fatigue, when he took a second cup of tea. Had one feculent motion, exceedingly well marked with healthy bile, but is offensive ; feels rather exhausted after this motion, and has retired to his couch ; no cramps or pain of any kind. 

Nine o'clock. — Has taken an enema ; it operated in half an hour ; motions highly bilious. He complains of excessive sickness at stomach j pulse good. 

Ten o'clock. — Has vomited an amazing quantity of yellow bile, and has drank a good deal of warm water. 

Half past ten, a. m. — Had another stool, and vomited more bile ; pulse good ; skin natural ; cramps completely removed. 

Half past eleven, a.m. — Sickness continues, and he vomits more bile. Drinks plentifully of warm water. 



112 

CASES OF EPIDEMIC CHOLERA. 

One o'clock, p. m. — Has not had any vomiting since last report. Feels greatly relieved in his head, and in every other respect. Has taken a glass of soda water, with a little wine ; pulse good ; no motion. 

Two o'clock, p. m. — Has had a motion, highly bilious, with broken faeces, and a very unusually strong smell of urine in it ; still feels sickness at stomach, and fulness of the belly, but no vomiting. 

Half past Jive o'clock, p. m. — Slept perfectly sound from half past two o'clock till this time, when he awoke complaining of feeling bilious, and very thirsty ; pulse good ; skin natural. Took a glass of soda water with a little wine; he is certainly greatly better in every respect, and though he feels heavy and drowsy, yet he has no symptom that gives me the slightest uneasiness. 

Repet. enema purgans, ut antea. 

The enema has operated ; motions the same as before ; highly bilious ; he says that he feels sick and faintish after each enema, which feelings remain on him for some time. : 

Quarter to eight, p. m. — Feels a good deal of restlessness, and nausea at stomach ; he drinks warm water, and vomits a little bile ; pulse much fuller, but soft, and 72 in a minute. Tongue rather excited ; feels thirsty ; slept occasionally, from this time till half past ten o'clock, and at that hour he took the following draught, and slept till half past twelve o'clock : — 



113 

CASES OF EPIDEMIC CHOLERA. 

ft Infusi Amar. Jiss. Sennse 3VJ. 

Tinct. Cardam. M. ft. haust. 

At half past twelve o'clock he awoke. Still complains of thirst, but his pulse continues good, and he has less restlessness and sickness at stomach ; and feels much better altogether since his last sleep. 

A glass of soda-water. 

One o'clock, a.m. — Awoke and took some cold water, and went to sleep again immediately. 

Two o'clock, a.m. — Pulse good; stomach easy; skin natural. Tongue the same as at last report. Slept from this time till four o'clock, a.m. when he awoke, complaining of excessive thirst ; but he had neither sickness at stomach, nor cramps. Removed from his hot room to the hall, and slept till half past five o'clock, A. M. 

12th, half past Jive o'clock, a. m. — Says that he feels a soreness over him, as if he had been beaten. Feels languid and weak ; no headach ; stomach better ; tongue rather excited, but not very foul ; pulse 72 in a minute ; skin natural. 

Repet. haust. amar. cum Sennd, v. a R Mist. Salin. febrifug. Ibj. 

Aq. Ammon. g u . xxx. 

Sp. iEther. Nitros. 3J. M. ft. mist. A glass every two or three hours. 

1 



114 

CASES OF EPIDEMIC CHOLERA. 

Twelve o'clock, noon. — Has had one very copious, bilious, and feculent motion ; pulse good ; skin natural ; countenance clear and animated, but he feels weak and languid. Tongue clean and healthy 

One o'clock, p. m. — Took some beef-tea with a relish ; this is the first food he has taken since the first attack. 

A glass of soda-water. 

Continued remarkably well during the whole day, and took his aperient draught at bedtime. 

13^A, six o'clock, a.m. — Passed an excellent night; had no motion, but made a great deal of urine during the night ; pulse 72 ; skin natural ; no pain or cramps of any kind ; says he feels weak and languid. Would not repeat the bitter mixture, lest the tincture should disagree with him ; but took some tea. 

Two o'clock, p. m. — Has had a small motion, perfectly consistent, smooth, and very tenacious ; makes water very freely. No pain or uneasiness of any kind ; fancied the tea he took disagreed with him, and occasioned flatulency and irritation. He has taken no medicine to-day, and now fancies a glass of sherry wine and a biscuit. 

14th. — Passed a good night, and took, at five o'clock this morning, 3J. Pulv. Jalapii Comp. in a glass of Aq. Menth. pip. At half past seven o'clock it operated, and brought away four very large feculent, offensive, and highly bilious stools ; he felt a good deal 



115 

CASES OF EPIDEMIC CHOLERA. 

exhausted afterwards, but slept till four o'clock, p.m. and awoke much recovered. 

A glass of soda-water and wine. 

15th. — Passed an excellent night ; pulse good — 76, regular, soft, and full. Tongue clean, but he feels languid. 

\6th. — Quite well. 

Repet. haust. Jalapii, 

which operated well, and brought away hardened faeces in considerable quantity, with a good flow of bile. 

\lth. — Passed a good night, and went out this morn ing in a palankeen. 

18th. — Mounted his horse, and rode out this morning. I now considered him quite well, but advised him to guard against constipation. He takes the following pills : — 

ft Pil. Hyd. gr. j. 

Aloes cum Myrrh, gr. ij. syr. q. s. 

M. fiat pilula, omni nocte vel p. r. n. sumenda. 

\9th. — The pill procured him a good motion. He feels quite well, and commenced to eat meat this day 



116 

PATHOLOGICAL OBSERVATIONS. 

SECTION 11. 

Pathological Observations and Inferences, fyc. 

The reader may observe, from the details of the appearances observed in dissections accompanying the cases now detailed, that the lesions produced by the disease in the solids, were not such as necessarily, of themselves, tend to a fatal termination. It was in my power to have given the particulars of a greater number of cases in which post mortem inspection was performed ; but, as the morbid appearances were nearly the same in all, and as the history of the progress of the disease in each was almost precisely alike, I have abstained from adducing more of the details than seemed to me to be necessary to the full illustration of the subject. Although the solids presented but few derangements, and these not always of a very serious nature, yet the condition of the circulating fluid, as observed, both during the life of the patient and on inspection after his death, seems to me to be such as to account for many of the symptoms of the disease, and for their rapid progress towards a fatal termination. 



117 

PATHOLOGICAL OBSERVATIONS. 

Before I proceed to inquire into the essential or efficient cause of the disease, I will first take a general view of the alterations presented by the different textures and fluids of the body, and of the relation which seems to exist between these alterations and the phenomena characterising the disorder. Having thus brought before him a statement of the lesions in which epidemic cholera usually terminates, the reader will be possessed of grounds whence he may proceed to draw his own inferences, respecting the nature of the pathological condition constituting the earlier stages of the disease, and thence to infer the nature of the causes from which it seems to originate. 

External Surface. — The appearances observable in subjects at the period of dissection, were a corrugated and shrunk state of the extremities ; considerable lividity of the surface ; and dark purplish colour of the lips and parts not covered by the cutis vera. The soft solids were apparently shrunk ; the eyes sunken, the features astonishingly collapsed and ghastly for the short duration of the disease, and the vessels at the surface contracted and bloodless. 



118 

PATHOLOGICAL OBSERVATIONS. 

Head. — The sinuses and veins of the brain, and of its membranes, were always congested with black, thick, and viscid blood. The tunica arachnoidea was frequently opaque, and somewhat thickened and adherent to the adjoining membranes. Some gelatinous or serous effusion was often observed in the ventricles, and between the membranes. The brain was sometimes soft and pulpy, but it seldom presented any very decided marks of increased action. 

The congestion of black blood and the serous effusion so often observed within the cranium seem to account for the stupor, deafness, vertigo, and noise in the ears, generally present during the life of the patient; and it was usually found that the lesions just alluded to were more marked in the cases wherein those symptoms were most manifested. 

Thorax. — The heart, and large venous trunks, were frequently distended by a thick black blood ; the substance of the heart sometimes appeared softer, and more easily lacerable than in the healthy state. The lungs were generally shrunk, collapsed, filled with black blood, heavier than natural, and of a fleshy, 



119 

PATHOLOGICAL OBSERVATIONS. 

hepatised, or bruised appearance. The pleura was usually pale and healthy ; the pericardium natural, and sometimes contained a very small portion of serum. 

The relation which these lesions bear to the derangement of the respiratory and circulating functions observed in the course of the disease, seems sufficiently evident. These lesions, also, were remarked to be great, in proportion to the extent to which these functions respectively were deranged. Whilst, however, I am ready to grant that a great part of these derangements was merely consequent on death, yet I must contend, that much of them had taken place before that issue occurred; and that the depression of the vital energy of the organs, at the time of the invasion of the disease, gradually led to, and became accompanied by, many of the derangements which these organs presented after death. 

Abdomen.— Upon opening the abdomen, a peculiar offensive odour — as remarked by Mr. Jamieson, in his Report of the Medical Board of the Bengal Presidency, respecting this diseas — was sometimes observed, particularly in those who died suddenly. The stomach generally 



120 

PATHOLOGICAL OBSERVATIONS. 

contained more or less of a watery, muddy, and sometimes a grumous fluid. The colour of this fluid was various ; sometimes it was colourless, at other times greenish, or passing to a yellow tint; and in some cases it was brown, approaching to black. The peritoneal surface of the organ seldom presented any other appearance than a greater congestion of the veins than was natural. ¦ The mucous surface was sometimes covered by a dark-coloured slimy mucus, and when this was removed, considerable congestion of the venous capillaries was observed. This congestion seemed to be chiefly seated in the sub-mucous cellular membrane, and was occasionally so extensive in particular points, as to give the appearance of ecchymosis of this coat. The internal tunic was occasionally much corrugated, seemingly much thickened, and doughy to the touch, more especially when it was not much distended by fluid or flatus. The stomach was frequently flabby and relaxed, and its coats could be more easily penetrated by a harder body than usual. In those cases, in which some degree of re-action of the vital energies had taken place, the internal surface of this organ, particularly about the pylorus, presented a livelier colour, approaching to red, and was apparently thickened and contracted. 



121 

PATHOLOGICAL OBSERVATIONS. 

The omentum was sometimes corrugated, or thrown to one side of the abdomen. 

The small intestines were, occasionally, more than usually constricted in parts, frequently distended by flatus, and their veins generally engorged with black blood : externally, they presented a doughy, thickened appearance, and their colour varied from a pale vermilion, through all the deeper shades, to a dark purplish hue ; the former being chiefly remarkable on the peritoneal surface of the duodenum and jejunum, the latter in the ileum, about where it terminates in the caecum. These shades of colour appeared to arise from the different degrees of congestion in the capillaries and veins in different parts of the canal, from the injection of the arterial capillaries, and from the colour of the blood which the vessels contained. 

When the small intestines were laid open, their coats seemed thickened, especially if the intestine was not distended, or if it was in any degree contracted; they were frequently flabby, and more easily torn than usual. The internal surface was generally found covered by a viscid, thick, and clay-coloured substance, which sometimes passed to a cream, 



122 

PATHOLOGICAL OBSERVATIONS. 

or yellowish tint. This was particularly remarked in those who died after a sudden and short attack of the disease. When this matter was removed, the mucous coat itself was usually pale in the upper portion of the small intestines, and dark-coloured and congested in the lower part, particularly where the ileum is blue or purplish externally. When the disease was of longer continuance, and more particularly when some re-action of the powers of the system had taken place, this viscid appearance was detached to a greater or less extent, and was floating in the fluid contents of the small and large intestines ; and the mucous coat then seemed more vascular, and the arterial capillaries appeared more injected, than in the former class of cases. 

The large intestines were frequently contracted, sometimes they were distended, and at others, they were both contracted and distended in different parts, in the same case. Congestion of the veins and venous capillaries was generally evident, especially of those seated in the cellular substance connecting the tunics. The external coat was generally dark-coloured, owing to the blackness of the blood in the congested vessels. The mucous surface was frequently very vascular ; 



123 

PATHOLOGICAL OBSERVATIONS. 

sometimes it presented a dark red colour, especially if the patient had lived for some time, and strong stimulants had been administered. These intestines never contained any faeces, and the fluids met with in them were generally similar to those found in the stomach and small intestines. 

Reference has already been made to the vascular appearances of the small intestines, and the symptoms referred to the umbilicus during the life of the patient; and the connexion between both seems evident. The irregular contractions and dilatations of the intestinal tube and the abundance of flatus in it evidently appear, from the early existence of the colicky pains, to follow close upon the invasion of the efficient cause of the disease ; and these pains may, consequently, be considered as an index of the first stage of these structural derangements, which, although originating in a defect of vital energy, may be farther increased by the morbid condition of the blood circulating in the vessels of these parts. 

The liver was generally darker than natural, and loaded with black, thick blood. Sometimes this organ assumed a purplish, or dark 

* 



124 

PATHOLOGICAL OBSERVATIONS. 

blue colour; at other times it was mottled, enlarged, flabby or pulpy, and easily torn. 

The gall-bladder was always distended by thick viscid bile, which was generally of a darkgreen or black colour, in subjects who died before the appearance of bile in the excretions ; and although the hepatic duct was large and permeable, the mouth of the common duct was generally constricted, and seldom permitted the bile to flow into the duodenum without considerable pressure made upon the gallbladder. In those cases which terminated fatally after an illness of long duration, and in which some re-action of the vital energies, and a flow of bile into the intestines, had taken place, the gall-bladder was generally empty, or contained but a small quantity of healthy bile; and the common duct, although not always free from some degree of constriction, was generally more permeable than in the former class of cases. In a few instances the gall-bladder was quite empty, relaxed, and flabby. In almost all the cases wherein bile was observed in the excretions, and the gallbladder was found empty on dissection, and consequently, when it could be legitimately inferred that this secretion had passed into the intestines during the life of the patient, I remarked, 



125 

PATHOLOGICAL OBSERVATIONS. 

that the viscid matter usually found lining the mucous surface of the small intestines, in the former description of cases, was detached to a greater or less extent, and was either floating in the fluid contents of the large intestines, or entirely removed, along with the matters which had been ejected from them. 

The spleen was generally enlarged, and engorged with black blood ; and its texture was frequently soft. In some cases it fell to pieces whilst the examination of it and the adjoining parts was being performed, owing as much to an inordinate degree of distension, as to relaxation or softening of its texture. The colour of this viscus was uniformly darker than usual. 

The kidneys were generally of a healthy structure, and presented not any organic derangement which could explain the complete interruption which their functions had experienced in the course of the disease. 

The urinary bladder was generally empty, and shrunk under the pubis : its mucous surface was frequently covered with a considerable quantity of a viscid, mucous secretion. The 



126 

PATHOLOGICAL OBSERVATIONS. 

contracted state of the bladder was evidently the result of the absence of secreted urine. 

The blood. — The peculiar appearance of the blood, particularly excited my attention in the first case of the disease which came under my care. In every dissection which I performed, I uniformly found the venae cavae, the mesenteric veins, the veins in the vicinity of the heart, the vena portae, the iliac and subclavian veins, and the sinuses of the brain, loaded by a thick, viscid, and black blood. The right cavities of the heart were generally distended with the same description of blood, and when any was found in the left cavities of this organ, it was similar in appearance to that lodged in the right. The lungs were always completely engorged with blood, of a pitchy or black appearance, and all the internal viscera presented a greater or less degree of congestion of blood, possessing nearly the same characters. The blood-vessels, at the external surface of the body, and in the extremities, were generally contracted and empty, or nearly so. 

That this condition of the circulating fluid was not consequent on death, although it might be more or less heightened thereby, is evident 



127 

PATHOLOGICAL OBSERVATIONS. 

from the appearances which this fluid exhibited when taken away from a patient, even at an early period of the disease. During the subsequent stage, and more especially as the disease advanced to a fatal issue, the particular characters of the blood which have been now noticed were the most manifest, as may be seen in the details of the foregoing cases. That this state of the blood was the first material derangement consequent on the invasion of the efficient cause of the malady, I shall not contend ; but that it was one of the earliest links in the chain of effects consequent to that cause, and that it afterwards tended, by a necessary and evident process, to heighten and to perpetuate the derangement whence itself sprung, I have not the least doubt. That the nervous influence, in some manner or other, received the first impression of the morbid cause, and afterwards gave rise to this condition of the circulating fluid, may be inferred, if we be permitted to conceive that a diminished function of the lungs, liver, and other excerning viscera, was co-existent, or nearly so, with that primary change ; and consequently, that the blood did not undergo an elimination of its effete and noxious constituents, to an extent requisite to the performance of the organic actions and the continuance of life. 



128 

PATHOLOGICAL OBSERVATIONS. 

The appearances on dissection, both as respects the solids and fluids, were precisely the same in the natives of the country, as in Europeans. The only difference — and which does not affect the general inference, was, that in the former the disease generally terminated rapidly, the powers of life being readily overpowered ; and that congestion after death was generally remarkable in these : in the latter, reaction more frequently occurred, and consequently, appearances of capillary action were more observable in them than in the former. 



129 

CHAPTER IV. 

OF THE CAUSES OF THE EPIDEMIC CHOLERA. 

Having stated, as circumstantially as I am able, the phenomena characterising the invasion of the epidemic cholera, and its progress to a fatal termination, (which appears to have been its usual issue during the height of the epidemic, when uncontrolled by a judicious mode of treatment), or to a return to the exercise of the healthy functions ; and having detailed the appearances exhibited by the internal viscera upon dissection, the next objects of inquiry which present themselves, are the causes to which we may impute the ravages which this malady has committed in the population of the East. As the signs of disease, and the lesions remarked after death has taken place, are so intimately related to the efficient or proximate cause ; and as the tran- . sition from the consideration of the one to that of the other, is both natural and necessary to the full exposition of my subject, I shall first proceed to offer some opinions re- 

X 



130 

PROXIMATE CAUSE OF 

specting the probable efficient cause of the disease, and next, adduce some remarks as to the predisposing, and occasional or exciting causes, which seem to co-operate with the foregoing one, and to occasion, by means of such co-operation, the development of that peculiar train of morbid actions constituting the disease under consideration. 

SECTION I. 

Of the Efficient or Proximate Cause of the Disease.* 

The morbid appearances so uniformly exhibited throughout the cases I have detailed, and the summary statement I have adduced in the second section of the foregoing chapter, shew that venous congestion was manifested, to a greater or less extent, in every stage, and in every instance of the disease, more particularly in the fatal cases ; and that this congestion differed only in degree, according to the strength and vigour of the patient, and the activity or intensity of the cause. 

* I must be understood as using the words efficient or proximate, in their present application, as synonymous terms. 



131 

EPIDEMIC CHOLERA. 

I have already shewn that the venae cavae, the right auricle and ventricle of the heart, and the pulmonary arteries, were, in every case, loaded with blood. The pulmonary veins also returned black blood to the left auricle and ventricle of the heart, and, when blood was found in the arteries, it was black and viscid. The liver and spleen were in a high state of congestion ; and the vessels of the brain, both veins and arteries, were extremely turgid with the same kind of blood. 

This singular and sudden change in the circulating fluid appears to be the effect of some uncommon influence over the vital powers; but it is a question, what that influence is, and how that change is produced, which thus deranges the functions and general balance of the circulating organs, and which seems to deprive the system of the power of producing those changes on the blood, which are requisite to the purposes and continuance of life ? 

In death from suffocation, we know that the heart continues to pulsate for some time after breathing has ceased, that the blood passing through the pulmonary vessels no longer receives the influence of oxygen, and consequently 



132 

PROXIMATE CAUSE OF 

that black blood is circulated : we know, moreover, that arterial blood alone can support the energies of the brain, and, therefore, that the influence of black blood upon this organ, must be deleterious to the whole circle of the vital actions. 

Bichat has proved, that, when black blood has been injected into the vessels of the brain, the functions of this organ become immediately disturbed, and very soon cease. 

Mr. Brodie has observed, that " darkcoloured blood, which has been transmitted through the circulating system, during the suspension of respiration, would seem to act like a narcotic poison upon the brain. No sooner does it enter that organ, than deleterious effects are immediately produced, the animal falls into a state of stupor, the pupils of the eye become dilated, the respiration is laborious, the muscles of the body convulsed, and the animal dies poisoned by its own blood." 

This fact seems to explain many of the symptoms of epidemic cholera; but I must observe, that, although the circulation generally was remarkably weak from the first, and the pulse at the wrist could seldom be 



133 

EPIDEMIC CHOLERA. 

felt, yet respiration never ceased altogether, although it was performed with great labour and difficulty ; and sometimes, especially at the close of life, was much slower than usual. The senses, too, were generally retained to the last moment of life, although stupor, deafness, and deficient sensibility, were often very considerable. It would appear, however, that, notwithstanding respiration was continued, the blood was either not oxygenated, or imperfectly so ; and the patient sunk like one who dies from the poisonous influence of tobacco. 

We are assured, by the best authorities, that extreme vicissitudes and irregularity of seasons, great excess of cold, heat, moisture, or drought, are productive of disease : and that such variety of seasons cannot exist without producing corresponding alterations in the composition of the atmosphere itself; but what these changes are, have never been explained, and, perhaps, never will. The existence of electricity in the general mass of air which surrounds us, is acknowledged by every one ; and to infer that this fluid, which is so wonderful in its effects, cannot exist in the atmosphere without a certain influence upon animal life, cannot be viewed as an unreasonable conclusion. The experiments and researches of modern 



134 

PROXIMATE CAUSE OF 

philosophers agree in proving, that electricity enters into the composition of all material substances, and some suppose, with Mr. John Hunter, that " a subtile substance of a quiet and powerful mobile nature seems to pervade every thing, and appears to be the life of the world ; and, therefore, it is probable a similar substance pervades organised bodies, and is the life of those bodies." We see, in the course of our daily observations, the sympathies that exist between the brain, the stomach, and other parts of the body; the instantaneous effects sometimes produced by affections of the brain and nerves, manifested in what is called irritability ; and we know that certain changes and modifications of fluids take place from certain affections of the vessels themselves. 

Mr. Hunter has explained how a morbid state of the fluids may induce an unhealthy action of the vessels, and how the latter may reciprocally occasion the former, supposing that the vital principle of the vessels, acting on that of their fluid contents, produces chemical changes by a concert of affection between both, which he has called " harmony." These notions at the time were considered obscure, but the experiments of Sir H. Davy, and of 



135 

EPIDEMIC CHOLERA. 

other modern inquirers, demonstrate the probability and rationality of his theory, and prove that there are electrical actions, by means of which all combinations and decompositions of matter are occasioned, and that what is called electricity pervades every substance, whether solid or fluid. 

Dr. Macartney is also of opinion, that when fluids change their composition, it is often effected by means of some vital action in themselves, and not by a fermentative process, or mechanical operation of solids upon them, as is commonly supposed : and recent discoveries in science shew, that all the changes and motions which occur in surrounding bodies, as well as in those that live, are the effects of subtle and invisible principles existing in or acting upon them, and regulating and governing their temperature. 

We see considerable vicissitudes in temperature from certain affections of the stomach, while respiration and circulation remain unaltered ; a circumstance which can only be explained upon the principle of local nervous excitement, or torpor, or some similar affection of the vital powers of the parts which undergo such transitions. This opinion is supported by 

? 



136 

PROXIMATE CAUSE OF 

Mr. Brodie's experiments, which prove, that respiration and circulation may be artificially kept up, after all connexion between the brain and heart and lungs was cut off; but, although the circulation was continued in these experiments for some hours, yet the body cooled as rapidly and regularly as that of another animal, in which respiration and circulation ceased upon the division of the medulla spinalis. These experiments shew, that the change produced by respiration upon the blood, is not of itself sufficient to maintain the ordinary temperature of animals, and that we must call in the aid of some other principle in order to account for the phenomenon. 

Mr. Abernethy very justly states, that experimental science has not informed us of more than reason has suggested from the consideration of the general phenomena of nature : that motion and changes occurring in surrounding bodies, and in our own, are the result of some subtile substance or substances which enter into their composition, or act upon them: and, when Sir Isaac Newton explained the laws of attraction and of the motion of those substances we call matter, he supposed that there might be an aether forming a bond of connexion and reciprocal action between 



137 

EPIDEMIC CHOLERA. 

their distant masses and molecules. However minute the atoms may be which compose those visible and tangible substances called matter, Sir H. Davy's experiments shew, that each atom is surrounded by electric substances, possessing powers of attraction and repulsion, which are not only capable of acting upon the integral parts of bodies, but likewise upon the largest masses of matter. These electric substances produce decomposition and recombination, by which means the mechanical properties that before existed may be destroyed. 

The agency of the electric fluid, and its existence in animated nature, have been fully proved by experiments upon the gymnotus electricus; and various other facts shew, that galvanic electricity is essentially connected with the human frame, and continually exerting its influence upon it ; but a variety of causes may concur to vary the equilibrium of this fluid ; and if we admit that a certain portion of it belongs to all substances, we shall find no difficulty in believing that any alteration in the quantity, quality, or intensity of its action, will produce corresponding changes in the habit or health of the body ; and that the sensibility of the nerves, as well as many other disorders which we cannot satisfactorily account for, may be owing to the body possessing too great 



138 

PROXIMATE CAUSE OF 

or too small a quantity of electric matter, which in fact may be the vehicle of all our feelings. We know that in damp and hazy weather, when the activity of electricity is diminished, our spirits are languid, and our sensibility less acute. At Naples, when the southerly winds blow strong, the air is supposed to be completely deprived of electricity, and, during its continuance the system is unstrung, and the nerves seem to lose their tension and elasticity. 

Dr. Johnston observes, in speaking of the diseases of the Mediterranean, that during the strong southerly winds, the circulating system in the human frame becomes wonderfully deranged ; and, according to Ritter, the electricity of the positive pole augments, while that of the negative diminishes the actions of life ; tumefaction is produced by the former, depression by the latter ; the pulse of the hand (he says) held a few minutes in contact with the positive pole is strengthened ; that of the hand in contact with the negative pole is enfeebled ; the former is accompanied with a sense of heat, the latter with feelings of coldness. 

From these facts and considerations, therefore, I am led to conclude, that either the absence of electricity from the human body, or some important change in its electrical 



139 

EPIDEMIC CHOLERA. 

state, arising, perhaps, from exposure to a negative electrical atmosphere, may be the cause of the dreadful and destructive epidemic which has recently ravaged the East ; and that the vicissitudes of the seasons preceding this formidable visitation may support this opinion. If, therefore, this view of the subject be correct, we may readily account for the sudden attacks of the disease, the changes in the temperature and sensibility of the body, and in the fluids, which changes seem chiefly to characterise it, and for the manner in which it has been limited to some districts, extended to others, and has successively ravaged all. 

How far this peculiar state of atmosphere and seasons in India may have influenced the change in the circulating fluid, to which I have ascribed the sudden death in cholera, is a question I am not prepared myself to answer, because I had neither the means nor the opportunity of collecting those facts that were likely to lead to correct information on this point. I suggested, however, to the Medical Board at Madras, in a letter to the superintending surgeon, Howard, dated Madras, sth of November, 1820, " That such an investigation might be attended with much advantage in tracing the cause of this disease." 



140 

PROXIMATE CAUSE OF 

I shall take leave, however, to observe in this place, that, for the last four or five years, my attention has been particularly attracted to the peculiarly thick and black appearance of the blood, in almost every case where I had occasion to perform the operation of venesection, whether in cholera, dysentery, fever, hepatitis, or rheumatism.* I mention rheumatism, because it was a case of this disease in which I was, in 1817, first struck with the black condition of the blood ; which condition was particularly remarkable in that drawn by leeches : this fluid was generally more like tar than blood- This appearance, however, I imputed to the change which this fluid is supposed to undergo in the stomach of the leech ; and, therefore, passed it unnoticed, till my attention was arrested by its continual presence, — whether the blood had been taken by means of venesection or of leeches, and by its nearly uniform occurrence amongst all classes of persons of whatever description — from the most delicate female to the most robust and hardy soldier. 

In the advanced stage of epidemic cholera, 

* According to this view, would not the inhalation of dilute oxygen gas, or of nitrous oxide gas, be attended with advantage in the treatment of these diseases ? 



141 

EPIDEMIC CHOLERA. 

the blood was so thick, that it would not flow at all, but came away in thick drops. At the very commencement only of the disease could blood be drawn ; and even then it had the appearance of thick black oil. If, however, it flowed freely till the fluid became thin and of a bright red colour, the operation was generally beneficial, and the case became manageable; but of this more hereafter, when I speak of the treatment of cholera. In cases of disease of the liver, fever, and dysentery occurring during the period referred to, the blood flowed freely from the vein, though in a languid stream ; but it was always thick and black. When leeches were applied, and particularly when applied to the praecordia or head, they remained fastened to the skin for upwards of two hours, without drawing more than half an ounce of blood ; and this, in general, was so excessively thick, that it could not be taken from them but with difficulty, and, in some instances, they died before they were removed.* 

* It has been observed to me, that the change which the blood undergoes in the stomach of the leech, would account satisfactorily for its peculiar appearance; but this certainly is not the case : because, while I admit that blood there undergoes a considerable change, yet that change does not produce the peculiar thickened and inspissated state I allude to. The only difference I have observed in blood taken 



142 

PROXIMATE CAUSE OF 

That this very unnatural and uncommon condition of the blood, which appears to me to be produced by an unusual accumulation of carbonaceous matter, must lay the foundation for formidable congestive disease, cannot, I think, be disputed. 

Carbon, being a constituent element of the animal fluids, is carried to the lungs through the medium of the circulation in them, and is extricated from the system during the function of respiration, in the form of carbonic acid gas. Mr. Ellis observes, that " as the circulation declined or ceased, so likewise did the emis- 

from the vein, and by means of a leech, is in colour, and not in consistence. I have made the comparison frequently, and can therefore speak with confidence upon the subject. 

The leeches at Madras are particularly large. The average quantity of blood which they bring away, deduced from an accurate admeasurement of what has been taken by many thousands, is about one ounce and a quarter each. Seeing that their services, therefore, can be so well regulated, I have always, in my own practice, applied as many leeches as would bring away a given quantity of blood, and ordered the bites to be stopped the instant the leech is removed. I would strongly recommend the same plan to be adopted by others, because I have seen very serious mischief arise from allowing the leech-bites to bleed during the night ; and there is sometimes more difficulty in stopping the bleeding from a leech than many people imagine. 



143 

EPIDEMIC CHOLERA. 

sion of carbon, and, consequently, the production of carbonic acid gas." This, I presume, implies that the freedom with which the chemical changes in the blood are effected depends entirely upon the state of the circulation ; but, independently of the function of the lungs, which are the chief outlet for the extrication of carbon from the blood, we find this substance given off, though in comparatively small quantity, during the course of circulation, especially from the minuter vessels ; and we know that it forms an important constituent of all the secretions. 

The change of the bright florid arterial fluid into the dark-coloured highly carbonated venous blood, is confessedly operated in the capillary vessels ; and it is reasonable to suppose, that the application of cold to the surface will check capillary circulation, promote the change in question, and thus heighten previously existing derangement both of the circulating fluid and of the moving powers of the body. 

If the obstruction were continued, would the carbon accumulate beyond its natural proportion ? and would the blood returning from the capillaries thus supersaturated with carbon, produce immediately deleterious effects in 



144 

PROXIMATE CAUSE OF 

consequence only of this excess of carbonaceous matter? Or if such effects were not to take place, and if the blood be not readily returned from the capillaries into the large vessels, in what manner would the diminution of carbon be effected during the temporary stoppage of capillary circulation ? 

That either a diminished evolution of carbon from the blood, or an impeded absorption of oxygen into it, — (either alternative will suit my argument equally well,) — actually has place in this disease, has been shewn by experiment. Dr. Davy analysed the expired air of the sick in cases of epidemic cholera, and found that it did not contain more than one third of the carbonic acid usually contained in the breath of healthy subjects, two thirds being retained in the blood. 

Mr. Ellis says, that, " If carbon be not emitted from the blood while yet in the large vessels, nor after it has ceased to be in motion, it must be given out by that fluid while in circulation, and after it has entered into the minuter vessels ; thus it becomes an animal excretion, derived like other excretions from the blood, and emitted like them by some appropriate structure from the surface of the body. Hence any cause, —as cold checking 



145 

EPIDEMIC CHOLERA. 

the circulation, restrains the production of carbon, or, although the circulation is not checked, the emission of this substance is prevented by smearing the bodies of insects with unctuous matter, which, in consequence, causes death." 

Whatever may have produced this change in the circulating fluid, and upon the excretion of carbonic acid from the lungs, which characterised the epidemic cholera, it is very certain that we have been unable to discover any sufficient cause for it, either in the weather or seasons of the year. The disease was known to prevail in hot, cold, wet, and dry weather, in dry and in wet situations, in low swampy countries, and on elevated land, at all seasons, and under all cognisable circumstances. It must have depended, therefore, upon the influence of some quality in the atmosphere which has been overlooked, or which was, perhaps, beyond the reach of human observation. 

It is a well-known fact, that in the very centre of extensive districts ravaged by epidemic cholera, there are certain narrow stripes or patches of country into which the disease has never penetrated, though all around was one scene of 

L 



146 

PROXIMATE CAUSE OF 

desolation.* This limitation of the disease to places where there existed no natural obstacles to its extension, militates most conclusively against any idea as to its being a contagious disease, and seems to point to the existence of some difference in the quality of the atmosphere ; and I have little difficulty in believing that difference to have been chiefly in its electrical state ; which state may also have had an intimate relation with the exhalations proceeding from the soil of the places where the disease was predominant. 

The general character of the invading symptoms of the disease favours this opinion : these symptoms more or less suddenly supervened, and the vital functions seemed as if some poison had been taken into the stomach, or infused into the blood. The effects produced upon the animal economy by the infusion of tobacco are indeed similar, in many respects, to a case of cholera; and it is a curious fact, that the appearances observed after death in the one case, are not at all unlike those which have been observed in persons who have died from the effects of this, or of any other violently 

* The hill-forts in Kandeesh were exempt from cholera, whilst the disease raged throughout the country. 



147 

EPIDEMIC CHOLERA. 

narcotic poison, as the poison of the cobra de capella, &c. 

I regard epidemic cholera, therefore, as essentially an affection of the nervous system, and consider the diminution of the nervous power to be the proximate effect of the efficient cause of the disease — that cause being the electrical condition of the air, arising from, or accompanied by, terrestrial exhalations of a kind unfavourable to animal life. That the depression or affection of the nervous influence soon affects the blood appears evident, and that the black, unoxygenised state of this fluid heightens the previous derangement, and leads to the extinction of life itself, seems equally probable. That the circulation of black blood produces this effect has been shewn by Dr. Goodwin, who states, with seeming propriety, that " when the pulmonary blood is no longer fitted to excite the sinus venosus and auricles to contract, they receive it into the cavity, and remain at rest." But, whether we agree with Dr. Goodwin and others, that the blackness of the blood consists in its unoxygenised state ; with Ellis and others, in an excess of carbon ; or, with some physiologists, in both these states combined, — still its effect upon the action of the heart and upon the 



148 

PROXIMATE CAUSE OF 

brain will be the same ; and death, or extreme debility, &c. will be the uniform result of the presence of venous blood in the left cavities of the heart, and in the arteries. Therefore the phenomena of the advanced stage of cholera (as those arising from any other causes impeding the changes produced on the blood by respiration,) may be considered to proceed chiefly from the presence of black blood in the heart and arterial system, blood of this colour being found in these parts. 

In epidemic cholera the circulation at the wrist soon ceases, but the pulsation in the carotid artery can be felt to be strong till a few minutes before death, and for some time after it ceases at the wrist ; shewing that the blood is carried to the brain till the last moment of life. We may, therefore, infer, that death in this disease is occasioned in the same way as in drowning, i. c. owing to black venous blood being sent to the brain, and destroying its influence.* 

* The patients, however, in general retain their senses to the last, although there are always drowsy and stupid appearances about them ; the eyes are generally turned, or drawn up in their orbits, and are half open, shewing only their white part ; but, whenever I could get a full view of the eyes, I observed that the pupils were much dilated. 



149 

EPIDEMIC CHOLERA. 

From all the foregoing considerations, I conclude that the constitution of the atmosphere, to which I attribute the disease — whether that constitution consisted of a change in its electrical conditions, or in the presence of certain unusual emanations from the bowels of the earth — greatly depressed, and consequently impeded, the vital and nervous functions ; and, owing to the intensity of this mode of operation, and, perhaps, to the co-operation of the exciting or occasional causes, thus tended to the destruction of the lives of those predisposed to its influence, giving rise, during the processes of its operation, to the phenomena characterising the malady. 

SECTION 11. 

Of the Predisposing, and of the Exciting or 

Occasional Causes. 

Although we are unacquainted with the nature of the exhalations producing intermittent fever, and are even unable to detect them in the atmosphere by any chemical test, still it is very important to know in what situations they are generated. In treating of the cause 



150 

PREDISPOSING, EXCITING OK 

of epidemic cholera, it is likewise important to point out the situation and circumstances which experience has proved to be somewhat favourable to the development of this disease. And here I may at once state, that there seems to be sufficient proof that the situations remarkable for the prevalence of intermittent and remittent fevers, are favourable to the action of the efficient cause of the disease upon the system, if not to the development of the cause itself. 

It has been customary to assign a variety of efficient as well as of predisposing and occasional causes to this disease : nor can it be denied that a state of derangement, very nearly resembling epidemic cholera, is produced by many deleterious substances — for instance, tobacco ; but I am disposed to consider an unknown morbific condition of the atmosphere, or, as Sydenham would have called it, a choleric constitution of the air, whether that constitution result from its electrical state, or from the nature of the terrestrial exhalations existing in it, to be the effective cause, without which the epidemic form of the disease could not have existed ; and whatever favours the action of this cause, I consider to belong to the predisposing and occasional causes only. 



151 

OCCASIONAL CAUSES. 

This morbific condition of the atmosphere, whatever may be its nature', appears to be powerfully debilitating or sedative. Whatever, therefore, either directly or indirectly weakens the body, will diminish its power of resisting this sedative agent ; and will consequently prove a predisposing cause of the disease. As this condition of the air, however, eludes our senses, it is no wonder that the more obvious predisposing and occasional causes, such as hunger, fatigue, intoxication, cold, &c. &c. should have been often regarded as the true causes of the malady. But as in former times, (i. c. before 1818) and under circumstances perfectly similar, neither cold, hunger, fatigue, nor intoxication, produced the disease, they cannot be considered in any other light than as concomitant or exciting causes, or as favouring the action of that cause upon the system, without which the epidemic disorder could not exist. They merely aid the action of such a noxious power, by diminishing the resistance which the system can oppose to its influence. Much of the modification which the disorder assumes, as respects both its violence and prevalence, may be easily explained by inferring a variation in the intensity of the actual cause of the epidemic, and in the degree of predisposition of the patient, or of his vital resistance to its effects. 



148 

brain will be the same ; and death, or extreme debility, &c. will be the uniform result of the presence of venous blood in the left cavities of the heart, and in the arteries. Therefore the phenomena of the advanced stage of cholera (as those arising from any other causes impeding the changes produced on the blood by respiration,) may be considered to proceed chiefly from the presence of black blood in the heart and arterial system, blood of this colour being found in these parts. 

In epidemic cholera the circulation at the wrist soon ceases, but the pulsation in the carotid artery can be felt to be strong till a few minutes before death, and for some time after it ceases at the wrist ; shewing that the blood is carried to the brain till the last moment of life. We may, therefore, infer, that death in this disease is occasioned in the same way as in drowning, i. c. owing to black venous blood being sent to the brain, and destroying its influence.* 

* The patients, however, in general retain their senses tfl the last, although then- me always drowsy and stupid appearances about them ; the eyes arc generally tinned, or drawn up in their orbits, and arc hall' open, shewing only their white part; but, whenever I could jiet a lull view ol the eyes, I observed that the pupih weic jihmli dilated. 

PROXIMATE CAUSE OF 



149 

From all the foregoing considerations, I conclude that the constitution of the atmosphere, to which I attribute the disease — whether that constitution consisted of a change in its electrical conditions, or in the presence of certain unusual emanations from the bowels of the earth — greatly depressed, and consequently impeded, the vital and nervous functions ; and, owing to the intensity of this mode of operation, and, perhaps, to the co-operation of the exciting or occasional causes, thus tended to the destruction of the lives of those predisposed to its influence, giving rise, during the processes of its operation, to the phenomena characterising the malady. 

SECTION 11. 

Of the Predisposing, and of the Exciting or 

Occasional Causes. 

Although we are unacquainted with the nature of the exhalations producing intermittent fever, and are even unable to detect them in the atmosphere by any chemical test, still it is very important to know in what situations they arc generated. In treating of the cause 

EPIDEMIC CHOLERA. 



150 

of epidemic cholera, it is likewise important to point out the situation and circumstances which experience has proved to be somewhat favourable to the development of this disease. And here I may at once state, that there seems to be sufficient proof that the situations remarkable for the prevalence of intermittent and remittent fevers, are favourable to the action of the efficient cause of the disease upon the system, if not to the development of the cause itself. 

It has been customary to assign a variety of efficient as well as of predisposing and occasional causes to this disease : nor can it be denied that a state of derangement, very nearly resembling epidemic cholera, is produced by many deleterious substances — for instance, tobacco ; but I am disposed to consider an unknown morbific condition of the atmosphere, or, as Sydenham would have called it, a choleric constitution of the air, whether that constitution result from its electrical state, or from the nature of the terrestrial exhalations existing in it, to be the effective cause, without which the epidemic form of the disease could not have existed ; and whatever favours the action of this cause, I consider to belong to the predisposing and occasional causes only. 

PREDISPOSING, EXCITING OR 



151 

This morbific condition of the atmosphere, whatever may be its nature', appears to be powerfully debilitating or sedative. Whatever, therefore, either directly or indirectly weakens the body, will diminish its power of resisting this sedative agent ; and will consequently prove a predisposing cause of the disease. As this condition of the air, however, eludes our senses, it is no wonder that the more obvious predisposing and occasional causes, such as hunger, fatigue, intoxication, cold, &c. &c. should have been often regarded as the true causes of the malady. But as in former times, (i. c. before 1818) and under circumstances perfectly similar, neither cold, hunger, fatigue, nor intoxication, produced the disease, they cannot be considered in any other light than as concomitant or exciting causes, or as favouring the action of that cause upon the system, without which the epidemic disorder could not exist. They merely aid the action of such a noxious power, by diminishing the resistance which the system can oppose to its influence. Much of the modification which the disorder assumes, as respects both its violence and prevalence, may be easily explained by inferring a variation in the intensity of the actual cause of the epidemic, and in the degree of predisposition of the patient, or of his vital resistance to its effects. 

OCCASIONAL CAUSES. 



152 

PREDISPOSING, EXCITING OK 

On this supposition we may easily explain all the occurrences which, at first sight, seem to favour the doctrine of contagion. Troops were attacked whilst marching; because the fatigue, privation, and variations of temperature to which they were exposed, produced the necessary predisposition, and often proved the exciting cause of disorder ; while the inhabitants of the country who were not so predisposed, were enabled to resist a cause of no great intensity. When, however, the immediate cause was more intense, the inhabitants, though they resisted it longer than the predisposed troops, still ultimately suffered. This accounts for the occurrence of the disease in many villages of the ceded districts, and in those between the river Kistnah and Hydrabad, after the troops among whom it prevailed had marched by or through those countries. Several reasons might be assigned for the cases which sometimes occurred among the troops at stations, soon after the arrival of corps or detachments in which cholera had prevailed. It is, I believe, a well-known fact/ that European soldiers, on arriving at a new cantonment or garrison, almost invariably get drunk. The debility consequent upon such a practice, may be considered a predisposing cause ; and if natives do not indulge to the same extent in spirituous liquors as Europeans 



153 

OCCASIONAL CAUSES. 

do, they have recourse to excesses equally debilitating. 

The attack of one detachment and the escape of another, while marching by the same route, and nearly at the same time, may probably be explained by considering the length of the journey which each had previously performed, the internal economy of the corps to which these attacked respectively belonged, and the degree of salubrity of, and the price and quality of provisions at, the stations through which they had marched at the time when such march was made. 

But it may be said, that predisposing are sometimes convertible into exciting or occasional causes of the disease ; nor will I object to the general proposition : nevertheless, lam still of opinion, that there must be some morbific condition of the atmosphere, whatever that may be, without which the disease cannot exist, and which has no necessary relation with the other classes of causes, farther than what may be occasional and fortuitous, although often concomitant. 

But whatever state of atmosphere produces the malady, or whatever predisposes the system to its invasion, I am decidedly of opinion, 



154 

PREDISPOSING, EXCITING OR 

that sudden exposure to cold is its most common exciting cause, owing to the check which it gives to capillary circulation on the external surface of the body.* 

With respect to the influence of particular kinds of seasons, of the states of the weather, and atmospherical vicissitudes, as predisposing and exciting, or as efficient causes of epidemic diseases in general, and of epidemic cholera in particular, much difference of opinion exists. But, although I consider that such states of the seasons in India may act either as predisposing or exciting causes, according to circumstances, yet I cannot conclude that such seasons should be considered as the efficient cause of epidemic cholera, seeing that this effect has not, on other occasions, been observed to follow the imputed cause ; and seeing that such a cause is inadequate to produce the effect, in the manner in which it has recently been observed in India ; and moreover, because, granting that the condition of the air, which I have inferred to be the cause of cholera, actually existed, the state of the 

* It is chiefly to the circumstance of females and children not being so much exposed to the predisposing and exciting causes of the disease, that they are less frequently attacked with it than adults, whose exposure to both are much greater. 



155 

OCCASIONAL CAUSES. 

weather may be considered as having been partly modified by that condition — unless, indeed, that condition resulted from the peculiarity of the season. I am, therefore, induced to consider the states of the seasons that are hereafter described to have been merely predisposing or exciting causes, according as such states and vicissitudes of the weather may have fallen out ; and as fortuitous or concomitant circumstances only, on which we can place no just value with respect to their agency on epidemic diseases generally, and on epidemic cholera more particularly. 

With respect, however, to the influence of season and weather on certain diseases, we have a sufficient share of authority, if we have not satisfactory proof. Lord Bacon says, "If the south wind blows for a continuance, with a serene sky, without rain, it is very pestilent; for it is during the blowing of the south that pestilential diseases spread." 

Dr. Short observes, that " long-continued sultry weather, whether the wind be southerly, or long still and calm, gives life and vigour to putrid, malignant, and pestilential fevers." 

Dr. Rutty is of opinion, that extreme vicissitudes are more prejudicial than any quality 



156 

PREDISPOSING, EXCITING OR 

of the weather long continued. He remarks, that " Whenever we observe the usual harmony and proportion of the winds and attendant weather to vary much, we may expect an unhealthy season ; as was notoriously the case in the excessive moist seasons preceding the great frost in 1740, and the no less unusually dry season, and long continuance of the northeast winds which succeeded the great frost for some years." 

Huxham confirms the observation in reference to England: he says, " We very seldom see severe and pestilential fevers become very general, except after some remarkable peculiarity of the atmosphere." Hippocrates remarks, that when the seasons do not observe their accustomed course, the diseases will be unusual and anomalous, and that great vicissitudes either of cold or heat are unhealthy:" and Ammianus Marcellus says, " Philosophers, as well as illustrious physicians, have recorded, that pestilence arises from great excess of heat or cold, or drought or moisture."* 

There can be no doubt that very unusually disturbed seasons prevailed at Madras and 

* " Hancock on Pestilence," pp. 302—4. 



157 

OCCASIONAL CAUSES. 

its dependencies, for several years previous to the appearance of cholera ; but the want of precise information as to this matter, beyond my own personal observation, which can only apply to the particular part of the country in which I was stationed, prevents me from entering into any detailed consideration of this subject. 

I shall merely observe, in general terms, and in a few words, that the years 1815-16 were extremely hot. Strong southerly and westerly winds prevailed, and very little rain fell. The highest range of the thermometer in the shade, at Madras, was 104°, and the lowest 66°. 

The year 1817 was extremely close, with variable winds, chiefly from the south and west, and a very great fall of rain, with thunder and lightning. The highest range of the thermometer was 99°, lowest 66°. 

1818 was similar to the preceding year. There were excessive, heavy falls of rain, continuing from July till January ; a great deal of thunder and lightning, and a severe hurricane in October. The greatest range of the thermometer was 103°, the lowest 68°. 



158 

PREDISPOSING, EXCITING OR 

1819 was variable, the weather extremely hot, and westerly and southerly winds prevailed, with less rain than during the preceding years. A smart shock of an earthquake was felt at Wallajaahbad, about forty miles from Madras, in October ; and, in the early part of the year, shocks of earthquakes were felt at Calcutta, Bombay, and at various other places in Hindostan. The greatest range of the thermometer was 100°, the lowest 68°. 

1820. — The weather was extremely irregular ; frequent and heavy gales were remarked, and thunder and lightning extended over the greatest part of the peninsula. More rain fell during this year than during the preceding. The highest range of the thermometer was 98°, lowest 69°. 

1821-22-23 were close, hot, sultry, and oppressive years. There was very little rain, but strong southerly winds prevailed, which scorched, like fire, the trees and grass over which it blew. 

It appears from Dr. Jameson's work on Cholera in Bengal, that, for some years before the epidemic cholera made its appearance, they had excessive heavy rains, great 



159 

OCCASIONAL CAUSES. 

droughts, storms, and earthquakes : he says, " that the changes which have taken place in the course and succession of the seasons within the last few years, in every part of Bengal and its dependencies, have been so striking, as to have not" only attracted the notice of attentive observers, but to have become a frequent topic of conversation." Bombay, doubtless has partaken, in common with all other parts of India, in the general vicissitude and irregularity of seasons ; and I imagine, there can be little doubt that this irregularity of seasons has been someway connected with that condition of the air to which I have imputed the epidemic ; and if the latter has not produced the former, the concomitance of the two conditions are worth attending to, and their co-existence as causes, either of one kind or another, — the one determining or exciting the influence of the other. There can, however, be no doubt that some more unusual and more extended cause than the state of the seasons, or of the atmospherical vicissitudes just referred to, must have existed then, that did not previously ; for we have witnessed, at former epochs, similar seasons and atmospherical vicissitudes to those now alluded to, without observing corresponding results arising therefrom ; and we have seen the same excesses, the same privations, the 



160 

PREDISPOSING, EXCITING, &C. 

same labour and exposure, in every degree, practised with perfect impunity till the year 1817. 

It is a singular fact, that while this epidemic raged in India during the years 1817, 1818, and 1819, there was also great sickness over almost the whole of Europe — a circumstance which favours the opinion I have endeavoured to establish, namely, that its efficient cause is one evincing more general relations, as well as a more intense mode of action, than can be assigned to mere vicissitudes of season. 

Before I leave this subject, I shall place before the reader an abstract of the meteorological observations made at Madras, from 1815 to 1820, including these two years. 



M 

Mean Temperature at Madras, (Goldin gharri). Years. January. Feb. March. April. May. June. July. August. Sept. October. Nov. Dec. 1815 75. 79. 80 80. 00 88. 60 92. 25 85. 90 84. 80 86. 60 86. 10 82. 35 77. 75 76. 75 1816 74. 75 75. 15 78. 05 81. 00 89. 75 89. 90 86. 05 84. 45 83. 90 83. 50 80. 55 76. 75 1817 75. 90 77. 50 80. 00 82. 70 89. 00 88. 60 88. 50 86. 65 83. 80 82. 75 77. 65 79. 25 1818 77. 70 79. 85 79. 70 84. 00 91. 90 90. 55 84. 00 81. 50 85. 00 82. 75 78. 50 77. 00 1819 73. 20 76. 25 79. 80 83. 85 89. 85 91. 00 88. 00 88. 25 84. 75 84. 00 81. 50 78. 25 1820 75. 70 78. 40 79. 65 85. 40 86. 10 88. 30 87. 40 86. 50 85. 25 85. 00 81. 37 78. 90 General 75315 77#8 25 79. 53 84.258 89.808 89.041 86.458 85.658 84. 8 83.391 79. 55 77. 81 Mean Mean Temperature at Calcutta, (from Jameson's Report.) "1 During the rainy season, which 68° 76 79 84 86 81,2,3! commences about the mid- 74 70 ) die of June, and terminates Range 47 to 75 65t082 73t086 78t091 81t093 77t090 about the middle of Octo- 66t086 56t078 J ber. Mean annual fall of rain at Calcutta, 70 inches; at Madras, 54 Inches. Mean annual fall of rain at Martinico, 100 inches; at Demerara, 80 Inches. (Chisholm.) 

161 



162 

OCCASIONAL CAUSES. 

1815. Barometer. Therm. Rain Gauge. General mean 29.922 83° Inches Observed. Reduced Greatest height 30.200 May 104.5 220.8 55.2 Least height 29.700 66.2 Extreme difference .500 38.3 

1816. General mean 29.974 82° Observed. Reduced, Gieatest height 30.228 May 100.7 158.5 39.6| Least height 29.720 66. Extreme difference .508 34.7 

1817. General mean 30.001 82.7 Observed. Reduced. Greatest height 30.300 May 98.5 254.8 63.7 Least height 29.725 66.8 Extreme difference .575 31.7 

1818. General mean 29.943 8 1.9 Observed. Reduced Greatest height 30.240 May 103.8 308.8 77.2 Least height 29.276 68.2 Extreme difference .964 35.6 

1819. General mean 29.951 83.2 Observed. Reduced. Greatest height 30.220 June 100. 109.8 27.45 Least height 29.600 64. Extreme difference .620 - - 36. 



163 

OCCASIONAL CAUB E 9 . 

1820. 

Barometer. Therm. Rain Gauge. General mean 29.96084 83.164 Inches Observed. Reduced. Greatest height 30.238 May 98.2 277.1 62.275 Least height 29.560 69.2 Extreme difference .678 29. 

The medium height of the Thermometer for five years before the year 1815, was 83°. 8 ; the medium height for the five years, from 1816 to 1820 inclusive, was 82°.6; the difference nearly a degree and a quarter. Mean annual range 34°. 

The medium height of the Barometer for the first five years, and that for the last, were exactly the same ; being 29.96 inches. Mean annual range 640. 

The mean monthly temperature, from the beginning of 1815 to the end of 1820, had been in January 75.3; in February 77.8 ; March 79.5; April 84.2; May 89.8; June 89.; July 86.4; August 85.6; September 84.8; October 83.3; November 79-5 ; December 77.8. 



164 

TREATMENT OF EPIDEMIC CHOLERA. 

CHAPTER V. 

OF THE TREATMENT OF EPIDEMIC CHOLERA. 

Having stated, as fully and distinctly as I am able, the history and symptoms of epidemic cholera ; having inquired into its pathology and its causes, it now remains for me to treat of that particular part of my subject to which the foregoing are preparatory, and entirely subordinate. It is to the more satisfactory treatment of this destructive malady that all our inquiries ought ultimately to aim ; and such inquiries, however they may appear foreign to this important object, when looked at superficially, if they in any way, or however indirectly, tend to its advancement, cannot be considered as being either unnecessary or unprofitable. 

In order to bring this important subject — more especially as it respects my own experience — before my readers, in as detailed and precise a manner as I can, I shall first give a general view of the treatment, with particular observations on some of the most 



165 

TREATMENT OF EPIDEMIC CHOLERA. 

efficient means which were usually adopted ; and I shall, secondly, detail several cases, illustrating the effects and utility of the particular measures which were resorted to, and recommended for the cure of the disease. 

SECTION I. 

General Sketch of the Treatment of the Disease. 

It is by means of a clear and distinct view of the nature of diseases, that we can ever hope to be successful in the treatment of them. This object can only be acquired by close, attentive, and unbiassed observation at the bed-side of the patient, where not only the various changes which take place in the course of disease should be carefully noted, but where, also, the peculiar effects of each remedy should be narrowly watched. 

For the treatment of epidemic cholera, I have always endeavoured to keep in view, as far as was within my power, the cause of those urgent and distressing symptoms which never failed to excite alarm, and to mark the disease. These symptoms generally assume the appearance of those of extreme debility, 



166 

TREATMENT OF EPIDEMIC CHOLERA. 

whilst oppression of the vital powers is the real cause ; if, therefore, the disease be treated as one depending upon debility alone, without attempting to remove oppression, the practice will be at least uncertain, and, in general, unsuccessful. 

Examinations of the bodies of patients who have died of epidemic cholera prove incontestably, that the system has been oppressed by venous congestion, and that the general disturbance of the constitution has arisen from this cause. The various changes which take place in the circulating fluids early in the disease, may, probably, arise from its effective cause of abstracting vital power, acting thus as a specific poison, and destroying the balance of circulation. Hence the blood is imperfectly propelled to the surface of the body, accumulates, in an unusual quantity, in the right cavities of the heart, in the large venous trunks, and in the lungs ; and owing also to its high state of carbonisation, or defective state of oxygenisation, overpowers the remaining energy of the heart and lungs, and deprives them of the power of performing their functions with regularity. The lungs, being thus oppressed and overloaded, have not the power of oxygenising [or decarbonising] the blood, and hence, black blood is returned to the left 



167 

TREATMENT OF EPIDEMIC CHOLERA. 

auricle and ventricle of the heart, which, being deprived of their natural stimulus, cease to act with their usual energy, and consequently, the circulation in general becomes languid. If this view of the subject be correct, the indications of cure will be self-evident: to remove oppression from the venous system, and restore the balance of the circulation, are the chief objects we should propose to accomplish. 

Bleeding, therefore, when it can be effected, should never be lost sight of. The object of resorting to it is to diminish the quantity of this fluid, in order to relieve the heart and lungs from oppression, and to enable them to perform their functions. 

This object, however, can only be attained in the early stage of this disease, and before the circulation ceases at the wrist; the necessity, therefore, of early assistance is manifest, because after this period blood will seldom flow from the veins, and when it does flow, it is generally in too small a quantity to afford relief. I have sometimes seen sixteen, eighteen, and even twenty ounces flow languidly, and in a very thick stream from the veins, then the bleeding stop suddenly, and the patient sink at once. I have considered that in these cases. 



168 

TREATMENT OF EPIDEMIC CHOLERA. 

the quantity of blood thus taken was merely that which had remained in the veins, after their circulation had been arrested, and that the bleeding ceased as a matter of course, when the veins were emptied. This circumstance has led to various opinions upon the propriety of bleeding, and has induced some to infer that death was accelerated by it. I do not mean to deny this fact ; but I conceive that the disease was then so far advanced, that death would have been the consequence under any circumstance, and that this issue was only hastened, probably, half an hour or an hour by the operation. 

We have instances, however, wherein blood, drawn even in the advanced stage of this disease, has continued to flow till the balance of circulation was restored, and the patient recovered. 

In these instances the blood was at first thick, black, and came away in drops ; at length it became thinner, and flowed with more ease, till the colour changed to a bright red. This is the change which should always be looked for, and whether it take place after the abstraction of one ounce or thirty, is of no consequence ; this change must supervene before the patient can be considered safe. Under 



169 

TREATMENT OF EPIDEMIC CHOLERA. 

all circumstances, therefore, I think we should never forego a trial of the lancet. 

That cases have occurred, wherein eighteen or twenty ounces of blood have been taken away, and the patient died, cannot be doubted ; but in all these cases it will be found that the bleeding ceased after the vessels had been emptied, whether one or twenty ounces had been abstracted. On the other hand, it will likewise be found, that if blood flows freely, till the colour changes from black to red, the patient, in general, will recover. When we observe, therefore, the thick, black, carbonated blood change to a natural red colour, and consequently to a thinner consistence, we may rest satisfied that the disease is under our control. 

I saw a very striking instance of this fact in the case of a young lady at Madras, who was attacked with cholera. The symptoms were decidedly marked, and the usual remedies were applied. The pulse was fluttering, and seemed oppressed. I ordered a vein to be opened, and gave particular direction to the gentleman who was in attendance with me, and in whose observation and judgment I had the fullest confidence, (Dr. Archer) to let the 



170 

TREATMENT OF EPIDEMIC CHOLERA. 

blood flow till its colour changed from black to red, without reference to quantity. At first it came away only in drops, and was exceedingly thick and black. Warm flannels were used to the arm, and in a few minutes, the blood began to flow more freely, but still in a very languid stream. After three or four ounces had been taken the colour changed, and it flowed with perfect freedom ; the pulse got up, became more regular and soft, and although not more than eight ounces were taken, the patient recovered rapidly. 

Although I recommend bleeding to be attempted at all times, and in every stage of the disease, I am fully aware that many cases have recovered where it has not been used at all : nor do I answer for its universal success; but I do venture to assert, that, if it can be accomplished in the early stage of the disease, and before the circulation has ceased at the wrist, in nine cases out of ten it will prove successful, especially if the colour of the blood change from black to red, if the pulse get up, and the spasms be relieved. 

In confirmation of this opinion, I cannot do better than detail a circumstance bearing upon it, which occurred at Madras in 1821, and 



TREATMENT OF EPIDEMIC CHOLERA. 171 

which has been alluded to already, (see page 26.) 

The General Harris East Indiaman arrived at Madras on the 20th June, 1821 ; her crew were in perfect health, and had been so during the passage from England. On the 27th June epidemic cholera made its appearance amongst them, and raged with great violence. Captain Welstead, and Mr. Colledge, surgeon of the ship, called upon me at the general hospital, to consult upon the best means of curing, as well as preventing the disease. 

I stated my views fully upon this subject to Mr. Colledge, and the line of future treatment was decided upon. This gentleman was unremitting in his attention to the men under his charge, and whenever he observed any of them depressed and low-spirited, he at once inquired into their feelings, and without a moment's hesitation took twenty to thirty ounces of blood from the arm, gave 9J. of calomel, with two grains of opium, and sent them on shore, well wrapped, to the general hospital under my charge ; and the subsequent disease shewed what might have been expected from less energetic measures. 



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TREATMENT OF EPIDEMIC CHOLERA. 

The disorder being thus checked before it had made any great invasion upon the constitution, was, when brought before me, in a manageable state, and I looked forward with confidence to a successful termination of it almost in every instance. 

Upwards of fifty men were landed from the General Harris Indiaman, under the disease, and sent to the general hospital ; and it is with peculiar satisfaction I can say, that the whole number returned in health to that ship before she left Madras Roads. 

Under the best management and greatest advantages, the fate of a patient with cholera is soon decided ; even if we succeed in conquering the first attack, the stage which follows is of equal importance, and requires not only great attention, but great resources, which no ship, however well supplied she may be, can command. 

For this reason the men were landed from the General Harris, and sent to the general hospital at Madras. It is impossible they could have been placed in abler hands than those of Mr. Colledge ; but with all his zeal, 



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TREATMENT OF EPIDEMIC CHOLERA. 

humanity, and professional tact, without the resources which belong to a general hospital, it would have been out of his power to have done the men justice. I mention this as much with a view of shewing the necessity of landing men so circumstanced, as to point out the propriety of adopting similar measures of cure on any future occasion. 

The following facts connected with this detail, will throw additional light upon the subject : — 

Nearly all the men who were attacked with this disease on board ship, and who were not bled, or from whom blood could not be drawn, died. Many of those who were bled, and who derived benefit, but whose subsequent treatment could not be closely watched from want of means, also died. Those men who were bled, and sent to the general hospital at Madras, where they could receive every attention, and had every means of accommodation, recovered. 

I enter more fully into these circumstances, with a view of giving the practitioner confidence in his attempts to cure the disease, and at the same time to give that credit which is justly 



174 

TREATMENT OF EFIDEMTC CHOLERA. 

due to Mr. Colledge, whose prompt, decided, and judicious treatment of one of the most destructive diseases that has ever visited the globe deserves the highest praise. I am perfectly persuaded, that if he had not paid the closest attention to the invading symptoms of the disorder, and acted in the most decided manner, many of those lives which have been preserved, would, under other circumstances, have fallen a sacrifice ; and I feel great satisfaction in having the opportunity of bearing testimony to the zeal and merits of this gentleman. 

Whilst I consider bleeding to be the sheet anchor in the treatment of this disease, it must not, at the same time, be imagined that this alone will cure it. There are other aids equally essential. The object of bleeding is to remove spasm and venous congestion ; to relieve the heart and lungs from oppression, and to check the most urgent and distressing symptoms ; and without this be in some measure attained, all our efforts will prove fruitless : but this having been once accomplished, the disease is brought into a manageable state, though it not unfrequently happens, that our most active efforts are afterwards required to remove a very opposite state of 



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TREATMENT OF EPIDEMIC CHOLERA. 

the disease, nearly as dangerous as the former^ occasioned by the re-action which occurs, under a state of system unfavourable to its development. 

I have thought it right to discuss thus fully the advantages of bleeding, because I knowthere is, among many of the profession in India, a very great prejudice against it. My own experience is decidedly in its favour, but it is not always that we can see patients in time to secure its good effects. In such cases we must have recourse to other measures, as antispasmodics and stimulants. 

Opium. — Opium has been recommended, and generally used in large quantities ; but I have seen very little good arise from it ; on the contrary, I have often thought that there was generally a greater determination to the brain, and a much greater degree of stupor, where opium had been given and depended upon, than where it had not. On this account, I very early discontinued its use, and latterly never gave it under any circumstances in epidemic cholera, except in combination with calomel. In general, I used camphor, ammonia, and aether, in the following form :—: — 



176 

TREATMENT OF EPIDEMIC CHOLERA. 

R Mist. Camph. | lss. Aquse Ammon. ti| xxxv. Sp. JEther. Vitriol. 31J. 

M. ft. mist. 

A desert-spoonful of this was given every ten, fifteen, or twenty minutes, according to circumstances. 

Rubefacients . — I have always used, with decided benefit, spirits of turpentine as an embrocation, for spasms of the extremities, &c. &c. ; and I have applied sinapisms to the legs and soles of the feet, and sometimes covered the whole trunk with them, from the clavicle to the pubis. I have also applied blisters occasionally, but I think sinapisms act more quickly and more certainly on the skin, and for this reason, I have generally resorted to them in preference. 

It was not at all uncommon to see these applications fail altogether in producing any effect upon the skin ; and in many cases, even where an effect was produced by blisters, there was nothing like that healthy discharge which we see proceeding from them in common diseases. 

Warm and vapour-bath. — The warm-bath, I am of opinion, did more harm than good 



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TREATMENT OF EPIDEMIC CHOLERA. 

in epidemic cholera. The fatigue arising from going in and coming out of it, and from rubbing and dressing the patient, exhausted him ; and when neither rubbing nor dressing was attended to, and when the patient at once was taken out of the bath, and wrapped in blankets, I think mischief was done by the blanket, thus moistened, being kept upon him. I never resorted to this treatment in cholera above two or three times, and subsequently not at all. 

The vapour-bath is better adapted for this disease, if the heat could be regulated ; but it cannot, and it is both too sudden and too intense. I have never seen any advantage obtained from it in this disease. 

A well-regulated sand-bath might be exceedingly useful, but I am not aware that it has ever been tried. I have found infinitely more benefit arise from the application of warm dry flannels to the surface of the body, than from any other application of this description ; and it was the remedy invariably used in my hospital, after I had satisfied myself of the inutility of the warm and vapour-baths. 

Nitric-acid blister. A nitric-acid blister has been strongly recommended, and I have 

N 



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TREATMENT OF EPIDEMIC CHOLERA. 

given it a full trial. It produces severe smarting of the skin, but I have never, in any instance, seen vesication produced by it. Whenever the acid acted upon the skin, it always made an eschar, but raised no blister ; I had consequently no confidence in it. 

Boiling ivater. — Scalding water has been recommended as a blister. I certainly think it more likely to be useful than the nitric acid. I have heard of good effects being produced by it, but have never used it myself. 

Of all the foregoing applications, I have depended most upon the common blister, the mustard poultice, and the warm flannel applications. 

The following is the way in which this disease has usually been treated under my direction : — 

A patient is admitted into the hospital, I shall say at noon, with all the symptoms of cholera ; a vein is immediately opened, and one scruple of calomel and two grains of opium are given in the form of a pill, and washed down with the camphor draught. The body and ex* tremities are well rubbed with dry flannels made 



179 

TREATMENT OF EPIDEMIC CHOLERA. 

warm, and bottles filled with hot water are applied to the feet and hands ; but if the spasms are severe, spirits of turpentine are used as an embrocation. In an hour we generally perceive the effects of these remedies, and whether the disease be in any degree arrested, or be proceeding in its progress. If the former, nothing more is to be done till evening, when the calomel pill may be repeated, and an enema exhibited. The following morning the bowels should be again fully evacuated, and then the patient may be considered safe. 

When blood, however, cannot be drawn from the arm, and the spasms continue ; when severe pain and burning heat are felt at the umbilicus and scrobiculus cordis, and are distressing; when the skin is cold, and deluged with cold, clammy dew ; and when there are oppression in the chest and difficulty of breathing—excessive pain and confusion about the head, with great intolerance of light — no pulse, or a pulse scarcely to be felt, and a cadaverous smell from the body, twenty or thirty leeches should be applied immediately to the umbilicus and scrobiculus cordis ; the calomel pill should be repeated, and the turpentine embrocations continued. Leeches ought likewise to be 



180 

TREATMENT OF EPIDEMIC CHOLERA. 

applied to the temples and base of the skull. 

When the leeches bleed freely, the application of them is always attended with decided advantage, and they should be allowed to remain till they have fulfilled their duty; after which, a large blister or sinapism should be applied over the whole abdomen. Sometimes the leeches fasten, but do not draw blood. In this case they should be removed immediately, and the sinapism or blister applied in their place. When the bowels are very irritable, and constantly discharging a watery fluid, small anodyne enemas, with camphor, may be given ; and the drogue amere, a nostrum used by the Jesuits, will be then found very useful in assisting the operation of calomel, which latter should always be repeated every two hours, till three or four scruples have been taken. 

Whenever we fail in checking the disease at first, we have no resource but to treat urgent symptoms, and they must always be met with decision as they occur. The patient ought never to be left a moment without an attendant who is capable of acting according to circumstances, and who may take advantage of every change. 



TREATMENT OF EPIDEMIC CHOLERA. 

181 

An opportunity sometimes offers in the advanced stage of the disease to abstract blood : this is indicated by a struggle or effort of the circulating system to overcome some resisting power, and is a most auspicious symptom, which should never be overlooked. This reaction indicates that the constitution is making an effort to restore the circulation, but is unable to do so till assisted by the abstraction of blood, which abstraction aids in removing that oppression which it has not power of itself to overcome. This is a point, in the treatment of epidemic cholera, of the greatest importance, requiring both tact and judgment; but the change in the circulation indicating the propriety of adopting and the time of performing it, should always be expected and taken advantage of as soon as it occurs. 

In this manner the treatment proceeds, sometimes with evident signs of success, at others, without the least impression being made upon the disease. A very few hours, however, will frequently develope what we ought always to hope for, and even to expect, viz. a favourable change. This is always accompanied by relief from the bowels, in the form of a blackish, grey, feculent, and tenacious discharge. Whenever this takes place 



182 

TREATMENT OF EPIDEMIC CHOLERA. 

there is hope, and the exhibition of calomel should be followed up with a smart purgative, if the stomach will receive it ; if it will not, an enema should be administered, and repeated till motions are procured. The purgative I have generally found to answer best at this stage of the disease, and to sit most lightly on the stomach, is the following draught : — 

R Pulv. Jalap. Comp. gss. 

Menth. Pip. |ij. M. ft. haust. 

and, as it is a matter of the very first consequence to act upon the bowels freely as soon as possible, if this draught have no effect in two or three hours, it should always be repeated. 

Urine is ueither secreted nor passed during the continuance of this disease ; whenever it appears, which it frequently does with a full and free discharge from the bowels, the occurrence is always favourable and satisfactory. 

Twelve or eighteen hours generally terminate this disorder either one way or the other ; but, when we succeed in overcoming it, the greatest attention and care are required, to preserve the patient against the effects of that 



183 

TREATMENT OF EPIDEMIC CHOLERA. 

general disturbance which the constitution has suffered in the attack. The whole system is shaken to its foundation, and the organic functions are so deranged, that I have known instances of men lingering in bad health for many months, while every care was taken of them, although they had been perfectly well to all appearance not many hours before the attack; and, indeed, I have seen some who have not recovered, and never will recover, from its effects. 

The subsequent treatment is now to be considered, and the indication in this stage is to guard against congestion in the abdominal and thoracic viscera, and in the brain ; each of which suffers in a greater or less degree, and sometimes the w r hole are attacked at the same time. 

There are generally observable, in the advanced stage of the disease, an unusual stupor and heaviness of the patient, and at times an obstinate sullenness that is exceedingly annoying and mortifying; because, when such symptoms are present, it is with the greatest difficulty we can get answers to questions, and consequently we often act in the dark, from the want of information beyond 



184 

TREATMENT OF EPIDEMIC CHOLERA. 

our own personal observation, which will not serve us upon all occasions. Patients affected with these symptoms seldom or never complain of pain ; but, on examining the abdomen, a very great fulness and doughy feel is generally found all over it, as if the intestines were completely overloaded ; pressure made upon the liver obliges the patients to shrink from it, and shew symptoms of uneasiness, though they positively and obstinately assert that they have no pain. 

The eyes are sometimes peculiarly bright, with contracted pupils, and there is an evident intolerance of light; yet these patients insist that they have no uneasiness in the head, and that they can look at the light with perfect ease. 

The pulse is often oppressed and labouring, notwithstanding a very large quantity of blood may have been taken during the first stage of the disease. 

These are symptoms that require immediate attention, and, when urgent, blood should be taken from the arm ; but, in general, leeches will answer every purpose, and I consider them a safer remedy in this stage of the disease 



185 

trp;atment of epidemic cholera. 

than general bleeding ; because they appear to me to empty the capillary vessels, and aid in regulating the circulation, without destroying power — ¦ a point of great importance where the constitution has already suffered so severely. 

This practice may appear too bold to some who have not observed the frequent or decided adoption of it in this disease ; and more particularly to those in India, who have a deep-rooted dislike to depletion of any kind, under the mistaken notion of its producing debility, and who do not discriminate between direct debility and oppression. The practice, however, has been proved, by no limited experience, to be singularly successful in the cure of this disorder. But the symptoms rendering it necessary require a most watchful and discriminating eye, because they are seldom complained of by the patient ; and I know that there are many who rest perfectly satisfied with the answers they receive, without making further inquiry, and who have often been surprised when they have unexpectedly found dangerous symptoms succeed a favourable report, after a lapse of not more than an hour or two. A minute examination of the patient, therefore, is particularly necessary in the treatment of epidemic cholera — a malady in which the sensibility 



186 

TREATMENT OF EPIDEMIC CHOLERA, 

appears to partake largely of the general disturbance of the system, and where the patient seems to be perfectly indifferent about his fate. Watchfulness and discrimination, therefore, are evidently of so much importance, that I cannot urge their adoption in terms too strong to the practitioner. 

When the patient shrinks from pressure on the abdomen, leeches should be placed over it in considerable numbers, and particularly in the neighbourhood of the liver ; and, when the head is affected, they should be applied at the temples and base of the skull. I prefer the latter situation, and I think I have observed greater advantage to arise from their application on this part, than when placed on the temples. 

Purgatives should, as a matter of course, be used in aid of the above remedies, but the congestive symptoms ought to be overcome, before we can adopt any regular plan of treatment to re-establish the general health. 

Whilst these symptoms of oppression and congestion require the most minute attention, we must not lose sight of the state of the alimentary canal, of the secretions of the small intestines, and of the alvine discharges. 



187 

TREATMENT OF EPIDEMIC CHOLERA. 

Though the irritability of the stomach sometimes continues till a very late period, yet in general it is subdued early, and that organ retains all that is taken, both as medicine and nourishment ; but as the whole line of the small intestines exhibits, on dissection of fatal cases, a most peculiar appearance, from the duodenum to the caecum ; as the bowel itself is very much contracted in its diameter, thickened, and pulpy in its appearance ; and as, when laid open, it is found rilled with a creamcoloured, thick, viscid, and tenacious matter, exactly like old cream-cheese, which glues the gut together, and obstructs its passage ; and, moreover, as this matter is to be found in every fatal case of cholera, so it maybe inferred to exist in some degree even in all that recover ; and therefore the removal of it must be a primary consideration. 

Purgatives do not seem, however, to act upon it at first, for they merely produce watery dejections: so long, therefore, as these continue, we may be sure that all is not right, even although they be reported copious and free. The dejections should always be examined with great care : until the above-described matter is brought away, I never consider 



188 

TREATMENT OF EPIDEMIC CHOLERA. 

that I have made much advancement in the cure. 

Calomel, in scruple doses, I have always found most useful in removing this particular matter. Sometimes I have combined it with aloes, and continued it every night and morning, till the dejections became of a blackish grey colour, substantial and tenacious.* The purging draught and the enema may then be had recourse to, with the best effects. 

This practice was followed up regularly every day with leeches, blisters, &c. &c. according to circumstances. In a day or two the motions were usually observed to become dark green, which colour always indicated an approach to healthy action. The calomel and purging draughts were still continued, however, for five or six days longer, till the dejections became more natural, and a visible improvement was observed in the appearance of the patient. He was then put upon an alterative 

* Three, four, and even five scruples of calomel were usually taken, before this effect was produced ; and the black, grey colour seemed always indicative of the action of calomel, being precisely the colour which is produced by calomel combined with ammonia. 



TREATMENT OF EPIDEMIC CHOLERA. 

189 

course of medicine for a month or more, according to circumstances. This latter measure is absolutely necessary to prevent a relapse, which is very common, and always dangerous. I have frequently witnessed, both in this and in other diseases, where men have been returned to duty before the organic functions were restored to healthy action, a state of disease produced, which, if it did not affect their lives, disqualified and rendered them unfit for service, before they had been many years in India. 

This plan of treating the epidemic cholera, which was adopted in the general hospital at Madras under my charge, during the prevalence of that disease from 1819 to 1823, was attended with a success that certainly far exceeded my expectations. 

I shall here enumerate the phenomena which directed my indications of cure, and by which I always regulated the subordinate details of the treatment : — 

First. — The general symptoms of a congestive state of the brain, heart, lungs, liver, and abdominal viscera. 

Second. — The black and thick state of the blood, and the presence of venous-coloured 



190 

TREATMENT OF EPIDEMIC CHOLERA. 

blood in the left auricle and ventricle, and in some of the arteries. 

Third. — The singular vermilion tinge upon the upper part of the small intestines ; and the dark venous vascularity of the lower part of the ileum. 

Fourth. — The peculiar viscid, tenacious, cream-coloured secretion and accumulation in the intestinal tube, which sometimes not only filled it, but actually glued it together. 

Fifth. — The change of the colour of the blood, from black to red, while flowing from the arm ; and the success of venesection in checking the disease, indicated by this change. 

Sixth. — . The favourable change which always followed dark, grey - coloured, and viscid dejections. 

Seventh. — Dark green motions, succeeding to the above-characterised motions, and the indication which the former furnished, viz. an approaching return to healthy function. 

Eighth. — Collapsed state of the bladder, and want of secretion of urine, and its secretion and appearance always proving favourable. 



TREATMENT OF EPIDEMIC CHOLERA. 

191 

These were the circumstances of the disease I always kept in view in treating cholera, and I never lost sight of them throughout the cure. My object was to remove congestive symptoms, and to effect the discharge of the viscid, tenacious matter from the bowels. Bleeding, both general and local, antispasmodics, aether, ammonia, and camphor, with stimulating external applications, effected the first ; and calomel, with aloes, the latter. I have often thought that much benefit was derived from the drogue amhre already alluded to ; and the gums composing it certainly appeared to be useful in aiding the calomel in removing this viscid and tenacious matter from the intestines ; and therefore I often gave it with calomel, in doses from fss. to |j. mixed with the camphor draught, and I was confirmed in the opinion, by appearances and by examinations after death ; where I observed, in some cases, that the viscid matter had been carried half down the ileum, leaving the upper part of the canal completely free from it. 

The vast accumulation of this matter, and its uniform presence in all cases of cholera, in addition to the difficulty of removing it, led me to believe that relapse was frequently occasioned by its continuance in the bowels, even 



192 

TREATMENT OF EPIDEMIC CHOLERA. 

after the circulation had been restored ; and therefore I considered its removal as a primary object, because it must be evident, that where the intestine is lined with such viscid matter, the action of medicines upon the living fibre must be interrupted, and the case protracted. 

Observing, even after the congestive symptoms were overcome, that little progress was made in the cure, till blackish grey, and, subsequently, dark green, viscid dejections were procured, I was anxious to see what effects could be produced upon the secretions of the stomach and intestines, by bringing in contact the various medicines used in cholera with the secreted matter. With this view I removed a considerable quantity of this matter from the intestines of a fatal case of cholera, where it was found in considerable quantity, and made a deliberate and patient trial in the presence of several medical men, who were doing duty with me in the hospital ; and the following were the results : — 

The secretion itself was concentrated, creamcoloured, or greyish yellow, like healthy pus. When mixed with alcohol, it formed a number of discrete coagula, minutely divided ; colour unchanged or ochry. 



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TREATMENT OF EPIDEMIC CHOLERA. 

Ammonia, aether, and camphor produced no alteration whatever upon it. 

Diluted nitric acid, precipitated it in small flocculi ; tartaric acid in solution, and in considerable quantity, completely dissolved it, and rendered it perfectly fluid. 

Cystic bile dissolved it sensibly, the mixture being intermediate in colour between the two. 

Calomel mixed with it in small quantity, formed a dark greenish grey, precisely similar to the dark grey dejections already mentioned, and appeared to dissolve it. 

Calomel and cystic bile combined rendered it more fluid, and produced a dark green colour. 

These experiments were repeated as often as opportunities occurred, but without removing the secreted matter from the intestines, and the results were invariably the same. 

The conclusion, therefore, which I draw from the foregoing facts are — 

Ist. That tartaric acid is the most useful drink, from its dissolving the matter. 

o 



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TREATMENT OF EPIDEMIC CHOLERA, 

2d. That calomel unites with, and separates this viscid matter, and produces those black, grey dejections which precede recovery, and which are unaided by, and unmixed with bile. 

3d. That the green dejections which succeed to the former, arise from cystic bile and calomel, in combination with this matter. 

These experiments have thrown a new light upon the treatment of cholera ; and in all cases which came under my care afterwards, the principles indicated by these experiments were observed and followed. Lemonade was given as common drink, which was always peculiarly agreeable to the patient ; calomel, in full or scruple doses, with drogue amere, was repeated boldly and with confidence : and when the congestive symptoms were once overcome, and the circulation restored, the subsequent treatment became simple and certain. 

When I saw dark grey dejections, I considered that the calomel was doing its duty ; and when I found them change to green, I felt satisfied that the biliary ducts were emulged, that bile had commenced to flow, and that all was safe. 



195 

TREATMENT OF EPIDEMIC CHOLERA. 

It must be remembered, and I cannot repeat the caution too often, that in every instance the strictest vigilance is necessary ; the medicines should never be discontinued, till healthy secretions are produced; and even after they have been produced, laxatives and alteratives should be taken daily, for at least a month after the patient is considered perfectly recovered. 

The urine seldom flows freely till a day or two after these viscid, tenacious dejections have passed off: this is a symptom that should never be lost sight of, as the patient cannot be considered quite safe till this excretion is re-established. 

The effects of calomel, lemonade, tartaric acid, and cystic bile, on the secretions of the intestines, seem to be deserving of attention in the treatment of fever, and many other diseases. 



196 

TREATMENT OF EPIDEMIC CHOLERA. 

SECTION 11. 

Farther Remarks on the Treatment of Epidemic Cholera, with Details of Cases in Illustration of this and the preceding Section. 

I had, in common with many other medical men, a horror of this disease, from the various reports which I had received of it, and the unsatisfactory account given of its treatment. The instructions, too, derived from superior authority, were so vague, that it was impossible to draw any rational conclusion from them. Magnesia and milk, burnt cork and castor oil, were all in their turn recommended as specifics. With such information, therefore, I really felt at a loss how to treat the first cases that came under my care ; and my attention was consequently directed to the treatment of symptoms alone, till experience taught me, that to remove congestion, and restore the balance of circulation, were the first indications of cure; and that if these were attended to in the early stage of the disease, it became as manageable as most other acute diseases. 

I likewise soon discovered that many of the notions which had gone abroad, and which had 



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TREATMENT OF EPIDEMIC CHOLERA. 

been strongly inculcated, were erroneous : for instance, to drink any thing cold was supposed to be attended with direful consequences. This is the reason which induced me at first, in these cases, invariably to give warm brandy and water and rice-water, though actually loathed by the patient. This loathing of warm fluids on the part of the patient was such as could not have escaped the attention of the most common observer; for, although the patient appeared to be dreadfully distressed by thirst, and was always calling for cold drink, yet, when any thing warm was presented, he put it from him with disgust. 

Anxious at all times to consult the dictates of nature in the treatment of disease, where there is no decided and manifest objection ; and, as I saw no good reason why warm drinks should be exclusively essential in this disease, more especially as there was so strong a predilection for cold drinks on the part of the patient, I resolved to step out of the beaten path, and gave my patients the nitric acid agreeably diluted ; and I was gratified to find not only that no bad consequences followed, but that it was a most pleasant beverage to the patient, relieving that most distressing and urgent symptom already insisted upon, viz. the 



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TREATMENT OF EPIDEMIC CHOLERA. 

burning sensation at the stomach. This, therefore, became the general drink in the hospital in this disease. 

It occurred to me, that, as the system seemed to be deprived of oxygen, the nitric acid might, in some degree, supply the deficiency.* Whether it acted in this way, or not, I will not take upon myself to say ; but this I know, that it was always most gratifying to the patient in allaying distressing thirst, and in removing the parched dryness of the tongue. 

The cases of Shaw, Mootamah, Mooto, and Sparling, f were the first that gave me confiin the practice of depletion, which further experience confirmed ; and upon this foundation I established the mode of treatment subsequently found to be so successful. It will appear, that most of the fatal cases was nearly moribund on their first admission into the hospital ; on the other hand, all the cases that 

* I frequently entertained the idea, that the inhalation of dilute oxygenous gas, or the nitrous oxide, might prove beneficial in this disease ; but I had no conveniences or apparatus for putting it in practice. 

f See pp. 202, 204, 205, and 206. 



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TREATMENT OF EPIDEMIC CHOLERA. 

recovered were brought for assistance before the circulation had completely ceased, and when blood could be freely drawn. 

Fifty-nine cases of epidemic cholera were treated by me in the general hospital at Madras, from the 23d of May till the 23d of August, 1819; of which number fifteen died, nearly one in four, as the following statement will shew : — 

From the 23d to 27th May . . 10 were admitted,. .5 died. Ist to 23d June . . 15 ditto ditto, 6 do. 3d to sth July 6 ditto ditto, .... 1 do. 7th to 23d August 28 ditto ditto, 3 do. 59 15 

In the cases where recovery took place, the disease was met at an early period ; and in those which terminated fatally, four, five, and six hours had elapsed from the first attack, before medical assistance was had recourse to. From this fact it appears evident, that, if the disorder be taken at its commencement, or within an hour after the seizure, it is as manageable as any other acute disease ; but the rapidity with which it runs through its course, requires the most active exertions before it can be 



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TREATMENT OF EPIDEMIC CHOLERA. 

checked, and the loss of an hour may cause the loss of a life ! 

The following extract of a letter from a very able professional friend, will give additional confirmation to the truth of this remark, more especially as it was written at a moment when he was surrounded by cases of epidemic cholera, and when his feelings were all alive to the destructive powers of this disease. " You know, I suppose, that we were detained a fortnight in camp between the Mount and Poonamalee, not being able to pay the detachment ; during that time, as might be expected, almost all the men were drunk regularly every day, and we were prepared by such excesses to suffer from any disease. We have, however, been particularly fortunate till our arrival at this station, not having lost a man, or having had one seriously ill, though we had been under canvass above five weeks. We fell in with a battalion of native infantry, who were suffering from cholera. The next day six Europeans were attacked : the number increased daily, and most of the first cases proved fatal.* I have just examined my journal, 

* In this instance the predisposition to disease had been created by previous excesses, and the arrival of the detach- 



TREATMENT OF EPIDEMIC CHOLERA. 

201 

and find that we have had forty-six cases, and eighteen died; sixteen out of the first thirty attacked, and two only out of the last sixteen. Our detachment is composed of very old and very young men ; the former were volunteers from the 84th and 86th regiments, and the latter young recruits. The disease for many days raged among the old soldiers, and the fatal cases, with the exception of four, occurred in their number. Persuaded that the first and principal object is to restore the balance of circulation, and that bleeding is the most likely means of doing so, it was always the first remedy employed. Many of the men not wishing to believe they were attacked with the disease, delayed coming for advice till they had tried burnt arrack, chillies, &c. in their own tents. The consequence was, that the blood either would not flow at all, or in such a way that the operation was of no use. Most of the first cases were of this kind, and very few recovered ; latterly they were alarmed, and generally came in good time ; the blood then flowed freely, and most of them recovered. The blood in every case was at first nearly black, 

ment at a station where the epidemic influence was in operation, occasioned the appearance of this malady among-st those thus predisposed to its operation. 



202 

CASES ILLUSTRATING THE 

and of the consistence of oil ; if it ran freely, the colour became lighter and lighter, and at last natural. I particularly remarked when this happened, that the pulse was always after to be felt, and not one died." — This detail is quite consistent with what I have myself seen. 

The following eleven cases were treated at the same time as the eight unsuccessful ones, the first detailed in the early part of this treatise. They followed each other in regular succession, from the 23d of May till the 23d of June, 1819 : they are all faithful and unadorned reports, made at the bedside of the patient. 

CASE XIV. 

27th May, 1819. — James Shaw, private H. M. 84th regiment, aged thirty-seven years, while in the tents on the south beach, was attacked, about ten o'clock, p.m., with severe pain in the lower part of his belly, and with continued purging and vomiting ; he first discharged the contents of the stomach and colon, and afterwards a muddy, watery, and offensive fluid ; the pulse small and struggling ; skin covered with cold dew ; confusion of his head, and cramps in the extremities. I understand he had thirty ounces of blood taken from his arm in the tent, before he was sent to the general hospital. When he arrived there, about eleven o'clock, 



203 

TREATMENT OF EPIDEMIC CHOLERA. 

p.m., his pulse was perceptible, but the skin continued cold, and covered with a clammy dew. He complained of the uneasiness about his head being very distressing. Twelve leeches were immediately applied to each temple, and the following draught given : — 

R Sp. iEther. Vitriol. Tinct. Opii, aa 3J. 

Mist. Camphor, M. ft. haust. 

Ten o'clock, a.m. — The leeches have bled very freely; pulse quick, and of rather greater volume, but the skin is still covered with a clammy dew, though warmer than it was; has neither had vomiting nor purging since admission into hospital ; he feels drowsy and sleepy. Let him be well covered with blankets, and allowed to remain quiet. He slept the greater part of the night, and had neither vomiting nor purging. 

28th. — The pulse much improved and stronger, but irregular and confused, 80 in a minute ; tongue rather white ; great confusion in his head. Let twenty-four leeches be applied to the back of the neck, as near the base of the skull as possible ; and give him Jiij. of the purging mixture immediately. 

Evening. — The leeches have bled freely, and he has had two full motions. Head much better, and his general feelings greatly improved. 



204 

CASES ILLUSTRATING THE 

R Calomel, gr. x. 

Conf. Rosarum, q. s. Ft. pilul. h. s. s. 

29th. — Complains of an unpleasant pain at the top of his head, which is confined to the space of a shilling. Let three leeches be applied immediately to the spot, and repeat the purging draught. 

Evening. — The leeches drew Jijss. of blood, and the pain is quite removed; he feels in every respect better. 

Rep. pil. Calomel. 

30th. — Has no complaint at all ; he feels perfectly well. 

Repeat the purging draught. 

31s/.— Fit for duty. 

CASE XV. 

26th May, 1819. — Mootamah, a Native woman, aged 18 years, wife to a private of the 84th regiment, was brought to the general hospital, about seven o'clock, p. m. She complained of excessive pain and burning about the umbilicus, and lower part of the body ; spasms at the stomach ; violent retching and vomiting of watery fluid, and frequent dejections of the same kind, with grinding pain, and contraction in the lower part of the belly ; skin cold, and covered with a 



TREATMENT OF EPIDEMIC CHOLERA. 

205 

clammy dew ; pulse small and languid : she expresses great fear of death. A vein was immediately opened, and a few drops of blood, sizy and black, came away ; but her arm was put into warm water, and in a short time the blood began to flow freely. Twenty-four ounces were taken, and the sizy, thick appearance of the blood was changed to a more florid and fluid state. As the blood flowed she felt relief, and by the time twenty-four ounces were taken, she felt quite well ; the pulse returned, and was full and soft. She was covered with large drops of perspiration, but complained of no pain of any kind, and she asked for food. An opiate draught was given, which put her to sleep for four hours ; she awoke perfectly free from all uneasiness. 

21th. — Two ounces of castor oil, with a little aq. menth. was given, which operated very well, and she was discharged quite cured in the evening.* 

CASE XVI. 

21th May, 1819. — Mooto, native dresser, belonging to the general hospital, was attacked with symptoms of spasmodic cholera, on the morning of the 27th May 1819, as he was proceeding on his duty round the hospital. He was bled instantly, to the amount of twentytwo ounces, and took an opiate draught, and was perfectly well in two hours. 

* This woman had not been attacked ten minutes when she was brought to the hospital. 



206 

CASES ILLUSTRATING THE 

CASE XVII. 

Ist June, 1819. —S. Sparling, a healthy woman, of a spare habit, aged 36 years, and a patient in the general hospital for a sore leg, was attacked suddenly, on this morning, about half past nine o'clock, with violent and acute spasmodic pains about the lower part of the belly and legs, and was covered with cold, clammy perspiration. The tongue was excited and white — not dry ; pulse small, frequent, and very weak ; vomiting and purging of watery fluid ; eyes sunk, and great expression of anxiety and fear in her countenance. I saw her at ten minutes before ten o'clock, and ordered venesection immediately, and the following draught to be given : — 

R Tinct. Opii, 

Sp. iEther. Vit. aa 3J 

Aq. Cinnamon, Aq. Purae, aa Jj. 

M. ft. haust. 

When the vein was opened the blood did not flow, was black and sizy, and only oozed out in drops ; by friction, however, it came away with more freedom, and as it flowed from her arm, she expressed the relief it gave her. When sixteen ounces had been drawn the spasms returned, and the blood ceased to flow during their continuance, which was not more than a minute or two ; but in that time a coagulum had filled up the orifice in the vein. This having been removed, sixteen ounces more of blood were abstracted, which relieved her, and she felt no sensation of faintness or sickness at 



TREATMENT OF EPIDEMIC CHOLERA. 

207 

stomach, although covered with cold perspiration ; but she expressed great relief as the blood was flowing from the arm. About this time the blood began to change from a black and sizy, to a more florid and fluid state, and six ounces more were allowed to flow before the arm was tied up. 

Half past ten. — The spasms still continue in her legs and feet, though by no means so severe as they were ; the pulse is softer and fuller, 96 in a minute ; she complains of considerable pain, and spasmodic twitchings about the lower part of her belly. 

Let her extremities be well rubbed with spirits of turpentine, and bottles filled with warm water be applied to her feet. 

Three ounces of the domestic injection, with 3J. of tinct. opii, to be exhibited as soon as possible. 

Half past eleven o'clock. — Much better in every respect ; quite free from pain and spasms ; skin cold and clammy ; feels lightness in her head, and considerable thirst ; tongue dry, and very white ; pulse quick and sharp, 106 in a minute; she is very thirsty. 

A little weak brandy and warm water occasionally, and a large spoonful of the following mixture every two or three hours. 

R Mist. Camph. Sp. iEther. Nitros. 31J. Aq. Ammon. 3J. 

Ft. mist. 



208 

CASES ILLUSTRATING THE 

Three o'clock, p. m. — No return of spasms ; but she complains of sharp pain at the epigastrium, and round the umbilicus. 

Let eight large leeches be immediately applied over the part pained, and continue the mixture. 

Five o'clock, p.m. — The leeches have bled very freely; pain much better; skin hot, but clammy. As the thirst continued, warm congee-water was given occasionally. 

Six o'clock, p. m. — Complains very much of acute pain at the crown of her head, which is confined to one spot, of great weight and pain at the base of the skull, of tightness over the head, and imperfect vision. Let the head be immediately shaved, and five leeches applied to the spot where she complains of pain, and five more at the base of the skull. 

These bled remarkably well, and completely removed all the unpleasant symptoms. 

Nine o'clock, p.m. — Perfectly easy ; thirst less urgent ; pulse 102 ; skin moist ; no pain of any kind ; has not had any motion since morning. 

R Calomel, gr. x. 

Opii Pur. gr. j. 

Ft. pilul. ij. statim sumendse. 

She was put to bed, well covered, and had two attendants to watch her during the night. 

Two o'clock, a. m. — Passed an excellent night, and and was not at all disturbed. Spasms entirely left her; 



209 

TREATMENT OF EPIDEMIC CHOLERA. 

felt an inclination, during the night, to relieve the bowels, but could not ; tongue foul and white ; pulse 90 in a minute ; skin moist and warm ; head light, but no pain ; that which she complained of at the crown of her head, and base of the skull, is completely removed by the leeches. 

R 01. Ricinijij. 

Aq. Menth. Pip. Jjss. 

To be taken immediately, and to be assisted by the common domestic enema. 

Twelve o'clock. — The bowels perfectly and fully emptied; dejections of a yellow colour; tongue still white and dry. 

R Mist. Salin. Febrif; Ibij. Aq. Ammon. jss. Sp. jiEther. Nitros. gij. 

Ft. mist. 

Two ounces of this mixture to be taken every three or four hours. 

Five o'clock, p.m. — Pulse very quick, 120 in a minute ; skin of the natural temperature ; no pain of any kind j has been purged four times, and passed darkcoloured slime in the last motion ; tongue cleaner, and 

very little thirst 

Cont. Mist, Salin. 

Rept. Pilul. Calomel, statim. 

Let her have a little arrow-root. 

p 



210 

CASES ILLUSTRATING THE 

3d. — Passed an excellent night; no pain at all; the calomel acted slightly on her bowels, and brought away a very dark-coloured, slimy motion; pulse small; skin warm; tongue clean and moist. 

Rept. Haust. Olei et Enema Contin. Mist. Salin. Febrif. 

Evening. — The medicines have operated well; tongue clean ; pulse good. 

She continued to take calomel at bed-time, and the purgative every morning till the sth, when she was perfectly well. 

CASE XVIII 

William Wilson, Honourable Company's pensioner, aged 40, has been a patient in the general hospital for some time, with sore eyes. 

June 10th, 1819. —He was attacked this morning, at eight o'clock, a.m., with vomiting and purging, excessive pain and burning sensation at the navel, and general spasms ; the muscles of the abdomen were all drawn towards the spine. The skin was cold, pulse small, and face covered with large drops of perspiration. 

Thirty-two ounces of blood were immediately abstracted, and the following draught was given :—: — 

R Tinct. Opii, 

Spts. iEther. Vit. aa 3J. 

Mist. Camph. fj. Ft. haust. 



211 

TREATMENT OF EPIDEMIC CHOLERA. 

Half past three, a.m. — Spasms completely checked ; no vomiting nor purging; skin continues cold, with cold, clammy perspirations; still complains of severe pain about the navel, but, to use his own expression, "heis in heaven to what he was ;" pulse languid. 

Let eighteen leeches be applied to the umbilicus immediately. Repeat the draught, and administer an anodyne enema, with camphor. 

Half past eleven. — The leeches have dropped off, and the pain is greatly relieved. 

Pulse quick, but soft and full ; tongue excited ; no vomiting or purging. 

Twelve. — The pulse is much improved, but the pain in his belly is returned with great severity. Apply a large blister over the whole belly. 

Five, p.m. — The blister has risen well, and he is quite free from pain. Tongue excited and white, but moist; no purging or vomiting; pulse soft and good, 98 in a minute. 

Let him have warm congee-water to drink, and give the following pill immediately. 

R Calomel, gr. xx. 

Opii gr. ij. 

Ft. pilulse. 

I now consider him out of all danger. 

Wth. — Passed an excellent night; pulse good; tongue less excited ; no pain ; has not had any mo^ tion. 



212 

CASES ILLUSTRATING THE 

R Olei Ricini, t f ij. Aq. Menth. Pip. f ij. Tinct. Opii g tt . xxx. 

M. ft. haust. Statim sumendus. 

Had one large stool from the oil which was perfectlynatural, with some mucus ; no pain of any kind ; pulse regular ; tongue clean and moist ; skin cool . 

Let the following draught be given at bed-time :—: — 

R Elix. Parigor. giij. Aq. Ammon. g tt . xx. Spts. iEther. Nitros. 3J. Aq. Menth. Pip. Jiss. 

Ft. haust. 

12th. — Pulse good; skin rather white ; no appetite; had a good motion this morning. 

R Infus. Amar. Comp. Tinct. Sennae giij. Cardam. 3HJ. 

Aq. Ammon. gl*.g 1 *. xxx. Ft. haust. 

This draught was repeated every night and morning till the 15th, when he was perfectly recovered. 

CASE XIX. 

James Farrall, private in H.M. 13th Light Dragoons, aged 26, was attacked, about 8 o'clock in the evening of the 19th June, with vomiting and purging, general 



213 

TREATMENT OF EPIDEMIC CHOLERA. 

cramps and flying pains all over him, for which some castor oil and laudanum were given in the barracks ; but about ten o'clock, p. m., the spasms became exceedinglysevere in his stomach, legs, arms, face, and lower jaw. He was, in consequence, sent to the general hospital, where he arrived at eleven o'clock. The spasms were excessively severe when he was admitted ; the pulse languid and small, but evidently oppressed ; skin cold, though not so cold as it usually is in this stage of the disease. 

Thirty-eight ounces of blood were immediately taken from the arm, which flowed in a full stream. Frictions, with spirits of turpentine, were applied over the legs and body, and bottles full of warm water to his feet, and between his thighs. 

Half past eleven, p.m. — Very much relieved. Continue the frictions, and give twenty grains of calomel, with two grains of opium, immediately. 

Twelve. — The spasms returned with great severity; every muscle in the body was as hard as a board, and he roared most violently with pain in his stomach ; pulse small, but with a sharp beat. Let twenty-five leeches be applied to the stomach immediately, and the following draught be given :—: — 

ft Tinct. Opii, Spts. iEther. Vit. aa 3J 

Aq. Purse Jj.. Ft. haust. 

Continue the turpentine friction and hot bottles. 



214 

CASES ILLUSTRATING THE 

Half past twelve o'clock. — Pain and spasms continue ; twelve leeches only have fastened at the epigastrium. 

Repeat the draught, and give him occasionally a little warm brandy and water. 

One o'clock, p. m. — No change; apply twelve leeches to the temples, and give warm congee-water and brandy for drink. 

Half past one. — The pain and spasms have subsided, but he feels great coldness, and complains of it. Give the following draught : — 

R Aq. Ammonise, g". 1 

Aq. Purse |j. Ft. haustus. 

Two, a.m. — He now feels quite relieved in every respect, and has fallen asleep. 

Three, a.m. — Complains of lightness and uneasiness in his head; pulse much improved. Let twelve more leeches be applied to the back of his head. Repeat the calomel pills. 

20th, Jive o'clock, a.m. — All the leeches have done their duty fully, and upwards, of thirty ounces of blood have been abstracted by them altogether ; he has neither vomiting nor purging. The spasms and uneasiness in the head are completely removed. 

Let a domestic enema be exhibited immediately. Continue the congee-water, and a little arrow-root occasionally. Nothing else was given during the day, and 



215 

TREATMENT OF EPIDEMIC CHOLERA. 

he continued perfectly free from pain or uneasiness. The enema had very little effect. 

R Calomel, gr. xx Opii Puri gr. ij. 

Ft. pilulse, h. s.s. 

21s?. — Passed a good night; feels no pain except in his loins; tongue clean; has not had any motion. Give the following draught immediately, and let a purgative enema be administered without loss of time. 

R Olei Ricini Jiij. 

Aq. Menth. Pip. |ij. Ft. haust. 

Evening. — The enema has had effect, and brought away some feculent matter, previous to the discharge, of which he was a good deal griped ; pulse quite regular, 78 in a minute, 

Repeat the calomel-pills at bed- time, and let him take a small wine-glass full of the following mixture, every four hours :—: — 

R Mist. Salin. Febrif. fbj. Aq. Aramon. g". lx. 

Spts. iEther. Nitros. gij. Tinct. Opii, Camph. fj. 

M. ft. mist. 

22d. — Feels quite well this morning; pulse good, 78 in a minute, but he has not been purged. Give £iij. of the purging mixture immediately. 

Evening. — Felt himself so well in the morning, that he has been running about all day, and has been 



216 

CASES ILLUSTRATING THE 

attacked this evening with giddiness in his head, and uneasiness in his belly ; pulse quick, and rather strong ; the purging mixture has had very little effect. 

Apply 28 leeches to the base of the skull immediately ; give a purging enema ; let the abdomen be well fomented, and repeat the calomel pills. 

23c?. — The leeches relieved his head the moment they began to draw, and he passed a tolerably good night; pulse regular, 86 in a minute, full and soft Tongue foul ; had a dose of the purging mixture about five o'clock this morning, but it has not operated. 

Let a purging enema be administered immediately, and one large spoonful of the following mixture be given every three or four hours. 

R Mist. Camp. Ifcj. Spts. ./Ether. Nitros. 31J. 

Aq. Ammon. g M . xxx. M. ft. mist. 

Evening. — He has been fully purged in the course of this day; the motions consist of dark green, and a black, viscid, tenacious matter. He is perfectly free from pain of any kind . 

Continue the Mixture. 

24th. — Feels perfectly well this morning, except from a pain in his loins. Apply a warm plaster to the small of his back. Continue the mixture, and repeat the purgative. This treatment was continued regularly till the 28th, when he was perfectly recovered. 



217 

TREATMENT OF EPIDEMIC CHOLERA. 

CASE XX. 

Mary Cramer, the wife of a private in H. M. 13th Dragoons, just arrived from England ; admitted into the general hospital about eight o'clock, p.m., the 20th June, 1819. 

She was attacked, about an hour since, in the barracks, with vomiting and severe cramps in her stomach and bowels ; she was also purged twice, and the evacuations, both from the stomach and bowels, were a white, watery, flocculent fluid. She is exceedingly restless, and complains much of thirst ; nothing had been given to her in the barracks except a little brandy and water, and in this state she was brought to the hospital. 

Twenty-eight ounces of blood were immediately taken from the arm, which gave her some relief; but the cramps and vomiting still continued, both in her legs and stomach. 

Frictions, with spirits of turpentine, were used to her legs, eighteen leeches applied to the stomach, an opiate enema with camphor was administered, and the following draught given : — 

R Tinct. Opii, Spts. iEther. Vit. aa 3J. 

Mist. Camphor. Jj. M. ft. haust. 

Ten o'clock, p. m. — She vomited the draught immediately, but retained the enema, and the leeches appear to be drawing well ; spasms in the legs much better, and she has much less pain in the stomach. Give the following pills immediately :—: — 



218 

CASES ILLUSTRATING THE 

R Calomel, gr. xx. 

Opii Puri gr. ij. Ft. pilulte. 

Eleven o'clock. — She is perfectly free from pain or spasm ; pulse soft and good ; leeches have bled very well, and she is disposed to sleep. 

21st. — Slept well all night; pulse good; tongue rather white and excited ; feels some pain and heaviness in her head, with intolerance of light, but she has no spasms, nor pain either in her legs or stomach. 

Apply twelve leeches to the back of the neck immediately. Let a purging enema be administered, and the following draught be taken. 

R Olei Ricini Aq. Menth. Pip. Jij. 

Tinct. Opii g tl . xx. M. ft. haustus. 

Evening. — The leeches have relieved her head wonderfully, and she is better in every respect, though the purgative has had very little effect. 

Repet. Pil. Calomel, gr. xx. 

22d. — Free from all pain of every kind ; her bowels have been very fully acted upon during the night, and the medicine is still operating : skin moist ; pulse soft and full, but weak. Let her have a little arrow-root and wine, and give two table-spoonsful of the following mixture, every two or three hours :—: — 



219 

TREATMENT OF EPIDEMIC CHOLERA. 

R Mist. Camph. £vj. Aq. Ammon. g u . xxx. Elix. Parigor. 3J. Confect. Aromat. 3J. 

M. ft. mist. 

Evening. — Feels much better in every respect. No medicine. 

23d. — Pulse 74, not strong, but tolerably good ; she was griped in the night, but not purged ; no pain or uneasiness, either in the head or stomach. Continue arrow-root as before. Let a common domestic enema be administered, and give the following draught immediately :—: — 

R Olei Ricini 

Tinct. Opii g". xx. Aq. Menth. Pip. |ij. 

M. ft. haust. 

Evening. — Her bowels have been freely emptied ; dejections of dark green colour. She is much stronger, and feels in every respect better. Let her have an anodyne draught at bed-time. 

24th. — Passed a tolerable night, but her tongue is white and excited ; the pulse is stronger, and rather quick, and she feels some lightness in her head ; but has no pain of any kind. 

Apply a blister to the nape of the neck, and repeat the oleum ricini. 

Evening. — Has had several copious motions since morning ; the blister has risen well ; head much relieved ; 



220 

CASES ILLUSTRATING THE 

skin cool ; tongue continues foul ; pulse small ; but she has no pain, nor uneasiness of any kind. 

R Calomel, gr. viij. Opii Puri gr. j. 

Syr. q. s. 

Ft. pil. h. s.s. 

Oleum Ricini very early in the morning 

25th. — Has taken the oil with excellent effect; she felt weak, but is much better in every respect, and has an appetite. From this time she recovered, and required nothing more than an occasional laxative till the 29th, when she was perfectly well. 

CASE XXI. 

William Brian, private in H.M. 13th Dragoons, aged 23, was attacked in the barracks, about five o'clock, p.m., 22d June, 1819, with purging and vomiting of a watery fluid; violent spasms in the stomach and bowels, and with all the usual symptoms of epidemic cholera. He was bled freely by the assistant-surgeon of the regiment, and the vomiting, purging, and spasms, &c, ceased at once. 

He was brought to the general hospital about eight o'clock, p.m., complaining of great pain and oppression at the epigastric region. 

Twenty-five leeches were immediately applied, and he took the following pills :—: — 

R Calomel, gr. xx. 

Opii Puri gr. ij. Ft. pil. 



221 

TREATMENT OF EPIDEMIC CHOLERA. 

23c?. —He passed a quiet night; the leeches remained upon him for a considerable time ; pain at the epigastrium relieved, though he occasionally feels it, and he complains of oppression in his breast, and difficulty of breathing ; pulse 64 in a minute ; no uneasiness about the head. 

Apply eight leeches to the right hypocondriac region, and twenty between the ribs, extending from the spine towards the sternum, and give him a purging enema immediately. 

Evening. — The enema acted upon his bowels, and brought away a great deal of morbid, black matter. He has been asleep almost ever since; the leeches have bled freely, and relieved him very much ; the oppression is removed. 

R Calomel, gr. xx. 

Opii Puri gr. ij. Ft. pilul. h. s.s. 

24th. — Says he feels quite in heaven; has no pain or uneasiness at all ; pulse 72 in a minute, soft and regular, but the tongue is a little excited. 

R Mist. Purgan. Jiij. 01. Menth. Pip. g". iij. Ft. haustus statim capiendus. R Mist. Salin. Febrif. fbj. 

Aq. Ammon. sy. Yin. Antim. jss. 

M. ft. mist. 

Capiat seger cyathum secunda tertiave quaque hora. 

Evening. — He feels perfectly well ; his bowels have been well acted upon. He recovered from this time, 



222 

CASES ILLUSTRATING THE 

without taking any other medicine, except an occasional laxative. 

CASE XXII. 

Ann Collingwood, belonging to H. M. 13th Dragoons, arrived from England, was attacked in the barracks, about half-past two o'clock, p.m., of the 23d of June, 1819, with the usual symptoms of epidemic cholera, and sent to the general hospital, where she was admitted at three o'clock, p. m. A little spirits had been given to her before she left the barracks, and this was all that was done for her. Complains of severe pain and burning heat at the epigastric region and scrobiculus cordis, and of spasms in her extremities. Skin cold, with a clammy perspiration all over her; pulse quick and thready. Twenty-six ounces of blood were immediately taken from her arm ; frictions, with spirits of turpentine, applied to the extremities, and over the epigastric region. She was well wrapt up in warm blankets, and the following draught given : — 

R Tinct. Opii, Spts. Mther. Sulph. aa 3J. 

Mist. Camph. fj. M. ft. haustus. 

Half past three, p. m. — The bleeding relieved the spasms immediately ; she feels better generally, but the pulse is exceedingly small and frequent, and she has a strong desire to sleep, which is indulged. 

Ten, p.m. — Has slept till this time, without any return of pain or spasm, and she feels better. Give the following pill immediately :—: — 



223 

TREATMENT OF EPIDEMTC CHOLERA. 

R Calomel, gr. xx. Opii Puri gr. ij. 

Syr. q. s. 

Ft. pil. 

29M. — Complains this morning of great thirst; tongue white and excited ; has not had any motion, but she has neither pain in the stomach or head. Pulse 76 in a minute, rather irregular. Give her the following purging draught immediately, and let her take a wineglassful of the saline mixture every three hours. 

R Olei Ricini Jij. Tinct. Opii, g tt . xx. Aquse Menthce Pip. 

M. ft. haust. purgans. 

R Mist. Salin. Febrif. iftij. Aq. Ammon. g tt . xxx. Sp. JEther. Nitros, gij. Antim. Tart. gr. ij. 

M. ft. mist. 

Evening. — Bowels freely evacuated ; stools of a very dark grey colour ; she feels wonderfully relieved. 

Cont. Mist. Salin. Febrif. 

30th. — She feels weak, but has no return of spasms or pain ; passed a good night, and perspires freely. 

Cont. Mist. Salin. Feb. 

July Ist. — Her bowels are constipated, but she feels quite easy. 

Rept. haustus Olei Ricini. Contin. Mist. Salin Feb. 



224 

CASES ILLUSTRATING THE 

She recovered from this time, and was discharged from the hospital perfectly well on the 3d July. 

CASE XXIIL 

23d June, 1819.— P. M'Kennah, aged 24 years, a private in H. M. 13th Dragoons, and just arrived from England, was admitted into the general hospital at nine o'clock, p.m., with violent pain and spasms in the extremities and stomach; his cries are dreadful, and the pain in the region of the stomach, arch of the colon, and edge of the diaphragm, appeared to be excessive, on the least pressure being made. The pulse is languid and small ; skin cold, and covered with perspiration ; and all the usual symptoms of epidemic cholera. He was taken ill about an hour before his admission into the hospital. Forty-two ounces of blood were immediately taken from his arm, and the following draught given :—: — 

ft Tinct. Opii, 

Sp. iEther. Vitriol, aa jj. Mist. Camph. gj. 

M. ft. haustus. 

Half past nine o'clock, p. m. — He felt relief while the blood was flowing from his arm ; the pain has now returned again in his stomach, and the pulse is hardly perceptible during the continuance of the spasms. 

Let the chest and epigastric region be well rubbed with spirits of turpentine, and afterwards a large mustard poultice be applied over the whole abdomen ; and give twenty grains of calomel, and two grains of opium immediately. 



225 

TREATMENT OF EPIDEMIC CHOLERA. 

Repeat the draught, and continue the friction. 

Ten o'clock, p. m. — The pulse is increased, and the pain diminished. 

Continue as before. 

Half past ten o'clock. — Fast asleep. 

Eleven o'clock, p. m. — Continues to sleep, and he breathes with more ease and freedom. 

Five o'clock, a.m. — Slept the whole night; pulse 112 in a minute, and oppressed; tongue white, and excited ; hot skin ; no pain of any kind ; has no difficulty of breathing, or uneasiness in his head. 

Let him have a purging enema immediately, and of the purging mixture; and, during the day, give him a wine-glassful of the saline mixture, as follows :* — 

R Mist. Salin. Febrif. Ibj. Aq. Ammon. g tt . xxx. Sp. iEther. Nitros. 31J . Antimon. Tart. gr. ij. 

M. ft. mist. 

Evening. — Has been well purged ; his skin is moist ; pulse 84 in a minute, and he is free from all pain. 

* In this case, the blood that was drawn from the arm was particularly red and florid, and with very little serum. It. came languidly at first, but towards the last it flowed with freedom. 

Q 



226 

CASKS ILLUSTRATING THE 

R Calomel, gr. xx. Opii Pur. gr. ij. Syr. q. s. 

Ft. pil. h. s.s. 

Cont. Mist. Salin. Feb 

30th. — Passed a good night; skin cool; tongue clean ; pulse 64, and weak ; no pain of any kind . 

Cont. Mist. Salin. 

Repeat the purging draught, and give arrow root. 

He was fully purged ; motions dark, green, and feculent ; feels weak, but in other respects quite well. Calomel at night, and a purgative in the morning, were continued, and he was perfectly recovered on the sth of July. 

CASE XXIV. 

J. Horan, private H. M. 13th Light Dragoons, aged twenty-six years; admitted into the general hospital at half past four o'clock, p. m., 20th June, 1819, with all the symptoms of epidemic cholera. Violent pain, and spasmodic contractions of the limbs, and at the stomach ; anxious countenance ; cold skin ; weak, languid pulse. He was bled before he left the barracks, but I am not informed of the quantity taken ; the symptoms, however, were so severe, that I ordered thirty-two ounces more to be immediately taken from his arm, and the following draught to be given : — 

R Tinct. Opii, 

Sp. .Ether. Vit. aa 3J. Mist. Camph. fj. M. ft. haustus. 



TREATMENT OF EPIDEMIC CHOLERA. 

227 

Let the stomach and extremities be well rubbed with spirits of turpentine, and afterwards a large mustard poultice be applied to the epigastric region, and give twenty grains of calomel and two grains of opium immediately. 

Five o'clock, p.m. — The skin is warmer, and he feels better, though he still has pain occasionally at the stomach ; and the pulse is small. 

Rept. haust. Anodyne. 

Half past Jive o'clock. — Complains of considerable uneasiness in his head, and intolerance of light; pulse frequent, but thready; skin hot, and thirst urgent. Apply sixteen leeches to the temples immediately. 

Six o'clock, p. m. — Much less pain, but he is very restless, and complains very much of thirst ; no motion since admission; says he has felt the inclination all day, but has not been able to relieve himself. Let a purgative enema be administered immediately. 

Seven o'clock, p. m. — Voided the enema, but no faeces ; his head feels very uncomfortable from a sensation which he cannot describe ; no pain in the stomach. Repeat the enema immediately, and give the following pill : — 

R Calomel, gr. xx. Opii Puri, gr. ij. 

Syr. q. s. 

Ft. pilulse. 



228 

CASES ILLUSTRATING THE 

Half past seven o'clock. — Voided an amazing quantity of scybala with the last enema; skin hot; pulse increased in strength and frequency ; confusion in the head continues, and a noise like the roaring of the sea. Fourteen ounces more blood were taken from the arm, and the enema repeated. 

Half past nine o'clock, p. m. — Has had some feculent discharges, which are morbid and offensive, from the bowels, since last report. The pupils of the eye are very much contracted, and he complains much of intolerance of light; thirst very troublesome. 

Let eighteen leeches be immediately applied to the back of his head, and a wine-glassful of the following mixture given every two hours : — 

R Mist. Salin. Feb. Ifcj. • Aq. Ammon. g". xxx. Antim. Tart. gr. ij. 

Sp. iEther. Nitros. M. ft. Mistura. 

Half past eleven o'clock. — The leeches have bled remarkably well, and his head is very much relieved ; he can now look at a lighted candle without inconvenience; he has passed more hardened faeces with the enema. Repeat the enema and saline mixture as before, and give the following purging draught immediately :—: — 

R Olei Ricini Jiij. 

01. Menthce pip. g tt . v. 

Aq. Purse, |ij. M. ft. haustus. 



229 

TREATMENT OF EPIDEMIC CHOLERA. 

29th, Jive o'clock, a. m. — Has passed rather a restless night; pulse 102 in a minute; the oil has operated, and brought away more hardened faeces ; he is free from all pain, but there is great heaviness in his head, and the intolerance of light has again returned; the skin is above the natural temperature. Let twelve more leeches be immediately applied to the base of the skull, # and a blister behind each ear ; continue the saline mixture. Let also the enema be repeated three times in the day, and the following draught given immediately : — 

R 01. Ricini Jiij. Tinct. Opii g tt . xx. Aq. Menth. Pip. Jij. M. ft. haustus. 

Evening. — He has been purged freely, and the blisters have done their duty remarkably well ; but he continues very restless and uneasy ; tongue white, and very much excited ; skin considerably above the natural standard ; pulse 106 in a minute ; says he has no pain, but is distressed from the want of sleep ; can look 

* From vein 46 J blood 46 

fl6)f 16 ) Leeches < 18 \ '12' 

57^ , by measure 

103 of blood in five hours, 

besides what had been taken away before his admission into hospital. 

N.B. — The blood drawn was particularly black, with a large quantity of serum, and a metallic pellicle over the 

serum. 



230 

CASES ILLUSTRATING THE 

at the light better than he did, but there is evidently great uneasiness in his head. 

Let the head be shaved, and cold vinegar and water constantly applied, and give the following pills immediately : — • 

ft Calomel, gr. xx Opii Pur. gr. ij. 

Q. s. ft. pil. 

Contin. Mist. Salina. 

Ten o'clock, p. m. — Pulse 102; head relieved ; he can bear the light quite well ; no pain or oppression ; skin much reduced in temperature ; tongue less excited. 

Continue the saline mixture. 

'30th, Jive o'clock, a. m. — Slept a little in the night; skin cooler this morning- ; thirst still urgent ; tongue dry and excited; pulse soft, about 90 in a minute; uneasiness in the head much relieved. 

Let him have four ounces of the purging mixture immediately, and give him a little arrow root. 

Evening. — Has been purged very freely during the day ; motions of a green colour, crude, and very copious ; head greatly better, but the tongue is still excited, and the pulse is 88 in a minute. 

Continue the saline mixture, and repeat the calomel pill. 

July Ist. — Purged very freely during the night, and passed a considerable quantity of viscid, tenacious matter, of different colours, dark green, black, and 



231 

TREATMENT OF EPIDEMIC CHOLERA. 

white ; tongue less excited ; thirst less ; pulse 84 ; skin moist ; head quite easy. 

Rept. Mist. Purgans. Contin. Mist. Salin. 

2d. — Pulse 79 in a minute, regular, full, and soft ; tongue less excited, and very little thirst ; feels pain at the small of the back. He had two full motions in the night. 

Rept. Mist. Purgans. Cont. Mist. Salin. Imponatur emplastrum picis lumbis. 

Evening. — The medicines have acted very well; motions very copious, and of a dark green colour ; there is slight increase of heat in the skin. 

Repeat the calomel pills at bed-time, and let him take the purging mixture early in the morning. 

Three o'clock, a. m. — The purging medicines have been acting very smartly ; motions not so green as they were, but of a brown colour, and consisting of a quantity of morbid, feculent matter; pulse 82; skin comfortable ; head easy ; no pain in the stomach, side, or bowels ; tongue less excited, and not so dry. 

Continue the saline mixture. 

R Pilul. Hydrargyri 3J. Calomel, gr. xx. 

Syr. q. s. Fiat massa ajqualis. 

Divide into twelve pills, and let one be taken three times a day. 



232 

CASES ILLUSTRATING THE 

R Infus. Gentian. Comp. Sjvj. Sennae, Jiij. 

Tinct. Cardam. M. ft. Mist. 

A wine-glassful to be taken night and morning. 

Evening. — His motions during the day have been extremely black and morbid ; pulse 66 ; in all other respects the same. 

4th. — His mouth is sore this morning, and he has considerable ptyalism ; passed a bad night ; had no motion during the night; complains of pain in his eyes this morning, though he can look at the light very well. 

Omit the pills, but continue the bitter aperient mixture night and morning, and the saline mixture through the day. 

Evening. — His motions are by no means so dark as they were, but he complains very much of pain at the occiput and of vertigo. 

Apply ten leeches to the occiput immediately. 

sth. — The leeches have removed the pain; pulse 88 ; tongue rather excited ; very little thirst ; had one motion in the night of natural appearance ; mouth very sore, and considerable ptyalism. 

He recovered from this time, by taking the aperient mixture regularly night and morning, till the 12th, when all medicines were discontinued. 



233 

TREATMENT OF EPIDEMIC CHOLERA. 

CASE XXV.* 

Veerdoopettah, August V7th, 1820. — At this place the spasmodic cholera seized me, at about half past one in the morning. I had been unwell from the 12th, and had quite lost my appetite ; but on rising this morning I found my head unusually heavy, with a great difficulty of breathing. I called my people up, and gave orders to march to Madura, (distance about twentyeight miles English). My head was now so very painful and heavy, as to oblige me to recline it on the table. 

Before the cattle could be put to, I was seized with a severe, acute, cutting pain across the lower edge of the belly, and an instantaneous inclination to stool. I went out, when, to my astonishment, a flow of water gushed like a torrent from me, and the whole of the internal organs seemed to have dissolved to one mass of fluid. Before I could leave the spot, these severe evacuations were repeated at least four or five times. 

At a quarter before two, my medicine-box having been packed up, and not wishing to create an alarm among my people, and having drogue amere at hand, I took a powerful draught of it, which I retained, and got into a covered cart, in which I was conveyed thirteen 

* As this case is interesting in several points of view, especially as respects the early symptoms and treatment of the disease, I give it in the words of the patient, as drawn up by him soon after his recovery. 



234 

TREATMENT OF EPIDEMIC CHOLERA. 

miles by little after sunrise. The purging being very frequent and severe during the march, I took about ten or fifteen drops of oil of peppermint in a beetle-leaf; with the next evacuation the leaf passed through me. At this time I became so very weak, and the spasms so severe, that I ordered a halt, and took down from the bandy my cot and box. From the latter I got my medicine, and took the ammonia draught, as prescribed by my friend Wilkins, which I immediately threw up. I afterwards took drogue amere, with peppermint and brandy, &c. which also came up. The spasms and purging at this time were very severe, and I became so debilitated, as not to be able to move from my cot without being lifted. I had, however, in the interim sent people out to endeavour to get a country dooly, or litter, to convey me to Madura, whence I was distant fifteen miles, and despatched my horsekeeper with a note to the officer commanding there, requesting he would prevail on the medical officer to come out a few miles on the road to meet me. The horsekeeper was scarcely gone, when Dr. Kenny, of his Majesty's 89th regiment, who was at a neighbouring village, having heard of my situation, very humanely sent a litter for me. On my arrival at the village, Dr. Kenny bled me ; and I soon found that it had the effect of checking the spasms a good deal. I moved on immediately towards Madura, and was met by a native dresser. This man gave me calomel powders with very strong draughts, and, as well as my recollection serves, he repeated them three or four times before I arrived at Madura. I was then much weakened, and quite helpless, and had given up all thoughts of recovery. 



235 

NON-CONTAGIOUS NATURE, &C. 

It would not be improper here to mention, that although I had a craving desire to drink water, it did not proceed from thirst, but a burning heat in the stomach, throat, and tongue. 

Shortly after my arrival at Madura the purging ceased, and I found no other symptoms but the spasms, and the heat in the stomach, &c. which were not so severe as they had been. It was then about five in the evening, (four hours and a half from the attack). Mr. Neilson, the medical officer at Madura, attended me immediately at the commanding officer's house, where I was taken, and, by his kind attention, I recovered. 

SECTION 111. 

Remarks in proof of the Non-contagious Nature of the Disease, and on the Preservative Means which may be adopted in order to escape from its Attack. 

Before I conclude my observations on the epidemic cholera which has lately ravaged India, I shall first add a few remarks in support of the opinion I have already stated, (see p. 152,) that the disease did not appear to be contagious ; and next notice a few of the measures which seemed to me to have been 



236 

NON-CONTAGIOUS NATURE OF 

best calculated to prevent the invasion of the disease. 

First, as respects the non-contagious nature of the epidemic. Here I must observe, that I am very far from conceiving that many pathologists of the present day will consider every disease which prevails epidemically, to be necessarily contagious. Doubtless, the particular causes which occasion epidemic maladies will greatly facilitate the diffusion, by contagion, of those which really possess that property. And it is not improbable, .that some diseases, which at first originate from an epidemic influence solely, may become contagious, or rather infectious, from the circumstances in which those affected by them may be placed, — as from imperfect ventilation, previous want of, and present inattention to cleanliness, crowdingtogether of the sick, &c. and may be disseminated more widely, owing to an infectious cause thus generated being superadded to the original and more generally prevailing causes whence these diseases at first sprung. We have proofs of such occurrences in fevers and dysentery ; but the epidemic cholera appeared under circumstances which could in no way favour the idea that an infectious property was in any instance generated. There was generally no crowding 



237 

EPIDEMIC CHOLERA. 

together of the sick — no want of ventilation — no want of cleanliness ; and the disease, at the time, more particularly when it was most prevalent and fatal —at the early period of the epidemic, — always terminated so rapidly, either in death or in recovery, that a sufficient time did not elapse, which, if we may judge from the progress of those maladies that are acknowledgedly contagious, is indispensibly requisite to the operation of those changes on the fluids and secretions whence a contagious property results. Moreover, the lapse of time between the existence of perfect health and of the full manifestation of disease was so short, that no such evidence of the intermediate changes, as exists in contagious diseases generally, could be detected in this malady. Very many, also, of those who were seized with the epidemic cholera, neither saw nor came within the sphere of any other individual affected with the disorder. 

The epidemic cholera, it should also be recollected, appeared simultaneously at several stations far distant from each other, leaving intermediate districts of country unaffected by it. It is true, that on several occasions, when the disease prevailed amongst the troops and inhabitants of a particular station or town, and 



238 

NON-CONTAGIOUS NATURE OF 

soon after troops or others arrived in these places, many of them were attacked with the disease. I have adduced an instance of this at page 200. But it by no means follows from this circumstance, that they were seized in consequence of the communication of a contagious principle from those who were labouring under the malady ; but, on the contrary, it is evident that they, having arrived at a district where the epidemic cause actively prevailed, in a state of predisposition, from fatigue, &c. were soon acted upon by this efficient cause of the disease. 

The sudden occurrence of the epidemic cholera in particular stations and districts, the astonishing violence with which it appeared, the great numbers which were immediately and simultaneously seized with it, and its very unexpected and sudden decline, and its total disappearance after committing unheard of ravages during a few days only, are circumstances wholly incompatible with the belief, that it either originated in, or was diffused by means of contagion. I have it in my power to adduce numerous facts in support of the above assertion ; but as a sufficient number have been already brought forward in the able report of Mr. Jamieson on the disease as it 



239 

EPIDEMIC CHOLERA. 

occurred in the districts, and amongst the troops under the Bengal Presidency, I consider it unnecessary to allude farther to them. 

In addition to the foregoing considerations, I may state, that medical officers, and attendants on the sick, were not affected by the disease in a greater proportion than other classes of persons in the districts or divisions of the army wherein the disorder was prevalent ; — that individuals who were seized with cholera, from amongst those who were in the hospital for other disorders, did not appear to communicate the disease to other patients who had intercourse with them ; — that when a single member of a family was attacked, the rest of that family were not more obnoxious to the disease, than an equal number from amongst the community ; and if more than one in a family or house were seized, it was generally simultaneously, or nearly so, and not in such a manner as would have led me to infer that the disorder had been communicated from the one to the other; — that when the disease was prevalent in a particular part of a town, in a certain street, or even in one house only, the circumstance was evidently attributable to the confined, unwholesome, and low situation of these places, or to particular predisposing, or exciting 



240 

XON-CONTAGIOUS NATURE OF 

causes, to which the individuals thus attacked had been exposed. 

In illustration of the above statements, I may adduce what occurred in the hospital under my charge. Indeed, both in that hospital, and during the course of my whole experience of the disease elsewhere, no more than two cases occurred to me, which the most strenuous supporters of contagion in this disease could adduce in aid of their views ; and these cases evidently appear to have arisen from a very different source than from contagion. The first instance was a soldier attending his wife in the disorder, who was himself seized by it, and died an hour before her. But it is evident, in this case, that both were exposed to the same efficient causes — the same epidemic influence ; the fatigue and anxiety experienced by the husband whilst attending his wife, proving the determining cause of that influence, and facilitating its operation : and it is equally evident, that if the husband's disorder had arisen from a contagious principle proceeding from his wife, that, like other contagions, it would have required a longer time than the very few hours which elapsed, to operate the changes necessary to its development. The next instance was that of a female 



241 

EPIDEMIC CHOLERA. 

who had attended her friend that died of the disease, in whom she was much interested : after washing her, and removing her from the ward, she was herself attacked. The same remark which was made as to the first instance equally applies to this. These patients were in a ward with between eighty and ninety persons, many of whom collected around their beds, and yet not one of that number was attacked with cholera. 

I never saw more altogether than five or six persons, whilst patients in the hospital, attacked with the epidemic cholera; and, although I have had thirty or forty cases of this disease in the hospital at one time, when it contained not less than from one hundred and seventy to two hundred patients, yet not one instance of cholera occurred which could be imputed to the admission of these cases. 

When I took charge, in 1819, of the general hospital, fifty-nine case of epidemic cholera were treated by me, between the 23d of May, and the 23d of August. I was without assistants at the time, and obliged to be in the hospital almost constantly, both night and day, harrassed and fatigued of course, _ and certainly liable to the operation of an infectious principle, 

v 



242 

NON-CONTAGIOUS NATURE OF 

had any such emanated from those who were suffering under the disease. But I never experienced any disorder, and only one of the hospital-servants had the disease — a degree of immunity even greater than that observed elsewhere. 

Numerous instances may be detailed of detachments leaving stations in which the disease was prevalent, losing men in it on their route to other stations, and yet, not communicating any infection to those whom they joined. This appears to be a strong circumstance in proof of the non-contagious nature of the disease. But I must also contend, that if the disease had even appeared amongst the troops which these detachments joined, the occurrence cannot be considered as by any means proving its contagious nature. The circumstance merely would have evinced, that the period at which the efficient cause of the epidemic came in operation, coincided with the arrivals of these detachments.* 

* Cholera attacked the field force stationed at Malligaum in Kandiesh, and raged with great violence amongst the corps posted on the left of the line; while the 17th battalion of Native infantry, who were posted on the right of the line, were exempt from it, notwithstanding they had continued communication with the other men. But, although they 



243 

EPIDEMIC CHOLERA. 

As the non-contagious nature of the disease is very generally admitted by the medical authorities of India who have had sufficient experience of the disease, and as this property is generally believed in by the community at large,* I should not have thought it necessary to advert to a contrary opinion, had not that opinion received the support of some distinguished medical authorities. I cannot, however, but think it unfortunate that the idea was ever suggested, because the dread of contagion may lead to serious consequences, inasmuch as it may withhold from the sick that assistance which they so much require. The strongest proof which I can adduce in opposition to it, came fully under my 

were exempt from the disease while they remained in this position, they suffered very much from cholera on their march from Malligaum to join Major-General Sir John Doveton's force in the Ellichapoor Valley. 

* It may be thought singular that I should adduce vulgar opinion in support of my argument on this topic; but I believe that enlarged views of the sentiments of the public, on matters of this description, will shew that they generally form opinions which tolerably approach to truth ; and that if they at all err on a question like the present, or upon the infectious nature of a disease, it will generally be on the side of affirmation. The "catching" property of a disorder will be that inferred by them, whenever the question admits of much doubt or discussion. 



244 

NON-CONTAGIOUS NATURE OF 

own experience, which has not been inconsiderable, and was derived chiefly from what I observed in the general hospital at Madras, whilst it was under my charge. This hospital generally contained from 1 70 to 200 patients, Natives and Europeans ; the wards were open, and a free communication existed between them, and yet, although patients were daily brought into them suffering under the epidemic cholera, although these patients were indifferently distributed throughout the hospital, and consequently, not excluded from the rest of its inmates, no more than five or six persons, exclusive of the two already noticed, were seized with the disease while patients in the hospital, during a period of five years ; and certainly these cases could not be imputed in any degree to contagion. I can view them merely as cases of cholera, occurring under circumstances of predisposition, during the prevalence of an epidemic cause, and as shewing even a much diminished ratio of attack to that observed where the disease prevailed. 

I shall now conclude with a few brief remarks on what seems to me to be the best preservative regimen that can be adopted, in order to avoid an attack of the epidemic cholera. All that I can, however, say under this 



245 

EPIDEMIC CHOLERA. 

head, may be comprehended under the general injunction, of avoiding the predisposing and exciting causes of the disease. Whatever tends, directly or indirectly, to debilitate or fatigue the system ; whatever lowers its vital energy —as excesses of every description — disposes to the operation of the efficient cause of the malady. On the other hand, lam fully persuaded, that whatever tends to preserve this energy, serves to render the system impregnable to its operations. 

Exposure to cold, to chills, to the night dew, and to wet and moisture, ought carefully to be avoided ; and if at any time these exposures are inevitable, the system should be fortified against their effects : but the mode of fortifying the system requires consideration. This should not be attempted, unless better means are not within reach, by wines or spirits ; these generally leave the system, as soon as their stimulating effects have passed off, more exposed than before to the invasion of disease. Permanent tonics, however, and those more especially which determine to the surface of the body, at the same time that they improve the tone of the digestive organs, and promote the regular functions of the bowels and biliary organs, may be resorted to on such occasions. For this purpose, infusion or decoction of 



246 

XON-CONTAGIOUS NATURE OF 

bark, or of calumba, may be taken with the spiritus mindereri, or any warm stomachic ; or the powdered bark may, combined with the spicy aromatics. The same medicinal means may be attended to, whenever the disease prevails at the place where the individual resides, and should be put in practice when he retires to sleep, and as soon as he rises in the morning, before he leaves his apartment. He should avoid, also, sleeping in low and ill-ventilated apartments ; and be equally distrustful of sleeping near, or even of passing through, in the night time, marshy or swampy districts. If, however, these latter precautions cannot be taken, the medicinal means already suggested should be adopted. 

The bowels should be attended to, and their functions regulated ; but in no case should this be attempted by debilitating purgatives, or by salts. The warm stomachic laxatives, and these combined with tonics, may be adopted with advantage, as occasion may require. The surface of the body should be kept in a warm perspirable state ; but excessive perspirations must be avoided. 

The diet should be regular, moderate, and easy of digestion. Whilst low living ought to be shunned, its opposite should never be 



247 

EPIDEMIC CHOLERA. 

indulged in. The stomach ought to have no more to do than what it can perfectly accomplish, without fatigue to itself, and to the promotion of its own energies. It must never be roused to a state of false energy, by means of palatable excitants, or weakened by distending it with too copious draughts of weak diluents. 

The state of the mind ought to be regulated in such a manner, as not to be excited much above, or lowered beneath, its usual tenor. The imagination should not be allowed, for a moment, to dwell upon the painful considerations which the disease is calculated to bring before the mind ; and least of all ought the dread of it to be encouraged. There is amoral courage, which is possessed by individuals who are even the weakest, perhaps, as respects physical powers, and which in them resists more efficiently the causes of inter-tropical diseases, than the bodily powers of the strongest, who are not similarly endowed with this species of mental energy. Those who dread not the attack of disease, more especially of epidemic diseases, and who yet possess sufficient prudence to avoid unnecessary exposures to their predisposing and exciting causes, may generally.be considered as subjected to comparatively little risk from them. This, I am 



248 NON-CONTAGIOUS NATURE, &C. 

persuaded, is particularly the case as respects epidemic cholera, and I wish to impress it upon the minds of those whom the observation concerns. 



249 

Admissions and Casualties from Cholera, in the Army of 

Fort St. George, both Europeans and Natives. EUROPEANS. _ Rate •§ » Rate Rate Total Total Per Cent of §6 Per Cent of PerMilleof Strength Admission Admission £ s Deaths Deaths YEARS. of the of Cholera, upon the -^ Q upon the upon the Army. Strength. §'g Admissions. Strength. H 1818 10,652 1087 Wcent. 232 21 Fcent. 21 $* mille. 1819 10,125 500 5 85 17 8 1820 9,416 343 4 69 20 7 1821 9,553 357 4 39 11 4' Grand Total.. 39,746 2287 6 ... 425 18 10 NATIVES. 1 ' ' ' f-i '" Rate •§ » Rate Rate Total Total Per Cent of §5 Per Cent of PerMilleof Strength Admission Admission £ S Deaths Deaths YEARS. of the of Cholera, upon the -gD upon the upon the Army. Strength, ¦g'g Admissions. Strength. 1818 58,764 2496 4^cent. 664 26 1 0 mille. 1819 63,782 2684 4 734 27 11 1820 76,870 3178 4 758 24 10 1821 82,046 2527 3 830 33 10 Grand Total.. 281,462 10885 4 2986 27 10 





PART II. 

TOPOGRAPHICAL AND STATISTICAL 

REPORTS 

OF THE DISEASES MOST PREVALENT IN THE 

DIFFERENT STATIONS AND DIVISIONS 

or the 

ARMY UNDER THE MADRAS PRESIDENCY. 





REPORTS, &c. 

The object of the following Reports is to shew, in as condensed a form as possible, the several diseases which were prevalent, at different periods of the year, in each division of the army ; to give a sketch of the medical treatment required, and to exhibit the degree of mortality which prevailed during the period embraced by these statements. I have added some observations on the nature of the climate, and on the comparative effects of disease upon the constitutions of the Europeans and natives, of the same military class, subject to the same duties, and exposed to similar vicissitudes. 

That something of this kind may be highly beneficial to the public service, will be readily admitted by all who are acquainted with the medical practice of India; and that it has not been before attempted by those who have long had possession of the necessary documents, must be a matter of regret to medical officers arriving in the country, and who, being strangers to its climate, are in some measure 



252 

TOPOGRAPHICAL REPORTS 

ignorant of the peculiarities of its diseases, as observed in its different localities. This has induced me to contribute my individual efforts, however imperfect they may be found, to supply the deficiency. 

The occasional publication of Reports similar to those which I am now about to attempt, may lead the way to an investigation of diseases otherwise imperfectly known to the mass of the medical community ; and, by lightening the labour and extending the knowledge of the military surgeon, may become the means of preserving many valuable lives that might otherwise be lost to the service. It is not an unfrequent occurrence, that corps are suddenly ordered into countries wherein the medical officers can have had no previous experience, and where the prevailing diseases differ materially from those he may have been in the habit of treating. Having no experienced guide, therefore, to guard him against the causes of disease prevalent in the district he is about to visit, or to direct him in the treatment which has been found most successful in combating their effects, he must feel at a loss, till time and observation put him in possession of what recorded experience might have at once furnished him with. Such has 



253 

OF DISEASES OF INDIA. 

been my lot. I have often and painfully felt the difficulty of which I now complain, and had long since determined to remedy the inconvenience, if ever I could collect materials for the purpose, being well aware, that, by assisting the medical officer in the performance of his duties, I should benefit the public service, and promote the cause of humanity. 

The publication of the returns made by the Medical Board at Madras, though extremely defective in many points, has given me the opportunity I have so long desired, and from those returns I have formed these statements. 

The present Reports, though they may not, perhaps, be critically correct, will at least prepare the way for better information; and, until that is procured, they will serve to direct the attention of the regimental surgeon to the diseases he is likely to meet in the several countries belonging to the Madras Establishment, while they will enable the government to provide for the comfort of their troops, and thus, perhaps, to prevent many of the evils that exist at present. 

The period from 1815 to 1821, inclusive, having been that of the most active service 



254 

TOPOGRAPHICAL REPORTS 

which has occurred in India for many years past, has, therefore, been selected for these Reports, as it was the best calculated to try the constitution of the troops. During this time, the country was the seat of war, and the troops were obliged to make most harassing marches, and to perform the severest duties of an active warfare. They were exposed to epidemic cholera, which prevailed the greater part of this time, to the influence of seasons more than usually variable, to excessive heat, heavy monsoons, and sudden vicissitudes of weather. 

During this period too, the army traversed a space of country, from between the Bth and 9th, to the 25th degree of north latitude, and from the 75th to the 80th degree east longitude. 

It was my good fortune to be with the army during the whole of this time, as a regimental, a staff, and a superintending surgeon, successively; I had, therefore, such opportunities as fall to the lot of few, of collecting information, and I now offer the result of them with deference to the public, with a view of leading to farther investigation, and not with a feeling that they possess any other merit than that which a devoted zeal to forward the interests 



255 

OF DISEASES OF INDIA. 

of the public service, and the cause of humanity, can give them. 

I cannot but think, however, that if similar statements were made and followed up at the sister Presidencies, a mass of highly valuable information, regarding the climate and diseases of India, might be collected, which might be the means of establishing a system of medical practice upon some rational footing. That this is imperiously called for, must be at once admitted, when we consider that, extraordinary as it may seem, there is at the present moment as much diversity of opinion respecting the treatment of the diseases of India, as there was fifty years ago; and this is the more singular, as the diseases have not increased in number, and they are certainly not numerous. 

The various situations of importance which I have held in the service, have enabled me to enter upon a work of this kind with some confidence, having had the opportunity of personal observation, in every important station and district under the Madras Presidency ; and having had the direction of very large establishments, both European and native, and the superintendance of general hospitals, both in field and in garrison quarters. 



256 

GENERAL EXPLANATION 

OF THE SUBJOINED 

TABLES OF DISEASE. 

There is so great a difference between the number of actual admissions into hospital, and the number of cases in the accompanyingtables of disease, that some explanation appears to be necessary : I must, therefore, state, that in the tables published by the Medical Board of Madras, on which these statements are founded, the number remaining at the end of one month is added to the admissions of another, j. c. the sick who remain on the 31st of January are added to the admissions in February ; and this mode of calculation is carried on from month to month, and from year to year, through the whole period of six years. The number of cases, therefore, which will correspond with the total column of admissions is immensely increased, when compared with the actual number received into hospital. 



257 

OF DISEASES OF INDIA. 

I shall consider the total column of admissions, therefore, as nominal numbers, because it must appear manifest that, to add the remaining of the preceding to the admissions of succeeding months, although necessary in an hospital return to shew the number in hospital at all times, must prove a fallacious guide in giving the state of sickness of corps or stations for any given period : for instance, a man may be six months in hospital, which will give six remaining for one admission ; and suppose ten men should remain in hospital for six months, there will be, at the end of six months, sixty remaining for ten actual admissions ; hence the numbers increase far beyond the true rate of sickness. 

The number of diseases in the tables published by the Medical Board, being carried on in this way from the total column of remaining and admissions, renders it impossible to separate the list, so as to make it correspond with the number of real admissions into hospital. I have, however, » endeavoured to make a reduction from the nominal to the absolute number of sick admitted ; and although the calculation may not bring the two to exact correctness, it will come nearer the mark, and shew more distinctly the real proportion of disease as it affects the European and native 

s 



258 

TOPOGRAPHICAL REPORTS 

constitution, than if the calculation had not been made. 

There are many other inaccuracies in the Medical Board's returns, probably from the carelessness of transcribers, but which I have no means of correcting, though they must, of necessity, prevent the possibility of these statements corresponding precisely in all their parts ; to make this matter, therefore, clear, I affix the Medical Board's returns for one year, which will explain in what manner the patients remaining of the preceding, and those admitted of the succeeding month, are blended together. The following statement will shew the numbers in the total column of admissions to be nearly double the number of men actually admitted into hospital. 

In the returns of the Medical Board, the 

total of the column of admissions into hospital, for the Presidency Division alone for six years, 

consists of 

Total. 

Europeans ... 38070 1 aoaaq 

Natives 30599 3 

when, in point of fact, admissions were 

the real 

Europeans 17912 J oqgaq Natives 18737 5 

Natives 

Difference 32020 



259 

OF DISEASES OF IXDIA. 

In computing the number of sick under medical treatment in January, 1815, the number admitted during that month is added to that remaining on the 31st December, 1814. I have, besides, added up the column of real admissions alone, which ought to give the exact number received into hospital for the period of six years. 



Table I. — Extract from the Medical Board's Returns for the Presidency Division, for the year 1815. Remained. Entered. Total. Dysentery. Fever. Ulcers * Venereal - dTsmIL Cured ' Dead> 2 I Remainin g- Strength. 1 £ \ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ For Jan. ... 220 247 223 394^ 443 641 99 23j 1 22 49: 176 76| 1 8 13 28 85 141 34 69i 67 101 220 229 383 8 7 3| 0 203 251 1685 6702 Feb. ... 194 162 194 199 388 361 81 llj 1 12 42 1 67 581 4 6 3 29 65 14 18 60 50 97 131 179 161 6 2 10 202 198 1205 4442 March 202 190 212 190 414 388 80 6 1 9i 38 71 64 6 3 5 34 65 15 12 78 60 101 154 216' 195 12 4 16 0 170 189 1167 4494 April 172 188 223 152 395 340 60 3i 3 9> 45 57 46j 4 7 4 28 49 89 55 141 12 103 147 231 186 6 4 10 157 150 1158 4611 May... 154 148 253 171 407 319 64 4 4 8; 60 39! 36J 2 7 5 28 25 19 17 96| 1b 93 144 204 143 8 10 0 195 175 1160 4692 June 201 191 263 267 464 458 75 15 4 7 58 86 44j 2 7 7 32 71 25 22 96 100 123 148 244 203 7 11 12 212 242 1456 5953 July ... 205 223j 330 328 535 551 93 20 5 13 68 139 49] 1 15 9 31 64 31 271 93 99 150 179 259 288 8 3 0 0 268 260 1796 5467 August 165 257 243 294 408 551 87 27 4 11 59 144 36| 1 44 22 23 75 28 40 1 37 90 90 141 175 281 18 8 13 1 202 261 1432 5888 Sept.... 195 211 221 233 416 444 87 15 4 161 47 116 46j 1 62 13 16 58 34 23 33 72 87 130 160 220! 7 2 0 0 249 222 1339 4575 Oct. ... 249 222 318 354 567 576 133 1120 21 54 210 59| 3 83 23 25 51 33 26 52 85 108 146 239 345 11 4 0 0 317 227 1520 5545 N0v.... 314 225 246 293 560 518 115 19 31 17 54 147 58 1 85 8 28 66 32 25 71 76 86 159 233 293 16 5 0 0 311 220 1531 5746 Dec... 309 218 291 274 600 492 129 22 18 15 70 135 75 1 76 9 35-43 27 29; 71 65 99 173 255 295 13 3 7 0 325 194 1523 5778 G. Total... 2580 2490 3017 J3149 5597 5639 1103 17696 130 644 1387 64727 403 121 335 717 361 328 770 751 1238 1872 2624 2993 120 44 42 13 2811 2589 16972 63893 Remained 1 Jan. ... 220 247 3237 3396 N. B. In this Return it will be found that the remaining of one month is added to the admissions of another, which makes the total column of admissions considerably more than the actual number received. In the above Table, I have added up the column of admissions alone, to which I have added the number in the hospital on the Ist January, 1815 ; which total amount for one year is 3237 Europeans, and 3396 Natives, instead of 5597 and 5639. See the gineral explanation of the Tables at p. 256. 



Table II. — Abstract of Diseases of the Presidency Division of the Army, for a period of Six Years, from 1815 to 1820, inclusive. Bit list "^ b 131 3 It || 11 «|^ h N The European Force never exceeded 1486. ll"l lf S | h|-s 15- l 3 33 11 II £1-3 |0 |S 1-s I The Natives never exceeded 5130. 17912 18737 36649 16402 17550 33952 266 50 316 738 551 1289 1092 Europeans cured 91 per cent. Natives ditto 93 per cent. NonunalAdmissions. K «£fiS£2^ Actual Admissions. C ?£^ P ** | | S g * " DISEASES. _I " <N Euro- Euro- Euro- bo • bo •*•••** *> *> peans. Natives. Total. peans. Natives. Total. peans. Natives. Total. Europeans. Natives. \ a t> G * bb • §b • Bo • bb • Fever 4892 7240 12132 2593 2810 5403 2299 4430 6729 30^ per cent. 16^ per cent. - ->l '3 :| -| | Hepatitis 4156 95 4251 2203 37 2240 1953 58 201125^ $ *»e^ '' Dysentery... 7586 843 8429 4021 328 4349 3565 515 4080 47-^ 1^ 1° W £ a § a "| S "S J Diarrhoea 1314 1078 2392 697 419 1116 617 659 1276 8^ 2^ «i«i"og'«g^S3Q£ Venereal 4298 3356 7654 2278 1303 3581 2020 2053 4073 2&ft 7^ p 'S «j WQ w « Cholera 129 424 553 69 165 234 60 259 319 &o 2 o E* 8 f* 8 ft' 5 § ° a Ulcers 1906 1874 3780 1011 728 1739 895 1146 2041 11 -f^ 4-f 5 Rheumatism.. 2832 3647 6479 1501 1416 2917 1331 2231 3562 17^ 8^ I g 1 |° §*« | t o"'| > Ophthalmia.. 2349 534 2883 1245 208 1453 1104 326 1430 14f 5 1£ |S'S g"S g.s acs a| o-i Other Diseases 8608 11508 20116; 4563 4466 9029 4045 7042 11087 '534 264 & £ <£ £ 2^ S^ SHS H 2^ Grand Total.. 38070 30599 68669J 20181 11880 32061 17889 18719 36608 £ £ jfi p h P 



262 

REPORT OF DISEASES IN THE 

PRESIDENCY DIVISION. 

Station. — The Presidency Division includes Madras, St. Thome, and St. Thomas's Mount. 

Climate. — The general state of climate in the Carnatic, is dry and hot. • The range of thermometer is, at Madras, from 75° to 92° ; but sometimes, in the months of May and June, it ranges as high as 98°, or 105°. I consider February, March, and April, while the southerly winds blow, the most disagreeable period of the year. The hot, windy season of May, June, and July, is generally the most healthy ; and I think the greatest degree of sickness prevails about the commencement of the monsoon, or from August to November. Sometimes, the sickness is greatest in December and January, and at other times in June and July ; but in general, the most sickly period is that which I have already noticed. 

Prevailing Diseases. — The more prevalent and destructive maladies are fever, 



263 

MADRAS PRESIDENCY DIVISION. 

dysentery, and liver disease ; but I consider fever to be the most prevalent in this division, and dysentery, which forms a large share of the diseases, to depend more upon circumstances than the climate, such as irregular living, hard drinking, and, probably, exposure to the sun. 

The great number of liver cases that are found on the returns of the Presidency arise, I conceive, from the practice that exists, of sending chronic cases of liver complaint from out-stations to the Presidency General Hospital. 

This circumstance appears .to me to account satisfactorily for the cases of liver disease being twenty-five per cent at the Presidency, while they are only fifteen and thirteen in the centre and southern division, and from five to twenty-two per cent in all other divisions of the army. Hepatitis should not, therefore, be considered as a disease altogether resulting from the climate of the stations of this division. 

Symptoms and Treatment of prevailing Diseases. —As the climate and diseases which prevail in the Presidency, Centre, and 



264 

REPORT OF DISEASES IN THE 

Southern Divisions are precisely alike, I shall treat them generally under the head of Diseases of the Carnatic ; and, for the sake of distinction, I shall call the Carnatic all that space of country situated between the western hills, and the coast which extends north and south, from Cape Comorin to the Kisthna River. 

The form of fever which prevails in the Carnatic, nearly resembles that called by Cullen synocha — continued or inflammatory fever. It shews itself with full, hard pulse, hot skin, suffused eyes, headach, and general pains ; but it is easily checked, if immediately attacked, and boldly treated. I attach great importance to this fever being attacked without loss of time, as its progress may then be stopped in a few hours. 

Bleeding, either general or local, according to circumstances, is a safe remedy. It will always be attended with benefit, and should never be lost sight of. The apprehension that blood is not rapidly made in India, is, I fear, a fatal error. Such an opinion never can be maintained upon any just principle, though it is a prejudice that exists in a great degree, even amongst those whose field for practice 



265 

MADRAS PRESIDENCY DIVISION. 

has been considerable. Such fears being sometimes inculcated by men high in office and in power, they cannot fail to paralyse the hands of medical men on their first arrival in India, and they serve to lay the foundation of erroneous notions of practice. The sooner therefore, the prejudice is pointed out the better, as candid and enlightened observation cannot fail of leading to the adoption of juster views. 

Bleeding I consider, in the first instance, as the sheet-anchor in the treatment of this disease, which, when followed up by active purgation, will, probably, in a few days remove it. But purgatives should, nevertheless, be prescribed as long as there is any degree of excitement in the system, and as long as the dejections are viscid, of a dark colour, or otherwise morbid. When the alvine secretions are altered, and become healthy, an alterative course of medicine may then be had recourse to with the best effects. 

I have known an emetic check the fever at once, particularly amongst the natives : and if it be given in an early stage, I have not a doubt that, amongst them, the tartar 



266 

REPORT OF DISEASES IN THE 

emetic mixture will rapidly effect a cure ; but it must be taken in the early period of the fever ; because, when the disease is neglected, even for a day or two, which is often the case, it becomes of a very different character, and assumes a form not unlike typhus, which is indicated by black, foul tongue, stupor, low, languid pulse, &c. &c, without possessing, however, the specific character of contagious typhus, as described by Cullen. We have no disease of this latter kind in India, but as the symptoms, with this exception, partake very much of the typhoid character, I am at a loss to know what else they should be called. 

The tartar emetic mixture consists merely of six grains of tartrate of antimony, dissolved in a quart of water. A wine-glassful taken every ten or fifteen minutes will prove an emetic ; if taken every two or three hours, it will be purgative ; and every five or six hours, sudorific. In either of these ways it may be given, according to circumstances. I have scarcely ever known it fail to check the progress of the fever in natives, when had recourse to, as an emetic and purgative, soon after the attack of the disease, and continued for two or three days as a sudorific. 



267 

MADRAS PRESIDENCY DIVISION. 

Amongst the natives, this disease should be narrowly watched, and quickly opposed ; because, if it be not at once removed, the patient is either liable to linger under chronic visceral obstructions, which will render him unfit for service, or he may at once fall a sacrifice to its violence. It is worthy of remark, that while the fevers prevalent in the northern Circars, Mysore, and all other stations above the Ghauts, terminate in obstinate intermittents, this form of fever, which is that most prevalent in the Carnatic, if neglected or badly treated, terminates invariably, as far as my experience serves me, in those symptoms which mark the last stage of typhus. When the case proves fatal, the patient dies in low muttering delirium. 

Proportion of Sick. — Natives do not appear to suffer in the same proportion here as in some other divisions, though they do so in a greater degree than in the Centre, Southern, or Northern Divisions, the Ceded Districts, or Travancore. The cures are equal to those in Travancore, less than those in the Centre and Southern Divisions and Ceded Districts ; and the deaths are the same as in the Centre and Southern Divisions, Ceded Districts, and Nagpore. 



268 

REPORTS OF DISEASES, &C. 

It appears that the proportion of sickness and deaths amongst the European troops is greater in this division than in any other in the army, while the cures are equal to those in the Northern Division, Ceded Districts, Hydrabad, and Nagpore ; but less than those in the other divisions, with the exception of the field force. 

This may be accounted for, with regard to Europeans, by the circumstance, that all bad or lingering cases are sent from out-stations of the army to the Presidency General Hospital. It will appear, however, from the returns of the Centre and Southern divisions, that there are more Europeans admitted into hospital in the Carnatic, generally, than in the northern Circars, or at any of the ' stations above the Ghauts, with the exception of Nagpore. 

Number of Troops composing each Division and Station. — At Madras, there are generally one European regiment, a company of artillery, and about four battalions of native infantry. At the Mount, there are two battalions of European artillery ; and although St. Thome" is not a military station, yet it is a place to which sick officers usually come from out-stations. 



Table 111. — Abstract of Diseases of the Southern Division of the Army, for a period of Sir Years, from 1815 to 1820, inclusive. II oi lloj git |-S H ji 181 8 |j -aBS. It ti «l | The European Force never exceeded 1222. |!.sf |pf ||.a p || |-£ 111 1 111 1 |p 2^ |3 |i | The Natives never exceeded 7877. 11036 23172 34208 10475 22042 32517 81 23 401 325 957 1282 305 nS^ toto '. '. '. '. '. '. '. '. ' '.It per cent No Si£U Admission, 1 § S S " DISEASES. Eur(> j Euro _ | Euro . _ « peans. Natives. Total. peans. Natives. Total, j peans. Natives. Total. Europeans. Natives. C«"C"S)-§o*S) # Sd' Fever 2913 12119 15032 1120 5313 6433J 1893 6806 8699 28f 5 per cent. 18 percent. . o'^.% I 'I :|: | :|: | : Hepatitis.... 1392 50 1442 498 22 520 894 28 922 13ft .... j, .... Br^|S«BB r^|S«8 IS^S': Dysentery 3496 1256 4752 1224 541 1765] 2272 715 2987 33ft .... lft .... £ " £ ~ g g a J t* 818 1 *J Diarrhoea.... 525 1207 1732 184 620 804 341 687 1028 5 .... lft .... « So,S o, S^ Ss « §Q JjQ § Venereal 2834 3399 6233 792 1462 2254 1842 1937 3779 27ft sft -3 * £ * '£ £ £ Cholera 414 1287 1701 145 554 699 269 733 1002 4 lft o 2 o gog o » o g, 0 S ° ft Ulcers 735 5301 6036 258 2300 2558 477 3001 3478 7ft .... 7ft .... & S £ 3 § g g «- g g § „- Rheumatism.. 993 4412 5405 351 1908 2259 642 2504 3146 9ft .... 6ft .... Ophthalmia.. 757 673 1430 265 290 555 492 383 875 7ft .... 1 .... g "S 2 "35 g, 3 eL^ & S §,« Other Diseases 4171 10835 15006 1460 4660 6120 2711 6175 8886 40ft .... 16ft .... <« &<« £ 2w2 w 2« S« S 55 Grand Total.. 18230 40539 58769 6297 17670 23967 11833 22969 34802 gg gg p g g 



270 

REPORTS OF DISEASES IN THE 

SOUTHERN DIVISION. 

Stations. — The principal stations in the Southern Division, are Trichinopoly, Dindigul, and Pallamcottah. The minor stations are Tanjore, Madura, Ramnad, Negapatam, Coimbatore, Sankerrydroog, and Salem. There are also some other small posts near the Western Ghauts, and towards Cape Comorin. 

Climate. — The weather is similar to that which is experienced in the Centre and Presidency Divisions. January and February are healthy months. I consider the most sickly period to be March and August. 

Prevailing Diseases. — Fever and dysentery, as in other divisions of the Carnatic, are the most prevalent and destructive diseases ; but dysentery I consider as depending very much upon irregular habits : for instance, drinking spirituous liquors, exposure to the sun, and to the night air. 

Proportion of Sick. — The proportion of sickness in this Division amongst Europeans, 



271 

SOUTHERN DIVISION. 

is less than it is in either the Presidency or Centre Division, the cures being greater, and the deaths fewer. Amongst the native troops, the admissions, cures, and deaths are equal. 

Number of Troops composing Division and Station. — At Trichinopoly, during the period of this statement, there were a European regiment, three or four battalions of native infantry, and half a company of artillery ; at Dindigul, a native battalion ; at Pallamcottah, a native battalion ; and at the minor stations, three, four, or five companies of natives, detached from the principal stations. 



Tab ie IV.— Abstract of Diseases of the Centre Division of the Army, for a period of Six Years, from 1815 to 1820, inclusive. If If |ll "I 3f£ §<| |! &£ || || |ll ti !| &t I The European Force never exceeded 2007. |3"k £<"x 3T 3 = v I" |"s" s 5§ |§ H§-g £p |£ 3.x « The Natives never exceeded 7551. 16649 20341 36990 15245 19420 34665 581 234 815 621 568 1189 321 Eur0 P eans cured 92 per cent. . Natives cured 95 per cent. Nominal Admissions. Actual Admissions. 1 S I 5 S " DISEASES. i" ~ — — * ™ Euro- Euro- Europeans. Natives. Total. peans. Natives. Total. peans. Natives. Total. Europeans. Natives. c? « c 5c 5 ' «« " »' « * .13 c •« bo ' bo • be • bo * £ ever f .: 4050 8946 12996 1620 3400 5020 2430 5546 7976 27^ per cent. 16fc per cent. I : 1 "• | : I Hepatitis .... 2254 100 2354: 902 38 940 1352 62 1414 15$ . . . .o2 . %%%'%£ ~ $'•" ~Z '• Dysentery .. 5605 1251 6856 2242 481 2723 3363 775 4138 384^ 2? oWg^gg^l^gJ: Diarrhoea.... 497 861 1358] 199 328 527 298 533 831 12 '.'..'. it '.'.'.'. §%"3 g | " - g Venereal.... 2832 2332 5164 1133 887 2020 1699 1445 3144 19A 4? | 1 1| X S Q S Cholera .... 724 1115 1839 290 424 714 434 691 1125 4^ '.'..[ 2"" «S E*S e"^ » *S s'S „- *S S Ulcers...... 2027 2006 4033| 811 763 1574 1216 1243 2459 13* . 3f J =|^lg§g^c§c £ r Rheumatism 1613 3360 4973] 646 1277 1923 967 2083 3050 log ' 6f " " $M I •-§ SL"B | Ophthalmia.. 1505 579 2084? 602 221 823 903 358 1261 io| .... 1 .";;.' g'S §•§ g,| § | g| Other Diseases 6597 12828 19425 2639 4875 7514 3958 7953 11911 44f .... 23f ... w g g 2 W g fc g"W g"Z Grand Total.. I 27704 33378 61082 11084 12694 23778 16620 20689 37309 | g ~ £ * g 6 £ * 



273 

CENTRE DIVISION. 

CENTRE DIVISION. 

Stations. — The principal stations in the Centre Division are Vellore, Arcot, Wallajahbad, Poonamallee, Nellore, and Ongole. — The minor stations, Chingleput and Chittoor, where two or three companies of natives are usually stationed. 

Climate. — The most sickly periods of the year are the same as in the Presidency Division, and the thermometer ranges alike in all these ; but I think the heat is more felt and more distressing than at the Presidency. I know not whether this feeling of a higher temperature arises from want of the sea breeze, which prevails at Madras, or from a want of the better kind of buildings, which there afford more protection from the sun. Ido not, however, think any difference of temperature whatever is experienced at any of these stations by those exposed to the open sun, which is the case with the European soldiery. 

Prevailing Diseases. — Fever and dysentery are the most prevailing diseases in this 

T 



274 

REPORT OF DISEASES IN THE 

division, more particularly the latter, which is one of the most destructive amongst the troops in India, and particularly so in the European constitution. It prevails in a greater or less degree in every division of the army where European troops are stationed, but it is much more prevalent in this.* I shall, therefore, treat of it amongst those of the Carnatic, where there are generally more European troops than in either of the other divisions of the army. 

*• This disease may be divided under two varieties, viz. acute and erythematic. 

The first is acutely inflammatory, and if not checked by bold and decided practice, will very soon terminate fatally, or lay the foundation for that chronic stage of dysentery 

* But more so in the Carnatic, Hydrabad, and Ceded 

Districts : viz 

Carnatic 37 per cent. Hydrabad 36 per cent. Ceded Districts . .30 per cent. Field Force 24 per cent. Nagpore 24 per cent. Mysore 22 per cent. Travancore 16 per cent. Northern Division 12 per cent. 



275 

CENTRE DIVISION. 

which disables so many men, and is the cause of the great number of discharges annually from the service. 

The cause of dysentery amongst the soldiery in India, arises unquestionably more from irregularity and diet than climate ; though I admit that, in some instances, the latter is intimately connected with functional derangement of the liver. The sick-list of a regiment is always increased after pay-day, and dysentery is the general disease. The symptoms are well marked : severe pain in the bowels ; straining; full, strong pulse; foul, loaded tongue; motions very frequent, and small in quantity; sometimes consisting of morbid, offensive matter, but generally, in the first instance, of mucus with blood ; and it is not unusual to see very considerable discharges of blood from the bowels. Upon examining the abdomen, a very considerable fulness and tension, with great tenderness, are observed, and particularly at the caput caecum and siginoid flexure of the colon ; the tongue is sometimes white and dry, and the pulse quick, small, and irritable, with general febrile excitement. 

The causes of dysentery being very nearly the same as those of fever and hepatitis, the 



276 

REPORT OF DISEASES IN THE 

treatment must be in many respects, also, the same. Dysentery is a disease that requires great decision in the treatment, because much is to be done in a few hours ; and if it be not got under control in that time, the patient is either lost, or the basis of a broken constitution is laid. 

The indications of cure are to diminish general vascular excitement, to remove acrid and accumulated matter from the bowels, to allay the irritation of these viscera, and to restore them to healthy action. As this disease is entirely confined to the large intestine from the caecum to the rectum, attention should be directed to that particular seat ; and therefore emollient injections should be used frequently, to clear away any matter that may lodge in it. Leeches should be applied in the course of the colon, particularly when there is tenderness of the abdomen. Calomel, in 9j. doses, will always allay irritation of the stomach, and should therefore be given, and be followed up by oily purgatives. In full plethoric subjects, general bleeding will always be attended with benefit ; but in those who have been long in India, I have found leeches answer better, because they diminish action without destroying power, and any quantity of blood may be taken by them. 



CENTRE DIVISION. 

277 

So long as pain continues, leeches may be applied, and, till the dejections become natural and healthy, the calomel in gj. doses should be given every night, and oily or saline purgatives every morning. Injections in the course of the day will be administered with benefit, and after the pain is removed, if a general soreness continue, a large blister over the whole belly will always be useful. 

In the treatment of dysentery, as well as of all other acute diseases in India, the first twelve or twenty hours are of the first consequence, in order to make an impression upon the constitution, and to bring the disease under control, before serious structural derangement has supervened : when these objects are accomplished, the future treatment may be regulated according to circumstances. 

Local pains may be removed by the occasional application of leeches. Tenesmus, which depends upon inflammation or irritation of the rectum, will be alleviated by anodyne enenias, not exceeding Jiss. or which will generally remain in the bowel ; but calomel, as a purgative, with oily and sometimes saline laxatives, must be prescribed till the secretions assume a healthy appearance, when tonic laxatives 



278 

REPORT OF DISEASES IN THE 

may be given, and continued till the cure is completed. 

The erythematic form of dysentery is much more obscure, and consequently more dangerous ; the symptoms are a dull, deep-seated pain in the bowels, sufficient to distress a patient, but not so severe as to excite alarm ; there is no external pain at all, the pulse is not materially altered, neither is there any increased febrile action; the tongue is excited, and the alvine discharges are exceedingly morbid and acrid. This disease is confined to the mucous membrane of the colon, and consists of a less acute form of inflammation of this membrane. If not treated successfully, it runs at once into ulceration throughout the whole intestine. Full doses of calomel, with such other purgatives as act upon the mucous glands, are required here, and should be continued without intermission, till healthy action is produced. Leeches, and blisters over the abdomen, are always attended with benefit; and the purgative I have found to answer best in combination with calomel, is castor oil and the following bitter aperient mixture,* quickened occasionally by 

* Infus. Gentian, Infus. Sennae 

Tinct. Cardam. |ij. 



279 

CENTRE DIVISION. 

two or three drachms of sulphate of magnesia. The object of the present work is to direct attention to the diseases of India, and not to treat these subjects at large, as it is my intention, at a very early period, to bring them more fully before the Profession. 

Proportion of Sick. — The proportion of sickness and deaths amongst the European troops in this division is infinitely less than at the Presidency, but greater than in any other, Nagpore and Hydrabad excepted ; while the proportion of sickness and deaths amongst Natives, is less than in any division of the army, except Travancore, and that of cures greater. 

Number of Troops composing each Division and Station. — During the period of this statement, there are at Vellore one European regiment, and two or three battalions of Native infantry ; at Arcot, which is a cavalry station, a regiment of European dragoons, and one or two regiments of Native cavalry; at Wallajahbad, two or three battalions of Native infantry; and at Poonamallee, which is the depdt for his Majesty's regiments, between four and five hundred 



280 

REPORT OF DISEASES, &C. 

Europeans, who had been discharged from the regiments, to be sent as invalids or pensioners to England, or they were recruits arrived from England. 



Table V. — Abstract of Diseases of the NORTHERN DIVISION of the Army, for a period of Six Years, from 1815 to 1820, inclusive. __^ •* Us! |1 o| |1| || || 31 || || _|| |-| g_ 111 1 | The European Force never exceeded 1449. ||5s ||-S| £.§.2 8 3 g| _5* || 3| £1* eg |S 3a I The Natives never exceeded 10472. 5210 36904 42114 4762 33561 38323 20 1212 1232 353 1735 2088 471 Europeans cured 91 per cent. I JNatives cured 90 per cent. Nominal Admissions. MnSTi^SfiSL.. Actual Admissions. Per Centege of Diseases upon the g g g § ® ™ Nominal Admissions. Effective Strength. *O »o i »O «5 DISEASES. >O Euro- Euro- Euro- . . . peans. Natives. Total. peans. Natives. Total. peans. Natives. Total. Europeans. Natives. B*fi•m' §) • m • " • Fever 1454 29911 31365 698 13760 14458 756 16151 16907 13^ per cent. 29 percent. o'^.Z | :|: | :|: | '• | : Hepatitis 570 97 667 274 45 319 296 52 348| 5^ 0^ SsSj^_« '• n'• Dysentery .. 1396 1404 2804 672 648 1320 724 760 1484 12^ 1^ fafc2^o§fiJ!§l_ : Diarrhoea.... 132 1204 1336 64 554 618 68 650 718 1^ .... 1^ .... _. § „ S "» _ISg£_ g 5 f Venereal 2558 6033 8591 1228 2776 4004 1330 3257 4587 23^ 5^ ~ £ 6 £ i« &,io (-h H « Cholera .... 87 889 976 42 409 451 45 480 525 00 T | .... Oft .... *S E^S s"*© g g," g"? « Ulcers 922 3715 4637 443 1709 2152 479 2006 2485 8^ 3^ ¦£ 8 $ » o g g _T § g g j Rheumatism.. 792 5863 6655 381 2697 3078 411 3166 3577 7^ 5^ g> J* c 3c 3 !T't2 gr'-g > S §•'„ > Ophthalmia . . 103 602 710 52 277 329 56 325 381 1 0^ £ 'S3 £ "35 §< 5 g/S £, 5 el's Other Diseases 2062 18515 20577 990 8517 9507 1072 9998 11070 194 17-& MM g w g2H g^ £W g^ Grand Total.. 10081 68237 78318 4844 31392 36236 5237 368451 42082 £ £ £ g -s js ~ 



282 

REPORT OF DISEASES IN THE 

NORTHERN DIVISION. 

Stations. — «The Northern Division takes in a tract of country which extends from Kistnah river south, to Ganjam north on the coast. The principal stations are Masulipatam, Ellore, Samulcottah, Vizianagrum, Vizagapatam, Chicacole, and Berhampore. The minor stations are Guntoor, Beswarah, Noozeed, Condapilly, Rajahpoor, Rajahmundry, Kimmedy, and Aska. 

Climate. — From November till March the climate is extremely pleasant. The thermometer ranges from 72° in the morning, to 88° and 90° in the day. The wind, during the latter part of November, the whole of December, January, February, and during the early part of March, is from the north and north-east. From the end of March till May, the wind becomes southerly, accompanied with clouds of dust. In May and June the land winds, which are strong from the westward, generally commence, and continue, with more or less 



283 

NORTHERN DIVISION. 

force, till the commencement of the monsoon in September and October. 

Prevailing Diseases. — The diseases peculiar to this division are fever and dysentery, which prevail most between the months of August and November. December, January, February, and March, are generally very healthy; but in April and May, during the period of the southerly winds, which are attended by immense clouds of dust, slight ephemeral fevers are common ; but they are of little moment, being easily removed by a few purgatives, or by an emetic. June and July are generally healthy, but sometimes, from exposure to the sun and hot winds, coup de soleil occurs. 

With the exception of Masulipatam and El lore, most of the other stations in this division are situated in the vicinity of mountains and thick jungle ; and sometimes near marshy ground, where fever occasionally prevails to a great extent, and where it is extremely formidable. 

Symptoms and Treatment of these Diseases. — The type of fever is bilious remittent, and very similar to what is found at 



284 

REPORT OF DISEASES IN THE 

Seringapatam and Wynad, in the western hills which divide Mysore from Malabar. It sometimes takes the quotidian and double tertian form, with some of the marked symptoms of typhus, such as stupor, black, dry tongue, and great debility, but without its characteristic contagion. The name which this fever generally goes by in India is jungle, or hill fever. When it is not completely eradicated, it always terminates in intermittents, which come on at particular periods of the moon. It has been known to continue for years to afflict those who became its subjects, whether they remained in India, or returned to Europe. 

This fever belongs exclusively to that part of the division where there are most hills and jungles. At Masulipatam and Ellore, both situate in an open country and sandy soil, the fever is by no means so formidable, though of similar character, and it is easily removed by purgatives. During my residence at Masulipatam, from 1808 to 1810, there was not a single casualty, or death from disease depending upon the climate, amongst the European residents, and not more than five amongst the details of European troops, namely, the artillery company, which consisted of about one hundred men. In the European regiment, 



285 

NORTHERN DIVISION. 

from hard drinking and exposure, the deaths were greater, of course, than amongst the residents ; but even amongst them there were few deaths. This is confirmed by the present statement, which will shew the deaths to be only six per cent, amongst Europeans, in six years. 

The treatment of this fever in its worst form, is similar to the treatment of the fever occurring at Seringapatam ; but what I wish to enforce — and I cannot impress the necessity of it too strongly —is active and decided treatment in the early stage. A copious depletion at the commencement, aided by emetics and purgatives, according to circumstances, may save much trouble, and preserve many lives ; while a timid, temporising treatment will lay the foundation for a broken constitution, and a protracted sickness. As the object of these statements, however, is not to enter at large into the detail of treatment, I shall confine myself merely to the indications of cure in such fevers, leaving the medical practitioner to exercise his own judgment regarding the choice and extent of his remedies, and their application to particular cases and circumstances. One thing, however, I must observe : if the disease be not checked in a few hours, the patient is 



286 

REPORT OF DISEASES, &C. 

either lost, or that state of disease supervenes, which renders him, for ever afterwards, a plague to himself, and a burthen to the service. 

Proportion of Sick. — The proportion of sickness in this division, amongst Europeans, is less than in any division of the army. The cures are equal to those in the Presidency, Hydrabad, Nagpore, and Ceded Districts. The deaths are proportionately less than in these divisions, but greater than in any other. The proportion of sickness amongst the natives is greater than in the Carnatic and Travancore, but less than those in all other divisions. Cures less, except in the field force ; and deaths equal to those in Hydrabad and Nagpore. 

Number of Troops composing each Division and Station. —At Masulipatam there were generally a European regiment of infantry, a company of artillery, and two or three native battalions. At the other principal stations, one or two battalions of native infantry ; and at the minor stations, two, three, or five companies of native detachments, from the principal stations. 



Table VI.— Abstract of Diseases of the Travancore Subsidiary Force of the Army, for a period of Six Years, from 1815 to 1820, inclusive. UU O 3 |11 O 3 -si | i-g |H 111 1 i| |g S^i 8-d S-o q« 1 The European Force never exceeded 1130 H-flflij-Bf d*f -3 i| «2 2g I! g|a S| i! aj I The Natives never exceeded 2566 6651 5973 12624 6415 5585 12000 17 139 156 164 228 392 76 Europeans Cured . . . . . . . . . .96 pej cent. Nomina! Admissions: NoSSft^ Actual Adnussion, »* O^^Mgj-upoa the I g § | § 9* - <O M DISEASES. *-• Euro- Euro- Euro- • peans. Natives. Total. peans. Natives. Total. peans. Natives. Total. Europeans. Natives. Ccc'bo-bJD-fcß-^ ¦ Fever 598 1527 2125 252 688 940 346 839 1185 5^ per cent. 6^ per cent. :|: | ;f :|: | '¦ Hepatitis 2385 53 2438 1002 24 1026 1383 29 1412 22-^ £ g 3 g^ „ % . m - w : Dysentery 1811 169 1980 761 77 838 1050 92 1142 16& .... | .... r o S g g g j= g "S J Diarrhcea 180 94 274 1 76 43 119! 104 51 155 lft ft SoS o « o S« Sq Sn § Venereal 2231 1359 3590 938 612 1550 1293 747 2040 20^ 5^ fl * <S ! ** "^ «- S ?£ J Cholera 220 209 429 93 95 188 127 114 241 2 ft "S S'S E*S a* 8 S.° S 2 p. Ulcers 448 2540 2988 189 1143 1332 259 1397 1656 4ft 10ft £ S £ g g g gog o g J B - Ophthalmia.. 531 1195 1726 224 538 762 307 657 964 4ft 5 c' x c 3c 3 o 4^ .> | §* g > Rheumatism.. 437 115 552 184 62 246 253 53 306 4 ft 2 '» 232 '3 eLS cu^ g«J §*"•§ Other Diseases 2651 3482 6133 1114 1567 2681, 1537 1915 3452 24ft 144 £ 8> 2w2 w £ fe w . Grand Total.. 11492 10743 22235 4833 4849 9682 6659 5894 12555 £ g g g 



288 

REPORT OF DISEASES IN THE 

TRAVANCORE DIVISION. 

Station. — This division includes Quilon, Anjengo, Cochin, and Alleppee, on the Malabar coast. 

Climate. — The soil of this district is sandy, the weather very hot, and liable to heavy falls of rain between June and December. After a shower of rain the sun generally comes out, and produces a disagreeable, moist, heat ; but under cover, the climate is cool and very agreeable. 

Prevailing Diseases, Symptoms, and Treatment. — The prevailing diseases of this climate are clearly those of the liver and dysentery, in the European constitution ; while ulcers and fever appear to be the diseases to which natives are most liable. 

Fever, in this country, is nearly equal both in the European and native constitution ; its character is similar to that of the one which prevails in the Carnatic, and the plan of cure 



289 

TRAVANCORE DIVISION. 

is of course the same in both, (see the Presidency Division) ; but liver diseases and dysentery are those which require more particularly to be looked after. The latter frequently depends upon the former : this dependence ought to be recollected, when we enter upon the treatment of dysentery. 

The symptoms of liver disease are sometimes very insidious, and not easily detected, particularly when the parenchymatous texture of the viscus is the part affected. The strictest attention, therefore, as well as professional tact, is, perhaps, more required in the management of this, than in any other disease in India ; and although it is a difficult task to point out clearly what close observation and pathological research can best disclose, yet there are some symptoms that may be depended upon, and those I shall endeavour to state briefly. 

Acute pain is present only when the coats of the liver are the seat of disease. This symptom is generally attended with febrile heat, full, quick pulse, and white, excited tongue ; which are often the only signs that indicate inflammation of the internal structure of the organ. To remove these derangements, 

v 



290 

REPORT OF DISEASES IN THE 

general and local bleeding, with smart purgatives, should be resorted to without loss of time, and repeated until they are completely subdued ; after which an alterative course of mercury, for a fortnight or three weeks, will effect a cure. This acute form of hepatitis usually affects healthy, robust men, on their first arrival in India, and frequently terminates rapidly in abscess, if not checked at its commencement : the practice, therefore, should be energetic, in order to subdue inflammatory action at the onset of the disease. 

The chronic stage of diseased liver generally occurs amongst old, debilitated Europeans, and amongst those who have suffered from the first or inflammatory stage, and who, having been discharged from medical treatment, had returned to their duty before this organ had recovered a healthy action. This practice of premature dismission from treatment is, I am sorry to say, too common throughout India. It is in the highest degree injurious to the constitution, and it cannot fail to load the pension and invalid establishments. This is the stage of liver disease in which mercurial action is required ; and this action is always most beneficially produced when mercurial remedies are exhibited as alteratives and laxatives. 



TRAVANCORE DIVISION. 

291 

To affect the mouth has frequently been considered the great desideratum ; but as there are many subjects in which ptyalism cannot be produced, to follow up a course of medicine for months, in order to attain an object that may be quite impossible, cannot fail of proving highly injurious to the constitution. Hence the danger and mischief of an indiscriminate use of mercury in the diseases of India. 

It has been asserted, and I believe it is generally believed, that when the mouth is once affected the patient is safe. I shall not here argue the converse of this position, but I can assert, that I have seen men die under the influence of mercury, and in a high state of salivation. lam aware that this is contending against the bulk of opinion in India, and I feel the responsibility I bring upon myself, in making the assertion ; but I do it with a view to correct what appears to me to be a very erroneous inference in practice 

—an inference which has done, I imagine, nearly as much mischief as the disease which the practice is intended to remedy. 

I do not intend to say that mercury is not a most valuable medicine, and, indeed, one 



292 

REPORT OF DISEASES IN THE 

from which more is to be expected than from any other, perhaps, in the materia medica; but it may be, and it certainly is, upon many occasions, carried far beyond the bounds of judicious administration. 

When the mouth becomes affected, it is very satisfactory, because it shews that the absorbents and the glandular system are not in a state of torpor; but to continue the use of it for months, or even till ptyalism is produced, I must contend, is most injurious to the constitution. I look to its effects upon the alvine secretions, and when I see them changed, and find healthy discharges produced, I consider that the use of mercury is beneficial. When I find my patient's strength and spirits recover, I feel quite satisfied, whether the mouth be affected or not. 

There is another state of diseased liver, which is more common and more obscure than either of those I have already noticed, and this is a congestive state, in which the portal system partakes very largely of the derangement, and which is accompanied by a loaded state of the gall-bladder, and by obstruction in its ducts. 



293 

TRAVANCORE DIVISION. 

The symptoms of this state are oppression and weight at the prsecordia and pit of the stomach, without pain, but with a sense of fulness and distension about the chest, as if there was not room to breath, or as if there was a heavy weight in the neighbourhood of the stomach. This is a form of diseased liver that would require more to be said upon it than the limits of this Report will admit, and therefore I mention it merely to direct particular attention to it, with a view to its farther investigation. 

Alterative mercurials, with aloetic purgatives, are, in this particular form of disease, of great importance : these, with local bleeding by leeches, warm poulticing over the whole epigastric region, and frequent friction with stimulating liniments, is the practice I have used with advantage. At a future period, I shall enter more fully into this subject, and shall advance such facts connected with its pathology as I have been able to collect. At present, I confine myself to the limits which I have prescribed for these Reports. 

As dysentery may probably depend upon the disease of the liver, and as we find in India that it actually does so depend in many cases, 



294 

REPORT OF DISEASES, &C. 

the removal of the latter disorder will frequently prevent the former. I shall not here enteF into the general treatment of dysentery, farther than to say, that the bowels ought to be kept in a lax state, and that leeches may be used with advantage to remove pain in the abdomen. Tenesmus, in general, depends upon irritation in the lower part of the rectum. When it occurs, small anodyne injections may be given with the best effects, or leeches may be applied along the sacrum. 

Proportion of Sick,&c. — The proportion of European sick in this division, is less than at any other division of the army, with the exception of the Northern Division and Field Force. The cures are greater, and deaths fewer, than in any other division. There is likewise less sickness amongst the native troops. The cures among them are equal to those of any other division, and the deaths fewer. 

The force is composed of one European regiment, two companies of artillery, and three battalions of native infantry. 



Table VII. — Abstract of Diseases of the Mysore Division of the Army, for a period of Six Years, from 1815 to 1820, inclusive. U o| || s | 75.1 J |s ll l| ll U 3 Is* h N o| I The European Force never exceeded 3088 P-Sf ||.Ss ||.2 2= | a 3* g| || £|* Sq |S ga I The Natives never exceeded 10533 17228 42004 59232 16225 38526 54751 313 753 1066 536 1692 2228 1187 E uro P ean s cured 94 per cent. natives ditto 91 per cent. „.,,,.. I Remains of the . , , . - . «• ' Per Centaee of Diseases upon the j2 S S S w Nominal Admissions. Nominal Admissions. Actual Admissions. Effective Strength. o S ° , n ti DISEASES. _, _, "* Euro- Euro- Euro- iuo • be • ¦" • ti • •« *^ peans. Natives. Total. peans. Natives. Total. peans. Natives. Total. Europeans. Natives. C«C •tJD'bJD'bb'bc* Fever 6438 31889 38327 2833 12118 14951 3605 19771 23376 26^ per cent. 46|j per cent. "^ o - > '§ :1 I I :|: | • Hepatitis 4359 207 4566 1918 79 1997 2441 128 2569 18^ 0^ g|g^^S :»^» • Dysentery... 5374 1721 7095 2365 654 3019 3009 1067 4076 22^ 2& I|uls^1 |u1s^ Diarrhoea 129 1353 1482 57 515 572 72 838 910 0^ 1^ « S3 <v | "§ g •- «Q« Q «Q« Q « Venereal 3858 4328 8186 1698 1745 3443 2160 2583 4743 16 5& "= * "= £ w " " Cholera 346 1833 2179 153 697 850 193 1136 1329 1& 2^ o g'S E« |° SSo< o S ° a Ulcers 1767 4831 6598 778 836 1614 989 3995 4984 7^ 8^ ¦sS^ggg§arg«g o r Rheumatism.. 1194 4367 5561 526 1660 2186 668 2707 3375 4^ 5^ g5g 5 g> J^B §-'5 .> "| o g .> Ophthalmia.. 904 794 1698 398 302 700 506 492 998 3^ 1 £ 'S Si '3 & S S-J (a. g-J Other Diseases 6192 16568 22760 2725 6296 9021 3467 10272 13739 25^ 22^ 2 121 2 I §« « I. « B« « & « Grand Total.. 30561 67891 98452 13451 24902 38353 17110 42989 60099 g H H H 



296 

REPORT OF DISEASES IN THE 

MYSORE DIVISION. 

Stations. — The Mysore Division includes Bangalore, Seringapatam, Chittledroog, Nundydroog, Ryacottah, and Mysore. — Malabar and Kanara, which include Cannanore, Tellicherry, Mangalore, and Manantoddy in Wynad, are also included in this division. 

Climate. — Bangalore, Ryacottah, and Nundydroog, are generally considered healthy stations, but Seringapatam, Serah, and Chittledroog, have always been considered the reverse, particularly to Europeans. For several years, however, no Europeans have been stationed either at Seringapatam or Chittledroog, and, consequently, that excessive degree of sickness which usually prevailed when they were made European stations, is not apparent. 

The great Mysore Valley is bounded by the Western Ghauts and Table Land of Mysore, and extends between the 76° and 77° of east longitude, till it is terminated by the mountains near the source of the Cauvery. 



297 

MYSORE DIVISION. 

Seringapatam, Serah, and Chittledroog, are situated in this valley, and are exposed to the influence of both the N.E. and S.W. monsoons. Rainy weather, therefore, prevails from the beginning of May till the month of December. 

The latter part of December, the whole of January, February, March, and April, are dry and sultry ; yet, in the mornings and evenings, a cold, bleak N. E. wind prevails between December and January ; and the hottest season is from the latter period to the commencement of the S.W. monsoon, in May. Heavy dews and a damp atmosphere prevail more or less throughout the year, but more particularly in the months of January, February, March, and April ; and the difference of temperature between the night and day is extreme. This is the most sickly period of the year. 

Prevailing Diseases.— To the generally moist state of the climate, and to the sudden transitions from heat to cold, may be attributed the prevailing diseases in this division ; which vicissitudes, according to concurring circumstances, produce fever, dysentery, or liver diseases. Fever and dysentery, however, exist in the largest proportion, and although fever is eight, and dysentery four per cent more than liver complaints, yet I am disposed to believe 



298 

REPORT OF DISEASES IN THE 

that a deranged state of the functions of the liver is to be found in almost every case of this fever ; but in whatever degree the liver may be affected in the first instance, there cannot be a question that it becomes seriously disordered in the progress of the disease, for alterations of this viscus, and indeed of other viscera, are invariably found on examination after death. 

The types of the prevailing fever are remittent, quotidian, or double tertian ; and when either of those forms of fever is improperly treated, and yet does not terminate fatally, it generally leaves a periodical quartan or tertian, which remains for years upon the subjects once affected by it, and whose accessions are generally influenced by the changes of the moon. 

Cannanore, and stations on the Malabar coast, are extremely healthy ; but at Manantoddy, in Wynad, situate in jungles and hills, fever prevails to a great degree, and is of the same nature with that which I have described as endemic at Seringapatam. 

The following information, received from the late Lieutenant-colonel Lambton, is applicable alike to Mysore, Wynad, and the Malabar 



299 

MYSORE DIVISION. 

coast, and is not out of place here. He says, " After the conclusion of the western monsoon, the weather on the Malabar coast is delightful and serene, and the atmosphere perfectly clear, till about the middle of January, when the weather becomes hot. Exhalations from the ravines are the consequence, and they increase so fast, that about the middle of February the whole of the low country is covered with a thick vapour, which, from being checked in its ascent by the cold regions at the summit of those mountains, continues to collect till the south-west winds set in. This immense reservoir of vapour is then condensed, and passes over the Mysore country, in those heavy rains which mark the western monsoon. 

" Previous, however, to the setting in of the rains, the evaporation above the Ghauts is very considerable, and the whole of that valley in which Seringapatam is situated is covered with a vapour, almost as heavy as that which hangs over Kanara and Malabar. This is generally in the months of February and March, and in the beginning of April, till the thunder-showers clear it away." 

Symptoms and Treatment of Prevailing Diseases. —In the treatment of 



300 

REPORT OF DISEASES IN THE 

this fever, — which partakes, at the commencement, of strong inflammatory action, with hard, full pulse, white, excited tongue, &c. &c. — bleeding, either local or general, or perhaps both, according to circumstances, is of the greatest importance in checking its activity. This remedy, with the addition of purgatives, may be said to comprise the whole treatment ; but the efficiency of both depends upon the boldness with which they are resorted to, in the first stage of the disease. 

Bark has been much used, and I have heard, with the best effects ; but from what I have seen of this fever, I would earnestly recommend, that the inflammatory and congestive symptoms should be removed, and the alvine secretions restored to a healthy state, before the bark be had recourse to. When the fever takes the regular intermittent form, it is wonderful how bark checks the paroxysm ; but even in this case purgatives are requisite between the expected monthly paroxysms, but it is unnecessary to continue the bark more than a few days, before and after these accessions. 

When a fever of this kind comes under my care, I always ascertain the time of its accession, 



301 

MYSORE DIVISION. 

which is generally governed by particular periods of the moon ; I prescribe, the purging practice till a day before the expected paroxysm, then I throw in the bark, and continue it either till the accession of fever, or for two or three days after the period has passed over, when purgatives are again commenced with, and followed up till the paroxysm is again expected. 

With this practice, I have seldom known these accessions of fever return more than two or three times ; but a course of alteratives and laxatives ought to be always continued for three or four months afterwards, until the alvine secretions are restored to a healthy condition, when I consider the cure effected. 

In treating the remittent form of this fever in its early stage, I have scarcely ever, myself, had it run into the intermittent form ; and, as the above practice has always proved useful in such cases as have come under my care, after they became intermittent, I am led to believe that more attention is too generally paid by some practitioners, to check the accession of fever by means of bark, than to remove congestive symptoms, or to restore healthy action and secretions to the intestinal canal ; —in 



302 

REPORT OF DISEASES IN THE 

other words, the symptoms are treated, and the disease neglected. 

I consider that, when bark is exhibited in this fever before the inflammatory derangements, which frequently exist in the large abdominal viscera, are subdued, and before the disordered secretions are removed by appropriate treatment, that the disease will frequently terminate in chronic obstructions of these viscera, and the other disorders contingent on such states. 

Proportion of Sick. — The proportion of European sick in this division is less than in any other division of the army, with the exception of Travancore, the Field Force, and Northern Division. The cures are greater than those of any, except Travancore and the Southern Division, and the deaths are fewer, except those of Travancore, and they are equal to those of the Field Force and Southern Division. 

The proportion of sickness amongst natives is greater than that of any other division of the army, except Nagpoor. The cures equal to those of Hydrabad, and less than those of the Carnatic. Deaths are the same as in Hydrabad, 



303 

MYSORE DIVISION. 

Northern Division, and the Field Force ; but greater than in the Carnatic, Ceded Districts, and Nagpoor. 

Troops of this Division. — Bangalore, the principal station, has generally a European regiment of dragoons, a European regiment of infantry, a company of artillery, and four or five battalions of natives. Nundydroog, Ryacottah, Chittledroog, and Seringapatam, have only one battalion of natives at each station. Cannanore has one European regiment, and two native battalions. Mangalore, one native battalion ; and at all the other minor stations, there are two or three companies of natives : making in all, one European regiment of dragoons, two European regiments of infantry, one company of artillery, and twelve battalions of native infantry. 



Table VIII. — Abstract of Diseases of the Ceded Districts, for a period of Six Years, from 1815 to 1820, inclusive. |.|ol >So| ;g£^ IS I'g 5^ §g |S ggjSj !¦§ |tj o| I The European Force never exceeded 1526 |l s I ||515 1 £|.a 2| -S* 8S |1 £S* 2q ¦ 1| gjj I The Natives never exceeded 5380 9085 16886 25971 8272 15973 24245 334 438 772 313 449 762 192 Europeans cured 91 per cent. Natives ditto , 94 per cent. Nomina. Admissions. No STd^ns. Actual Admission, ** C-ggongj-upo n the | g § § •* - DISEASES. | _ <N Euro- Euro- Euro- be • fen ' -^ • *• .' 4 » -M peans. Natives. Total. peans. Natives. Total. peans. Natives. Total. Europeans. Natives. C m C ' bo • S) • So • So '¦ Fever 2794 9110 11904 1258 4191 5449 1536 4919 6455 24 percent. 20^ per cent. "^ o* ~.> II:1 :| ¦ Hepatitis 2486 58 2544 1119 27 1146 1367 31 1398 21^ 0-^ % M %3 % Z % '¦ £ a £ '¦ Dysentery 3526 847 4373 1587 390 1977 1939 457 2396 30^ 1^ £^£^flSfi-"3«"£j Diarrhoea 32 356 388 15 164 179 17 192 209 0^ 0^ „ §3 « S * fc "s «Q« Q £ Q § Venereal 2783 4229 7012 1033 1946 2979 1750 2283 4038 27^ 9^ "S^-S^ia* 11 * 0"^^"0 "^^" Cholera 220 571 791 99 263 362 121 308 429 1^ 1^ o S'S £ o » o g,° « o g, Ulcers 773 2803 3576 348 1290 1638 425 1513 1938 6& 6^ 5 if S g g g Jo g g «" Rheumatism.. 484 4152 4636 218 2010 2228 266 2142 2408 4^ && c « c c gl Ophthalmia.. 521 424 945 235 196 431 286 228 514 4-& 0^ £ "S Jj *X g,S E^te g- s g- tS Other Diseases 2711 8747 11458 1220 4024 5244 1491 4723 6214 234 19A MM S MSM S2 W 2^^^ Grand Total.. 16330 31297 47267 7132 14501 21633 9198 16796 25994 g g fg g g 



305 

CEDED DISTRICTS. 

CEDED DISTRICTS. 

Stations. — This division includes Bellary, Gooty, Kurnool, on the Tomboodra and Cuddapah. 

Climate. — The vicissitudes of the atmosphere in this division are very great and sudden, as in Mysore. In January the thermometer ranges from 60° to 98°, and there are heavy fogs and winds varying all round the compass. In February the thermometer is from 60° to 98°, and the weather more sultry and oppressive : the winds are south-east and south-west. In March the thermometer is from 68° to 105° and 106° : strong south-west winds prevail, with close, sultry, and very oppressive weather, and sudden transitions from heat to cold, and sultry nights. During April, the thermometer is from 78° to 110° ; and the weather cloudy and oppressive, with strong winds from the south-west, some showers, and clouds of 

x 



306 

REPORT OF DISEASES IN THE 

dust. This weather continues till November, when the thermometer falls, and ranges from 66° to 88°, with heavy dews at night, and frequent showers. The interval from March to December is the most sickly period; and 1816, 1817, and 1818, were the most sickly years. 

Prevailing Diseases. — Fever and dysentery, as in other divisions, are the principal diseases amongst the European troops ; but hepatitis bears a greater proportion to these diseases in this division than in any other, with the exception of the Presidency, Mysore, and Travancore : and 1 am disposed to consider this disease as the endemic of the climate. At Kurnool, where I was stationed with a European regiment for eight months, the liver was found diseased in almost every case of death that happened during that period, from whatever disease this fatal termination occurred. lam induced, therefore, to consider European constitutions as peculiarly liable to diseased liver in this climate, while fever may be considered the endemic in regard to the native constitution. 

Venereal sores and common ulcers underwent an extraordinary change in this climate, 



307 

CEDED DISTRICTS. 

they became purple, with ragged edges, bled profusely, and resisted every application. The protracted convalescence, likewise, observed at this station, was extremely singular; the debility that remained after the disease was removed, was striking, and could not be satisfactorily accounted for, either by the nature of the disease, or the remedies required for its cure. 

Symptoms and Treatment of Diseases — -The diseases that prevail amongst Europeans in this division of the army, require as active a treatment as those in any other division — bleeding, local and general, aided by purging, being the chief remedies. I was much struck at the rapidity with which disease ran its course in this division, and that the liver should be found diseased in almost every instance. Various circumstances, however, appeared to me to be the cause of this ; and amongst them I must not omit to mention the unqualified use of narcotic drugs and intoxicating liquors — not such as Europeans usually drink, but such as are more destructive to life than the climate is, with all its vicissitudes. 

The liquors to which I allude are made 



308 

REPORT OF DISEASES IN THE 

with fermented toddy, mixed with opium and stramonium, to which chunam or lime is occasionally added to promote fermentation. This is a very common and destructive beverage, used by European soldiers at all times, and in every part of the Madras territories ; and as, I believe, it partakes of the character of spirits, it is subject to a tax, which produces a considerable revenue to the government.* 

In camps there is another kind of liquor, which is notorious from its pernicious effects : this is called bogee. It is made from a grain called ragee, mixed with water, and fermented. When new, it is a very agreeable 

* I am well aware, however, that the government do all in their power to prevent European soldiers procuring these liquors, and that their orders on this subject are most strict ; but although Europeans cannot themselves purchase a drop of it, the cook-boys, who are natives, can always procure it ; and therefore the soldier can command it at any time, in defiance of all orders. So long, therefore, as this spirit is made, so long the soldier will drink it, whatever orders are given : and it becomes a question, whether the population of the country should be deprived of liquors to which they have been long habituated, on account of advantages to the European force, who only indulge in it to excess, and who form so very small a proportion of the population. 



CEDED DISTRICTS. 

309 

acid drink ; the natives use it in common, and I believe it is innocent ; but as it is prepared for European soldiers, I have reason to know that it is a most intoxicating and destructive liquor. 

The ingredients usually added are opium, bhang, stramonium, and a kind of cake made in squares, like chocolate, called majum cakes. These are composed of bhang, stramonium, nux vomica, jaggery (a species of sugar), and milk. A small quantity of this in a cup of bogee will produce an effect, not exactly of intoxication, but a peculiar madness and pleasurable sensation, (as the soldiers have often told me,) that renders them careless of every thing but pleasure. 

If they were to stop here, it is probable no great injury would arise, but they drink to excess, and the consequence is, that in the course, perhaps, of one night, a man lays himself up with a fatal dysentery, and a day or two terminates his existence. This, and indeed all those drinks, are sold at a very small price : three or four fanams, or, in English money, one shilling, would purchase enough to make eight or ten men drunk, and, consequently, 



310 

REPORT OF DISEASES IN THE 

to occasion the loss frequently of half the number. 

These pernicious liquors are to be found in all camps, and almost at every station in the army ; but at this station, (Kurnool,) where there was a very extensive bazar belonging to the camp, and another attached to the town and fort, I had an opportunity of making myself acquainted with the whole matter ; and although I had no power to check or control the sale of these articles, I was at least prepared for the treatment of the diseases produced by them ; and, as congestive states of the venous system, and active inflammations, were the consequences, local and general bleeding, with the exhibition of active purgatives, were indispensably requisite ; but, I lament to say that my means of practice were at this time very limited, from the following circumstances : — 

First, the difficulty of procuring leeches. As there were none to be got in the neighbourhood of the Tomboodra river, I was under the necessity of sending for them from Gooty, Cuddapah, and Cummum; for I must be allowed to remark, that the lancet will not always answer the purpose of leeches ; and, although 



311 

CEDED DISTRICTS. 

I had men constantly posting to bring supplies, I found it impossible to procure them in the quantities required. 

Second, deficiency of medicine. There had, for some time, been a deficiency of medicine with the army ; and, on the present occasion, the medical stores of this division were completely empty, and neither calomel, jalap, nor the purging salts, were to be procured. 

I had no purgative but oil, which, although a valuable medicine, is not suited to all the acute diseases of India, in their various stages. I mention this deficiency, with a view merely of directing attention to the matter ; because the most active treatment is required in the diseases of the climate, which run rapidly through their course, and, if not checked at the commencement, they terminate, in a very short time, either in ulceration in the bowels, or abscess in the liver. 

I regret to say, that I lost more men while the regiment was in this division, than I had ever done before at any other station. 

Proportion of Sick. — The proportion of European sick in this division is greater than 



312 

REPORT OF DISEASES IN THE 

in that of Mysore, Northern Division, and Travancore, but less than in all others. The number of cures is equal to the Presidency, Northern, Nagpoor, and Hydrabad Divisions ; and the deaths fewer than in those divisions. 

Sickness amongst the natives exceeds that amongst the Northern, Southern, Centre, and Travancore Divisions, but is less than in all others : the cures less than in the Centre and Southern Division, but greater than in all others ; and deaths equal to what they are in those divisions, including the Presidency and Nagpore. 

It is singular how infinitely more Europeans are disposed to liver disease and dysentery than the natives ; — liver disease, in the former, being 21^, and in the latter only -^ per cent ; and dysentery, in the European, being 30 T 4^, and in the natives only 1-^ per cent. Ulcers appear to be the only disease the Europeans and natives are nearly equally liable to in this division. 

Number of Troops, &c. —At Bellary there was generally a European regiment of infantry, a company of artillery, and three battalions of natives. At Kurnool, during 1816 



313 

CEDED DISTRICTS. 

and 1817, there were, a European regiment, a company of artillery, and two battalions of native infantry; one battalion of native infantry at Gooty, and another at Cuddapah. 



Table IX.— Abstract of Diseases of the Field Forces of the Army, for a period of Six Years, from 1815 to 1820, inclusive. Hll |||| |p || || || U || 3|| t6 || || | The European Force never exceeded 2428 51"*5 c'"le '"l H^* 151 5 3d 3-S § | 3| £§* 2q Jq 3.a3 .a I The Natives never exceeded 8412 8825 25848 34673 7798 22647 30445 376 1332 1708 369 1050 1419 1101 Europeans cured 88 per cent. :=== —— _____________ _____ JNatives cured 87 per cent. Nominal Admissions. NoSSSMSS-. Actual Admissions. *« C^goMM-jj^ n the g | g g « "^ .^ 00 CO DISEASES. " ~ ~ CO Euro- Euro- Euro- fe . . — peans. Natives. Total. peans. Natives. Total. peans. Natives. Total. Europeans. Natives. B <" C • go • §j • &> ' ™ * ever 2526 18849 21375 910 7729 8639 1616 11120 12736 18ft per cent. 32^ per cent. ~o « >| -| •§ -| : Hepatitis .... 909 91 1000 328 38 336 581 53 634 6^ .... 0^ .... « 3 § t* g « % '• « - : Dysentery .. 3389 2107 5496 1221 864 2085 2168 1243 3411 24-^ .... 34 .... £^ C 2^c§aJ'li r § : Diarrhoea .... 79 751 830 29 408 437 50 343 393 Oft . . . . 1 .... v 55 » | a S n ft 1 Venereal 2644 4037 6681 952 1656 2608 1692 2381 4073 19ft 7 ¦S* IS*««f1 S*««fi { « "£»£.£ Cholera 571 1428 1999 206 586 792 365 842 1207 4ft 2ft 'S b"S E "S f p, ° S* ° S. Ulcers 653 2826 3479 236 1159 1395 417 1667 2084 4ft .... 4% .... 3 2 £ S § g § „- g g § „- Rheumatism- 613 2458 3071 221 1008 1229 392 1450 1842 4ft 4ft g> L* g* "g g*S > '-g §"'¦= Ophthalmia.. 173 422 595 63 174 237 110 248 358 lft .... Oft .... £ » 2| §,? &l E. 5 g,S Other Diseases 2241 10635 12876 807 4361 5168 1434 6274 7708 16ft 18A « «t« « gW 2^ gW gZ Grand Total.. 13798 43604 57402 4973 17983 22956 8825 25621 34446 § 3^^^^"^^" 



315 

FIELD FORCES. 

FIELD FORCES. 

The Field Force was composed of all troops employed on field service from 1815 to 1820, namely, — ¦ the army of reserve on the Tomboodra in 1815; the force under Colonel Marriott, at Kurnool, in 1815 to 1816; Brigadier-General Pritzler and Colonel Thomas Munro's force in the Dooab, in 1817 ; and the first and third division of the army of the Deckan, in 1817 and 1818; the field force under General Pritzler in the Dooab, in 1818, 1819, and 1820, as well as various corps and detachments not included in any division return made during this period of six years. 

The Dooab and southern Mahratta country is, in all respects, like the Ceded Districts, and the troops which served there from 1815 to 1820, were liable to the diseases peculiar to that climate. The treatment is the same. (See Ceded Districts.) 

That part of Wig Jield force called the first and third division of the army of the Deckan, 



316 

REPORT OF DISEASES IN THE 

under the immediate command of his Excellency Lieut. -General Sir Thomas Hislop, Bart. and G.C.8., and with which army I had the honour to serve as superintending surgeon, was assembled at Hurdah, near the Nurbuddah, in October 1817. The troops, whilst marching to this point, during the months of August, September, and October, suffered dreadfully from the excessive heavy monsoon, which set in that year, and fevers were very general. In November^ however, the weather became fine, and the troops healthy. By the end of November, the army were formed for active service, and crossed the Nurbuddah river on the Ist of December. They proceeded without interruption towards the Vindiah mountains, where they arrived on the 6th, and ascended the high table land of Malwah, on the 7th of December, at Onchode. 

The space of country between the river and these mountains has a rich soil, but which is much neglected, from the circumstance of its belonging to that predatory class of men called Pindarics. This district is covered with low and loose jungle ; and there is very little of it cultivated, except near the villages, which are all extremely neat and clean. It is evident that it is capable of great improvement, the 



317 

FIELD FORCES. 

soil being very rich, and remarkably well watered . 

The troops became particularly healthy on ascending the high table land of Malwah, where the climate was delightfully pleasant, and they continued so during the period they served in that country. From December till February, the mornings and nights were excessively cold, the temperature was sometimes as low as 30 degrees of Fahrenheit's thermometer, and ice in our wash-basin was by no means unfrequent. During the day, the thermometer seldom rose above 80°; but I am told it is as hot here as in any other part of India during the land-wind season, of which, however, I cannot judge from personal observation, having left that country in February ; but if I were to form an opinion from the general appearance of the inhabitants, and the comfort of their villages, I should certainly consider them not only a healthy but a happy race. They are strong and robust, clean in their persons, and extremely well clothed. The face of the country is open, rather flat, and highly cultivated with wheat and poppies, which give it a beautiful appearance. 

Prevailing Diseases. — During seven months, from September to March, these divisions 



318 

REPORT OF DISEASES IN THE 

traversed a very extensive space of country; in the early part of this march they proceeded through unwholesome climates, and were exposed to heavy rains and great vicissitudes of weather, the thermometer ranging from 30° to 40° in the morning and evening, and from 94° to 106° in the day. Fever, of the bilious remittent form, was most general both in Europeans and natives. This disease prevailed most during October and November; but, by attention and decision in treating it, we never had, at any time, a heavy sick-list ; for, although the number of sick were considerable, they were very soon cured, and returned to their duty with very little loss by death. 

The symptoms of this fever were highly inflammatory, with excessive pain in, and determination to, the head, which, if neglected, soon terminated fatally. 

The treatment most successful in Europeans, was a copious bleeding at the commencement, which at once arrested and removed the most distressing symptom, headach. This, followed up by full doses of calomel, of from ten to twenty grains, and by the subsequent exhibition of active cathartics, effected a cure in a few 



319 

FIELD FORCES. 

days, without the aid of bark. I have, on various occasions, stated, that the success of treatment depends entirely upon the activity and boldness with which the disease is met in the early stage ; and this point is of so much importance, that it cannot be insisted upon too much, or repeated too often. 

The treatment amongst the native troops was more simple, but its salutary effects depended entirely upon its timely application. Six grains of tart, emetic, dissolved in a quart of water, of which a wine-glassful given every ten or fifteen minutes, till full vomiting was produced, at once relieved headach and thirst. The same dose, repeated every three hours during the following day, acted smartly upon the bowels, and kept a constant moisture on the skin. On the third, day the patient was generally free from fever, and recovered rapidly from that time ; but in some cases, where the tongue continued foul, three grains of emetic tartar were dissolved in a quart of water, of which a wine-glassful was given every four or five hours. This seldom failed in two or three days to remove the fever, without further aid. I have noticed this treatment, when speaking of the fever in the Carnatic ; and the success which I have invariably seen to follow it, induced 



320 

REPORT OF DISEASES IN THE 

me to recommend its general adoption throughout those divisions of the army which were under my superintendence. 

Some medical officers, however, preferred the usual and general mode of treatment, i. c. small doses of calomel and antimonial powder often repeated ; but, from the observations I have been able to make, I found that they had always a heavy sick-list, and had more men unfit for duty than those who treated them with the tartar emetic solution. One point, however, I cannot lay too much stress upon, which is, that not only the utility of this remedy, but the successful treatment of fever generally in India, depends entirely upon its early employment ; because, if fever be neglected at the commencement, the most obstinate remittents and intermittents follow, which, if their lives be preserved, disqualify the sufferers for the active duties of life in India. 

Proportion of Sick. — The proportion of sickness is less in this force than in any of the divisions, except the Northern Division. The cures ape less, and deaths equal to those in Mysore and Southern Division, but less than in any other, except Travancore. 



321 

FIELD FORCES. 

The sickness amongst natives is greater than in any other divisions, except Hydrabad, Nagpore, and Mysore ; cures fewer, and deaths equal to those in Hydrabad, Mysore, and Northern Division ; but it must be remembered, that many of the deaths in this force were occasioned by wounds. 



Table X. — Abstract of Diseases of the Hy drab ad Subsidiary Force, for a period of Six Years, from 1815 to 1820, inclusive. Iliillli 1-P i It it 5j || II all li Ii ol I The European Force never exceeded 2644 II I ! l| I H^\ SB II 1-S 11 If h|.2 |S |S I* | The Natives never exceeded 11641 19743 55425 75168 18054 50831 68885 497 2433 2930 1013 1714 2727 626 Europeans cured 91 per cent. I [Natives cured 91 per cent. Nominal Admissions. N< SSL Actual Admissions. ** CtB %B&%£Sg aa ** 1 g § 8 °° " DISEASES. : " ~ — — " S Euro- Euro- Europeans. Natives. Total. peans. Natives. Total. peans. Natives. Total. Europeans. Natives. _? o! _f I « •Sj • " •% '¦ J ever .; 7358 34439 41797 2922 14706 17628 4436 19733 24169 33^ per cent. 30^ per cent. \ !K! | : 1 :|: | :|: | '• Hepatitis .... 2296 253 2549 912 109 1021 1384 144 1528 104.. 0^ SSS'Sg*-*,^-^: Dysentery 7964 6717 14681 3162 2869 6031 4802 3848 8650 36^ 5£ r o W r o^ gg g '.-5 g-5 '. Diarrhoea.... 90 397 487 36 170 206 54 227 281 oj .V.'. Oft i.':: § * I "3 g U 111 1 g |g Venereal.... 5548 9932 15480 2203 4241 6444 3345 5691 9036 25A 8^ $ * 5 * *« S.M ° |j c- Qu Chole ra 386 2336 2722 154 1098 1252 232 1238 1470 1A 14 ' "g jfS go "'S g,° •'3 « U[ c ers 1283 7007 8290 510 2992 3502 773 4015 4788 5^ .... 6£ ..'.'. £ - * 8 § § g rf § § § M » Rheumatism.. 1648 10207 11855 655 4359 5014 993 5848 6841 7A 9 g» cf g- '¦§ §J S Ophthalmia.. 809 1776 2585 322 759 1081 487 1017 1504 3^ .... 14 ' 2582 '58 S "si 8, S £,"3 £, S g-t? Other Diseases 5364 23596 28960| 2130 10076 12206 3234 13520 16754 24^ 20£ «^^2HgZ2W£^ Grand Total . . 1 32746 96660 129406 13006 41379 34385 19740 55281 75021 c2c2_:_-_:__-*' 



323 

HYDRABAD SUBSIDIARY FORCE. 

HYDRABAD SUBSIDIARY FORCE. 

Stations. — This division of the army includes the cantonment of Secunderabad and Jaulnah. 

Climate. — The south-west monsoon commences generally at Hydrabad about the beginning of June, and continues, at intervals, till about the middle of October. During November and December the sky is frequently cloudy, the winds easterly, and sometimes, when the north-east monsoon is heavy, a considerable quantity of rain falls. From the beginning of January to the end of May, the sky is generally clear, and the weather dry. Dews are not unfrequent in January, and the early part of February; and, in some years, slight showers of rain fall during these months. The annual fall of rain is, I believe, estimated at thirty-two inches; but some years it does not amount to half that quantity. The mean temperature in the house during one year, as deduced from observations made at sun rise, two o'clock in the afternoon, and sun set, has been, in January 74£, February 76^, March 84, 



324 

REPORT OF DISEASES IN THE 

April 9lJ r , May 93, June 88, July 81, August 80L, September 79, October 80, November 76^, December 74-^, giving as an annual mean 81^. Had the observations been made earlier in the morning and later in the evening, and the thermometer placed in a more exposed situation, it is probable that the annual mean would have been at least two or three degrees lower. Indeed, the daily range, which more especially affects health, is very considerable during November, December, January, and February, amounting, in the shade, generally to about 20, and not unfrequently to 30. 

In 1817, the months of April, May, June, and July, were very close, sultry, and hot, with some thunder storms, and frequent showers, the thermometer ranging from 72 to 88, 98, 102, and 103; towards the end of July, the weather became damp, with drizzling rain, the thermometer ranging from 76 to 80, and the weather occasionally very hot. This unsettled state of the atmosphere continued till the end of August, when the monsoon set in, and continued till October and November. A great deal of rain fell during this period, and, at its close, the weather became delightful till March and April, when the hot season commenced . 



325 

HYDRABAD SUBSIDIARY FORCE. 

The most sickly period is, generally, during the wet and cold seasons, and the proportion of European deaths, which is greater in this Division than in any other, with the single exception of Madras, chiefly occurs at this period. 

Prevailing Diseases. — The climate of Jaulnah is colder than that of Hydrabad, and liable to greater variations of temperature ; the prevailing diseases, too, are the same at both stations ; but I have reason to think, that fevers are more frequent at Jaulnah than at Hydrabad. Remittent fever and dysentery are particularly prevalent at both these stations, especially about the end of the monsoon, during the cold weather, and are to be ascribed to great and sudden variations of temperature. 

This form of fever was particularly noticed amongst the European horse artillery-men, and considered to arise from their being lodged in a close, crowded, and uncomfortable barrack ; but, when the fever became prevalent, the men were removed to tents. This removal was always followed by an immediate decline of the disease., It was also remarked, that in some years the fever was attended with great determination to the head ; in other years, 



326 

REPORT OF DISEASES IN THE 

to the chest ; in others, to the liver ; and, in some cases, to the head and chest alternately. 

Fever and dysentery are the most prevalent and destructive diseases throughout the whole of this force ; but, as it is a well known fact, that few cases of diseased liver have ever recovered, if allowed to remain either at Secunderabad or Jaulnah, and as, from my own observation, I have found that, in most cases of examination after deaths from fever and dysentery, the liver was either in a high state of congestion or of suppuration, I am disposed to believe that disease of this organ generally accompanies both these disorders, and is far more prevalent than these returns would seem to indicate ; and I should almost be inclined to consider it as the endemic of the country in regard to the European constitution, while fever exclusively is the endemic of the natives. 

Symptoms and Treatment. — This fever comes on with excessive pain in the head, flushed face, suffused eyes, full, quick pulse, and loaded tongue. The treatment is similar to that which is recommended in. the diseases of Mysore, but as the liver is (as I have already observed) in every instance more or less diseased 



327 

HYDRABAD SUBSIDIARY FORCE. 

in this country, I would recommend particular attention to that organ. It is a singular circumstance that this fever, like that of Mysore, frequently terminates in the most obstinate intermittents, attended with considerable enlargement and hardness of the belly, which has been called physconia. But, from what I have myself seen, I should be disposed to think that all these cases of hard and swelled abdomen are the effects of visceral obstruction, arising from previous disease, frequent relapses, or imperfectly cured cases of fever, dysentery, or inflamed liver or spleen — a view of the subject deserving the particular attention of the medical practitioner.* 

Men in this state of enlarged abdomen seldom or never complain of pain, but they are disabled from performing the active duties of soldiers, and are consequently either invalided, pensioned, or discharged from the service. But as I consider this a matter of real importance to the service, both as it regards the effi- 

* I have been led to suppose that these obstructions are the result of the inappropriate use of bark, thrown in with the intention of checking fever, without a due attention to the removal of the visceral derangements accompanying it. 



328 

REPORT OF DISEASES IN THE 

ciency of the army, and the public expenditure, I shall bring it under consideration in my remarks on the general return for 1821. 

The proportion of European sickness in this force is less than in the Carnatic and Nagpore, but greater than in any of the other divisions : cures the same as at the Presidency, Northern Division, Ceded Districts, and Nagpore ; and deaths greater than in any other division, except the Presidency. 

The Native sickness is greater than in any division, except Nagpore ; the cures equal to those of Europeans, and equal to those at Mysore ;' and deaths the same as in Mysore, Northern Division, and Field Force. 

At Secunderabad there were, generally, during the period of this statement — an European regiment, a regiment of native cavalry, four or five battalions of native infantry, and a company of artillery. At Jaulnah an European regiment, one troop of horse artillery, two companies of artillery, two or three regiments of native cavalry, and four or five battalions of native infantry. 



HYDRABAD SUBSIDIARY FORCE. 329 

During the years 1817, 1818, and 1819, the bulk of the Hydrabad force was called the second division of the army of the Deckan, and of course actively employed on field service, in that space of country situated between the Godavery and Tapty rivers. 



Table XL— Abstract of Diseases of the Nagpore Subsidiary Force, during a period of Forty -eight Months, in the Years 1816, 1817, 1818, 1819, and 1820. I-Iji l||t ||aj || II II ll fl* p >| oj I The European Force never exceeded 684 S3 | £jTs: H l « = v |« 1-s II II SO 3« 3-S g The Natives never exceeded 7355 3586 27400 30986 3289 24670 27959 61 1141 1202 155 591 746 1079 Euro peans Cured 91 per cent. —__—__ __ ===========I==============^===:=====^— — — — — Natives ditto 90 per cent. Nominal Admissions. „ Remains of the Actual AdmiwJraw Per Centage of Diseases upon the *O C* m *obo b- c* Nominal Adnussions. Actual Admissions. Effective Strength. ¦ S ® DISEASES. ~ ~—¦— <N 00 Euro- Euro- Euro- <* peans. Natives. Total. peans. Natives. Total. peans. Natives. Total. Europeans. Natives. W> « : "S • "S • X ' ti • £ ever v: 2618 25259 27877 917 10337 11254 1701 14922 16623 82^ per cent. 514 per cent §^ " I il 111 1 !| 1 Hepatitis.... 205 41 246 72 17 89 133 24 1576*.... oj.. ' £ 5 g « 2 « 2 • 2- 2 '¦ Dysentery... 795 1385 2180 279 568 847 516 817 1333 241 2|2 | i^g^Sg" :|g| • Diarrhoea.... 96 1032 1128 34 424 458 62 608 670 3 ..'" 2? "" '* %^ S " S S " S 3 Wreal.... 496 3030 3526 214 1243 1457 282 1787 2069 13^ .. 6? """ -S^^S^SOSPS £ lolera 61 639 700 22 272 294 39 367 406 ll ... 1$ " " £ € i «*S »*S S ° « Ulcers...... 93 3700 3790 33 1517 1550| 60 2183 2243 2^ .... 7l7 l '.'.' Rheumatism.. 157 2427 2584 45 996 1041 1 112 1431 1542 5? 4? to Zc S.-2 111 1 g,-2 S Ophthalmia.. 39 402 441 14 165 179! 25 237 262 l| .'.'.'. 0% '.'.'.'. I '8 g -g £, Hi §-| S,| Other Diseases 825 8231 9056 289 3375 3664 536 4856 5392 25A .... 16? Grand Total.. 5385 46146 51531 1919 18914 20833 3466 27232 30693 g ~ g' 5 g | gg 6 g 6 



331 

NAGPORE SUBSIDIARY FORCE. 

NAGPORE SUBSIDIARY FORCE. 

Topography and Climate. — The town of Nagpoor lies on a flat plain, with occasional rising hills and black cotton soil, open on all sides, except the west, where there is a low range of tabular trap-hills. It was on the summit of these hills, during the year 1816-17, that Colonel Scott's brigade was cantoned when they suffered so severely from fever. The nearest formidable jungle to Nagpore is the Shawpore Forest, and that is about one hundred miles distant ; but the desert country near Nagpore is covered by a stinted, scattered brush- wood. 

From June to the end of October is rainy ; from November till March is cold and dry ; and from April till June is the hot season. The nights and mornings are generally cold throughout the year, and the variation of temperature is very great. From November to February the thermometer ranges between 50 



332 

REPORT OF DISEASES IN THE 

and 90, and sometimes considerably above 100. 

The general character of the whole country, from the river Godavery to the Nurbuddah, is alike ; and I should say there is a gradual ascent from the coast to the high lands of Malwah. The soil is black and stony, covered by scattered jungle, and in some parts by excessively high grass, which I have myself found by measurement to be twelve and fifteen feet high. These jungles and high grass, covering a very extensive space, through which troops are obliged to march, are generally in the morning covered with dew, and the evaporation from them makes the cold excessive ; it is always in the morning that the troops march — that period of the day when the causes of fever are generally most concentrated, and the system most susceptible of their influence : and I have no doubt that much disease is produced in these countries from this cause ; the necessity of attention to this fact, and, therefore, of warm clothing for the troops, particularly the natives, is manifest. 

Prevailing Diseases. — Amongst the European troops, fever and dysentery are the 



333 

NAGPORE SUBSIDIARY FORCE. 

most general and destructive diseases ; but I consider fever as the endemic of the climate, both in regard to Europeans and natives. lam of opinion that dysentery, in this district of country, depends more upon irregularity of living and drinking, than upon climate ; and the same observation holds good in regard to liver complaints. 

Character of the Endemic. — The fever at this station differs materially in its character at different periods of the year, and requires very different treatment. In the cold season, after the rains, although there is great pain in the head, as well as other inflammatory symptoms, it would appear that bleeding is not attended with the same advantages as it is under similar circumstances in all other parts of the country, or, indeed, in the same country during the hot season. 

In the rainy season, and for some time afterwards, the fever is characterised by complete and regular paroxysms, consisting of well-defined cold, hot, and sweating stages, with perfect intermissions. As the air becomes dry and colder, the paroxysms become less complete, till there is neither cold nor sweatingstages, and the fever is almost entirely reduced 



334 

REPORT OF DISEASES IN THE 

to the appearance of a simple febrile excitement of the vascular system, which comes on gradually at the usual hour, and advances slowly to its maximum, rarely very high, and then declines. 

Treatment. — The success of treatment in this fever during the rainy season, and for some time afterwards, appears to depend entirely upon bark being given in considerable quantity. I shall use the words of a highly respectable medical officer, Dr. John Wyllie, who served with the brigade at Nagpore the whole time they were there, from 1816 to 1821. 

He says, " Bark is the grand remedy, not throughout the cold season, but throughout the rainy season, and for some time afterwards ; without it there is no means of curing the fever from July and August till the end of October. 

" After the rains have ceased for some time, or towards the beginning of November, when the air has become dry and cold, and with the progress of the dry weather, I have invariably found the bark become less and less beneficial, and have experienced it to be more and more necessary to purge and give calomel. By the 



335 

NAGPORE SUBSIDIARY FORCE. 

end of January, or even before that time, I have found that the bark was of scarcely any use ; and that the cure was only to be effected by repeated purgatives, and the administration of calomel and antimonial powder ; and that the same remedies were efficient throughout the hot season; but that they again lost their power soon after the commencement of the rains." 

In further confirmation of this view of the subject, the following extract of a letter from a medical officer in charge of a regiment, dated Nagpore, November 1818, may not be uninteresting :—: — 

" The light company, only sixty- three strong, were detached amongst the hills for a few days in search of Appah Saib,* sixty-one of whom have returned with fever, and, generally speaking, very severe : eleven men died. The fever being accompanied with great determination of blood to, and severe pain in the head, I followed the bleeding system, assisted by purging and blistering ; but was much disappointed at finding all my efforts of no use, the paroxysm returning as violently as ever, 

* The Nagpore rajah. 



336 

REPORT OF DISEASES IN THE 

and the patient losing ground daily. In this dilemma I consulted a medical officer, who had been some time at Nagpore, and in charge of Europeans, who recommended the cinchona. Never having used this in the fevers we have had in Malwa, and having a kind of prejudice against it, I tried it, but with little hopes ; I soon, however, changed my opinion, and now feel more indebted to it than to any medicine in the materia medica. I am persuaded if I had not adopted this practice, I should have lost sixty or seventy men during the last month (October). I never saw any thing so decided in its effects. In the first place I give an emetic, then throw in the bark in doses of two or three drachms every hour, or oftener if necessary, which generally prevents a return of the paroxysm ; but, if it does return, it is comparatively slight, the bark is continued, and there is no return of fever ; but the headach continues, the tongue is foul and loaded, the dejections black or green ; and now for calomel and purgatives, which complete the cure. In the hot season the fever requires a very different treatment, and bleeding and purgatives is the only cure." 

There is certainly something singular and very unusual, both in the fever and the treatment. 



337 

NAGPORE SUBSIDIARY FORCE. 

I have given a longer extract from this letter than I otherwise would have done, because I have a full conviction that the author of the letter has detailed faithfully the facts as they stand, and I notice them with a view to promote further inquiry. 

It is probable that circumstances connected with the climate, might have induced a greater debility at the particular season to which the foregoing account especially relates, than during the hot weather ; and that tonics, such as bark, given in the large and frequent doses mentioned, may have become necessary to obviate that state of debility which prevented the beneficial action of the usual remedies. This supposition is partly confirmed by the fact, that after the administration of bark, calomel and other purgatives were found to possess their usual efficacy. 

From the reports, however, which I have seen of this fever, it would appear that, in the first stage, there is an almost total absence of derangement of the functions of the abdominal viscera; but, as the fever changes with the weather, these functions become more disturbed, and the characteristics of existing de- 

z 



338 

REPORT OF DISEASES IN THE 

rangement in the abdominal viscera more visible, viz. : costiveness, tympanitic state of the intestines, furred tongue — sometimes a smooth, glossy tongue, of a purplish red colour ; scanty, high-coloured urine ; a dirty, yellowish colour of the eye ; a dry, harsh, unperspiring state of the skin, and often a tendency to oedema. 

I have never treated this fever myself at Nagpore, though I have treated many cases that have been sent from that country to the general hospital at Madras ; in all of which cases I have observed great derangement of the visceral functions : and whether this is a primary or secondary affection, must be determined at some future period ; for my own part, I am disposed to think that attention to the state of the stomach, liver, and bowels, at the commencement of the malady, might prevent much of the disease and wretchedness that follow it. 

The proportion of European sickness in this force, is greater than in any other division, except the Presidency and Centre Divisions ; cures the same ; and deaths equal to those of the Centre Division, but more than those in any other, except the Presidency and Hydrabad. 



339 

NAGPORE SUBSIDIARY FORCE. 

The Native sickness is greater than in any division of the army ; cures equal to those of the Northern Division, but less than those in any other, except the Field Force ; and deaths the same as those of the Carnatic and Ceded Districts. 

The force at Nagpore and Ghanda in 1818, 1819, and 1820, consisted of a regiment of European infantry, two and a quarter companies of artillery, one troop of horse artillery, six battalions of native infantry, and a regiment of native cavalry. 



Table XII.— General Returns of the Sick of the Madras Army, for the Year 1821.* No. I.— Admissions into Hospitals, the effective strength being 9553 Europeans, and 82,046 Natives.— Total 91,599. Cholera. Fever. Liver. Dysentery. Diarrhoea. Rheumatism. Ulcers. Venereal. Ophthal- other Total mia. Diseases. Admitted. DIVISIONS OF THE ARMY. Euro . Nat . Euro . Native& Euro _ Euro Nafc &^ — ___, Centre'Sision " It ,S !2J! SS 5 ?47? 47 78 145 172 162 288 142 152 231 2722 72 47 50 881 1527 3566 3662 Sill 151 5 I 3 a 'I i !I! I ?! 1 s I 11 1 11 1 1 ? 11 1 111 1 Nagpore Subsidiary Force... 43 46 792 3744 65 8 289 122 82 169 77 266 55 466 266 423 18 83 356 1^36 2043 656S Sdd Z^tln^tl UH2 283 H69 93 2 27? 123 3 105 2 ' 265 4°4 ° 24 ' ' 64 26 « 9 » 992 22062 206 3^36 andSholapoor j — 316 1002 •• 3 ... 96 ... 30 ... 169 ... 158 ... 110 ... 28 ... 474 2336 357 2527 3442 18165 2110 95 2910 1338 4251371 754 3683 4170 645 24913749 393 706 3902 13645 17429 49399 * See the observations commencing at page 351, on the following ten Tables. 



Table XIII. — General Returns of the Sick of the Madras Army, for 1821. No. II. — Cures. d 111 "I i Other * DIVISIONS OF THE ARMY. Euro. Nat. Euro. Natives. Euro. Nat. Euro. Nat. Euro. Nat. Euro. Nat. Euro. Nat. Euro. Nat. Euro. Nat. Euro. Natives. Euro. Natives. Presidency 64 43 581 1001 454 4 648 64 108 171 140 254 130 141 202 236 45 51 764 1426 3136 3391 Centre Division 18 154 39 1521 97 6 102 189 8 142 72 341 22 278 19 253 5 62 83 1331 465 4277 Southern Division 27 133 268 1022 143 8 197 134 95 113 65 342 75 403 208 216 31 92 406 1858 1515 4321 Travancore Subs*. Force.... 22 31 35 201 206 3 105 29 13 31 62 144 19 398 184 162 17 9 304 417 967 1395 Northern Division 10 94 34 1214 23 9 15 55 24 84 19 336 10 292 54 317 1 53 95 962 285 3416 Mysore Division 106 93 439 2941 502 14 538 110 22 205 64 450 159 778 421 507 90 119 917 1812 3258 7029 Ceded Districts' 4 352 366 1427 54 3 70 124 1 122 15 238 33 235 233 449 59 51 117 1138 952 4139 Hydrabad Subsidiary Force. 13 442 448 1920 191 9 336 145 20 138 109 493 64 438 324 457 91 97 376 1181 1972 5320 Nagpore Subsidiary Force... 34 31 741 3525 56 7 244 110 71 165 72 217 49 447 237 359 16 78 322 1145 1842 6084 Field Force in the D00ab.... 12 85 269 1411 83 1 235 105 3 103 22 242 35 227 333 236 9 33 92 885 1093 3328 Field Force, Kandeesh, ) ,„„ o __ , w , OA 1O _ ..„ andSholapoor !J 163 8?2 1 75 - 30 139 14 7 ™ - 28 428 1979 3101621 3200 17055 2009 65 2490 1140 365 1304 640 3116 596 3784 2215 3288 364 673 3476 12583 15485 44679 



Table XIV.— General Returns of the Sick of the Madras Army, for 1821. No, 111. — Deaths. Cholera. Fever. Liver. Dysentery. Diarrhoea. Ulcers. Venereal. Op^ al " D?Be^es.D ?8e^es. Total Dea Dead OF THE ARMY. Euro# Nat> Eur(% Nat# £ura Nat Euro Nat EurQ Nat> g^ Nat Euro Nat Euro Nat> Euro Nat- Euro- Nat> Euro _ Nat> Presidency 7 27 11 26 29 3 49 11 9 6 4 8 2 — 2 3 — • — 27 31 140 115 Centre Division 6 64 4 25 5 2 11 8 — 5 — 5 1 1 2 2—l 11 32 40 145 Southern Division 8 71 9 29 3 1 39 16 1 8 1 2 _ ] ... 1 — I 15 13 76 143 Travancore Subsidiary Force — 10— 31— 9 11 ____ 3 1 1 — _ 6 11 18 29 Northern Division 5 26 3 28 2 1 1 5 1 2 — 8 _ 1 — 3 — 1 11 53 23 128 Mysore Division 3 58 9 67 28 5 43 13 1 -6-1 9 — 8 1 7 — — 14 55 100 228 Ceded Districts — 181 1 39 3 1 3 13 — 3 — 4 — — 2 6 — — 5 29 14 276 Hydrabad Subsidiary Force 1 224 6 139 23 4 26 23 4 —2 6 1 1 — 11 39 68 442 Nagpore Subsidiary Force 9 15 16 71 4 — 31 13 6 6 2 4 — 2 5 6 — — 12 38 85 155 Field Force in the Dooab _ 57 7 13 5 — 24 13 _ 1 _ 2 _ 1 — _ — — 4 40 40 127 Field Force, Kandeish, and Sholapore — 97— 22— — — 3_ — _____ 6_— _ 13 —141 39 830 66 462103 17 236 119 19 41 8 44 3 23 14 36 3 116 354 604j1929 



Table XV. — Abstract^ shewing the Per Cent age of Deaths in the different Divisions of the Army, for the Year 1821. Effective Admissions. Deaths Per Centa g e of Deaths calculated Strength. Admissions. Deaths. on the Effective Strength. DIVISIONS OF THE ARMY. Euro. Natives. Euro. Natives. Euro. Natives. Europeans. Natives. Presidency 1457 7571 3566 3662 140 115 10 per cent. 2 per cent. Centre Division- 410 9937 671 4598 40 145 10 2 Southern Division 1007 7951 1689 4785 76 143 7 2 Travaneore Subsidiary Force 988 2817 1025 1522 18 29 2 1 Northern Division „ 431 9279 319 3803 23 128 5 1 Mysore Division 2043 12297 3618 7607 100 228 5 2 Ceded Districts 473 6008 1014 4738 14 276 3 5 Hydrabad Subsidiary Force 1182 9726 2278 6149 68 442 6 5 Nagpore Subsidiary Force 969 7089 2043 6563 85 155 9 2 Field Force in the Dooab 59$ 6120 1206 3636 40 127 7 2 Field Force, Kandeesh, and Sholapore 3251 2336 ... 141 4 



Table XVI.— General Returns of the Sick of the Madras Army, for 1821. No. IV. — Transferred to other Hospitals or Stations. Cholera. Fever. Liver. Dysentery. Diarrhoea. Rheuma- ulcers. Venereal. Ophthal- Other Total 1 J tism. nua. Diseases. Transferred DIVISIONS OF THE ARMY. Eura Nat> Euro- Nat< Euro- Nat# Euro _ Nat> Euro> Nat- Euro , Nat, Euro . Nat. Euro . Nat. Euro . Nat. Euro. Nat. Euro. Nat. Presidency 1 ... 2 ... 2 1 1 ... 1 5 ... 13 ... Centre Division 5 20 ... 9 3 22 6 2 2 16 6 7 ¦ ¦• 20 11 96 33 Southern Division 2 1 ... 1 5 1 15 6 Travancore Subsidiary Force 1 1 10 ... 58 ... 25 1 18 1 113 Northern Division. 24 ... 1 ... 1 ... 2 -- 32 ... 11 ... 11 34 ... 116 Mysore Division 16 1 ... 2 7 1 13 ... 6 ... 9 1 3 3 166 8 220 Ceded Districts 3 .. 11 6 ... 1 •-¦ 37 ... 10 ... 12 ... 2 1 15 1 97 Hydrabad Subsidiary Force 23 6 27 4 ... 5 14 ... 6 11 42 1 4 6 16 3 2 14 15 50 149 Nagpore Subsidiary Force , 4 2 3 3 11 ... 1 ... 11 4 Field Force in the Dooab 5 2 1 ... 1 ... 1 11 ... 21 Field Force, Kandeish, and Sholapore 35 ... 37 ... 1 ... 10 ... 2 ... 23 ... 5 ... 15 8 ... 136 1 61 12 126 29 2 18 41 2 14 35 172 4 97 26 96 12 7 46 279 185 895 



Table XVII. — General Returns of the Sick of the Madras Army, for 1821. No. V. — Remaining in Hospitals on the 31st Dec. 1821. Cholera. Fever. Liver. Dysentery. Diarrhoea. Rheuma- ulcers. Venereal. Ophthal- Other Total tism. mia. Diseases. Remaining. DIVISIONS OF THE ARMY. Euro Nat> Euro< Nat Euro- Nat# E uro . Nat. Euro. Nat Euro. Nat. Euro. Nat. Euro. Nat. Euro. Nat Euro. Nat Euro. Nat. Presidency : 2 1 34 13 26 1 57 4 24 3 20 26 10 9 23 32 3 ... 102 62 301 151 Centre Division 1 ... 3 22 21 1 6 5 ... 1 6 41 6 30 6 22 3 4 16 96 68 222 Southern Division 1 ... 5 36 8 2 9 8 2 1 12 26 8 27 29 21 2 4 23 49 99 174 Travancore Sudsidiary Force ... 6 ... 2 ... 1 ... 5 8 ... 41 6 12 13 7 33 68 Northern Division 1 27 2 1 12 12 ... 36 3 21 3 17 1 45 12 151 Mysore Division 1 ... 28 103 73 ... 34 6 ... 3 9 25 5 31 46 48 2 ... 57 74 255 289 Ceded Districts 6 50 8 ... 2 4 ... 3 2 37 1 16 20 75 1 3 7 41 47 229 Hydrabad Subsidiary Force ... 17 67 27 1 32 5 ... 1 10 40 6 21 39 25 3 5 27 47 161 212 Nagpore Subsidiary Force 28 126 2 ... 9 2 4 3 4 35 6 15 20 34 1 1 22 38 96 260 Field Force in the Dooab 14 37 5 1 18 5 6 21 5 14 31 26 ... 2 1 64 80 170 Field Force, Kandeish, and Sholapore 1 ... 72 ••• 1 ••¦ 5 21 ... » ... 10 ... 1 ... 30 5 2 136 553 178 8 170 46 32 17 74 316 50 233 223 322 15 26 269 553^1152 1926 



Table XVIII. — Abstract of Deaths from Diseases included under the general term of" Other Diseases"* in the General Return. 1 8 | Is I 3 t p 1 il is is 111 1 Is is is f la 3 1 E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. 3 24 •• 32 18 71 8 22 14 26 1 43 4 11 3 10 24 9 1 6 1 2 ¦• 3 •• 1 4 3 •• 1 •• 1 •• 1 .-1 ..3 .-2 E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. 1 1 ¦• 2 1 3 - 3 2 •• 1 •• 1 •• 1 •• 1 •¦ 2 •• 3 •• ¦ 5 -9141 7 •• 1 ¦• 1 •• 1 -2 1 4 E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. 1134141112 •• 212 •• 126 ¦• 4 •• 117231 •••• 3 fill 356 * See General Return of Deaths, Table XIV. t In this total there is a deficiency of five in the Europeans, and an increase of two in the Natives. The difference, however, is of no moment, as the object of the Return is to shew the Diseases that are classed under the head of " Other Diseases," in the whole of the general Statements which I have made from 1815 to 1821 ; I have kept this Return separate from the others, because it is that which alone enables me to judge of the Diseases most fatal in India. 



Table XIX. — Per Cent age of Deaths of the most Destructive Diseases, for 1821. FEVER. LIVER. DYSENTERY. CHOLERA. Europeans. Natives. Europeans. Natives. Europeans. Natives. Europeans. ' Natives. DIVISIONS OF THE ARMY. H 5° J | | ° | | |* g § ffc H X H §£ H f* §| ff II If l| If I! if II if is i| i 5 is 11 is 11 is of "SiO «g| -gigS -si «s'fo -si gab g^; gw"S gz gwb gz gag gg gw Q <v 3 aifig <u3 ,^» „§ isg<u «3 Ohio Uoj U o> « O <d U v v O o U • oj O 0 O v jj tf _tf ci a eric; cs£ (S cS ££ £(£ se percent per mille per cent permille percent percent per cent per x m. percent percent per cent per mille per cent per mille per cent per mille Presidency 1 72352 37 4* 63 14 1 94 36 3 per cent Centre Division 9-9 1 2 3 128 2 8 2 4 8 24 1 32 6 permille Southern Division 3924 1 39 1 16 3 10 2 23 8 34 9 Travancore Subsidiary Force 001 14100793300 24 3 per cent Northern Division 8723748 15285 33 1 29 2 permille Mysore Division 142541 21 4729121584 permille Ceded Districts , 22 2656 25 14 68200 30 3 percent percent perxm. Hydrabad Subsidiary Force 1 5 6 1 92 28 4 6 2 12 2 7 830 2 permille Nagpoor Subsidiary Force 21216400 11 3 10 219 32 2 Field Force in the Dooab 2182580084 10 200 40 9 Field Force, Kandeish, and Sholapore 0 0260 00 000 3900303 Number of Admissions of _ _ . . the above Diseases. Four m ten thousand. Europeans. I Natives. p It is singular to observe, that while the number of admissions of liver disease is far greater Lj ver " os amongst the Europeans than amongst the natives, the deaths bear a much greater proportion to Dvsentp 9QIO I^B the admissions in the native troops, than is the case with the Europeans. Cholera 357 2527 



Table XX. — Abstract, from the preceding Table, of Per Centage of Deaths of the most Destructive Diseases, for 1821. Per Centage of Total Per Centage of Total Total Number of Deaths of the most Deaths of the most E. N Deaths of the most Destructive Diseases, Destructive Diseases, Total Dpattis in thf> Army riurincr tha Destructive Diseases. calculated upon the calculated upon the ±Ol&l , „„, ¦ n tUe Army aurm S tne • Number of Admissions. Effective Strength. year 1821,1 821 , were 604 1929 And the Deaths of Fever, Liver, Dysentery, and Cholera, were 444 14281 428 E. N. E. N. E. N. 160 501 f? ver .JJ 46 2 19 25 7 6 Leaving 160 Deaths amongst Europeans, and cs ee e r nn t cry-::::::::: Jg Al I 18 9 H % TJ:? hs &mongst ****«™ «**<**, Cholera 39 830 11 33 4 10 Number of Admissions of the above Diseases. Effective Strength. E. N. E. N. Fever 34423 442 18165 . Liver 2110 95 I Dysentery 2910 1338 | 82046 Cholera 357 2527 



Table XXL— Per Centage of the several Diseases in each Division of the Madras Army, for the Year 1821. Travancore Hydrabad Nagpore Field Force, DISEASES. Presidency Centre Southern Subsidiary Northern Mysore Ceded Subsidiary Subsidiary Field Force kandeisn, Division. Division. Division. Force. Division. Division. Districts. Force. Force. in the Dooab. and sholapoor. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. E. N. Fever 43* 13ft 10* 15* 28ft 13ft 3ft 6ft B*l3* 23*25* 78ft 25ft 40* 21* 81ft 52* 47*24 0 30* Hepatitis 34* 0* 34* 0 15* Oft 21* 0* 6 0* 29* 0* 13* 0 20* 0* 6ft 0* 15* 0 0 0 Dysentery 51* 1 31* 1* 24* 1* 11* 1 3ft 0* 30* 1* 15* 2* 33* 2 29* 1* 46* 2 0 2* Diarrhoea 9* 2* 1* lft 9* 1* 1* 1* 6* 0* 1 1* 0* lft 1* 1* 8* 2* 0* lft 0 0* Venereal 15* 3* 10* 2* 23* 3* 19* 6* 13* 3* 22* 4* 53* 8* 31* 5* 27* 5* 61* 4* 0 3* Cholera 5* 1 6^ 2 3* 2* 2* 1* 3* 0* 5* 0* 0* 9* 1* 7* 4* 0* 2 2ft 0 9* Ulcers 9* 2 7* 3 8* 5* 1* 16* 2* 3* 7* 6* 7* 4* 6 4 Jft 6* 6ft 3ft 0 4* Rheumatism 11* 3* 23* 3* 7* 4* 6ft 4* 4* 4* 3* 3* 3* 5* 11 5* 7* 3ft 4ft 4ft O 5* Ophthalmia 3ft Oft 3* 0* 3ft 1* 1* 0* 0* 0* 4ft 1 12* 0* 8* 1 1* lft 1* Oft 0 Oft Other Diseases 60* ,20* 32* 14* 43*24* 33 15* 24*11* 48* 15* 27* 20* 36* 13* 36* 17* 16* 16ft 0 14* Total per Centage of the various Diseases for 11 !: 244* 48 163* 45* 167*59* 103*53* 73*40* 176*61* 213 ft 78ft 192* 62* 210* 92* 203 59* 0 72* Average Diseases in six years, from 1815 ceding Statement. 6*6 * 237 70 188 61 165 61 106 45 93 66 128 91 142 j 69 150 85 173 95 101 [76 



Table XXII.— Abstract shewing the Total Strength of the Army serving under the Presidency of Fort St. George, both Europeans and Natives; the Total Admission of Diseases, and Rate of Cures, calculated both upon the Effective Strength of the Army, and upon the Actual Admission of Diseases into Hospitals during the Year 1821. Total Rate of Disease calculated upon E - N - E - N. E. N. E. N. E. N. E. N. Presidency 1457 7571 3566 3662 245 per cent 48 per cent 3136 3391 215 per cent 44 per cent 88 per cent 92 per cent Centre Division ? 410 9937 671 4598 164 46 465 4278 113 43 69 Southern Division 1007 7951 1689 4785 168 60 1515 4321 150 54 89 00 Travancore Subsidiary Force 988 2817 1025 1522 104 54 967 1395 97 49 94 90 Northern Division 431 9279 319 3803 74 40 285 3416 66 "" 36 89 90 Mysore Division 2043 12297 3618 7607 177 61 3258 7029 159 57 90 Q2 Ceded Districts 473 6008 1014 4738 214 78 952 4139 201 68 93 87 Hydrabad Subsidiary Force... 1182 9726 2278 6149 192 63 1707 5251 144 53 75 85 Nagpore Subsidiary Force ... 969 7089 2043 6563 210 92 1842 6084 190 85 90 92 Field Force in the Dooab 593 6120 1206 3636 203 59 1093 3328 184 54. ' 90 91 Field Force, Kandeish, &c 3251 2336 72 1979 60 ...... 84 9553 82046 1174291 17429 49399 ~~~ 15220 44611 , 



REMARKS ON GENERAL RETURNS, &C. 

351 

REMARKS 

ON THE PRECEDING 

GENERAL RETURNS FOR 1821. 

As the returns of the medical board have been « made out with more precision and correctness for the year 1821, than for any former period, I have separated them from the others, and selected them as a foundation for some observations, by which I shall be enabled to shew a defective system of hospital discipline, calculated to produce not only serious loss to the service, but to involve a deep and heavy expense to government. 

I have preferred the returns of this year, too, as they present less sickness, the army being in quarters not exposed to fatiguingmarches, and having in a great degree overcome the fatigues of the preceding campaign. 

It will appear from this return, (see Table XXII.) that the effective strength of the European force of the Madras army was 9553 ; and that the admissions into hospital, out of that number, was 17429, or, by average, 182 per cent. 



352 

REMARKS ON THE 

It is very certain, that the whole European force was not sick during that year ; and therefore I may fairly infer, that the number of admissions into hospital must have been caused by the repeated re-admissions of men who, having been sick, had probably been discharged from medical treatment before the original disease was completely eradicated, or, perhaps, before the patient's constitution had recovered from the effects of the disease. 

Although there were fewer men lost to the service this year, than in any of the preceding years since 1815 ; yet it will be seen, from the general returns of deaths, invalids, pensioners, and discharged men, which follows these remarks, that 895 men were lost to the service ; of this number 77 were discharged, 200 invalided, and 618 died. (See Table XXIII. and those following it.) 

As the men who suffered in the last war had been disposed of* during the years 1818, 1819, and 1820, I conclude that the loss this year must have arisen from sickness alone, which I think will be borne out by the statement alluded to. 

* By " disposed of," I mean discharged, invalided, or pensioned. 



GENEIIAL RETURNS FOR 1821. 

353 

It will appear, likewise, from this table, that the number of Europeans admitted into hospital, for all diseases, is 1 7429 ; the number of cases of fever, liver complaints, dysentery, and cholera, amounts to 8819, but the whole numerical European strength is only 9553 ; consequently, the number of cases of these four diseases alone amount nearly to the whole effective strength of the European army. 

The general rate of sickness in an European regiment, unless under very extraordinary circumstances, or during a very sickly period, is seldom above ten per cent ; this rate is termed healthy, and any thing above it is considered sickly : but I should say, that the rate of sickness in European regiments is generally under ten per cent : compared with the rate of sickness amongst natives, and including every species of disease, it is three to one. 

Syphilis, rheumatism, and such other diseases as are not peculiar to any particular part of the world, form a large proportion of this number, and, if neglected, are calculated to produce either a heavy non-effective list, or to increase the number of discharges from the service; but the diseases which I consider to 

A A 



354 

REMAUKS ON THE 

be the cause of decided loss by deaths, as well as by crowding the non-effective establishment, are fever, dysentery, and hepatitis ; and it is to these that I am desirous of drawing particular attention. Here a question naturally arises, viz. From what cause does it happen, that 17429 Europeans should be received into hospital during a period of twelve months, out of 9553 men? The answer to my mind is obvious — that the same persons must have been admitted again and again ! In the course of these observations, I have frequently adverted to the premature discharge of men from medical treatment, after the first and most urgent symptoms only of disease have been subdued, as a cause of the ultimate loss of men to the service, as well as of the immense number of sick on the returns. If this explanation be not adopted, we must suppose that the whole European force had been sick at least twice over, which is very improbable ; and therefore I think it is a fair inference, that the number of sick upon the returns depends upon the repeated re-admissions of the same sick men who have been discharged whilst convalescent, and who have returned with relapses : and I am convinced, that from this cause a very heavy loss has been sustained by the public service. 



GENERAL RETURNS FOR 1821. 

355 

It will be admitted by all those who have been in the habit of visiting hospitals or attending sick soldiers, that when a soldier feels himself relieved from the distressing or more urgent symptoms of disease, he not only becomes impatient of control, and the restraint of an hospital, but is anxious to be discharged. In such cases, much depends upon the zeal, judgment, and medical tact of the regimental surgeon ; but it sometimes happens that his judgment is overruled, and that men are thus dismissed from medical treatment before the functions have been restored to an healthy action ; and, consequently, blame may be attached to him without his really deserving it : because it is almost impossible to believe, or even to suppose, that any person in authority could urge the discharge of a patient from medical treatment, upon the mere caprice of a soldier's opinion, and at the risk of his health and his services ; and yet I have known it asserted by authority, that " whenever a soldier declared himself capable of making a march — and the question was always put to him — that he was immediately (unless some very obvious objection offered) discharged." Now this, as a general principle, seems wrong, and if it really was the custom (which, by the 



356 

REMARKS ON THE 

way, I very much doubt,) of any person, while performing the duties of an hospital, or exercising the superintending offices of the profession, to adopt this practice, there cannot, in my mind, be two opinions of the mischief it is calculated to produce ; because, although lam ready to admit that the urgent symptoms of disease may be removed, and that the patient may feel comparatively well, yet I must maintain, that if a patient be discharged from medical treatment and hospital discipline before the functions are restored to a healthy state, that relapse must follow as matter of course; and that if this be often repeated, it cannot fail to produce chronic disease, and general visceral obstruction ; — circumstances which tend to load the pension and invalid lists, and occasion the discharge of men from the service, before they have been twelve or fourteen months in India. 

All the profession are aware of the danger of relapse, and every medical officer is anxious to guard against it. To prevent relapse, indeed, is considered of so much importance in every well-regulated regiment, that a convalescent establishment is not only carefully attended to, but it actually forms one of the standing 



GENERAL RETURNS FOR 1821. 

357 

orders of the regiment. If, however, this regulation was zealously and rigidly adhered to, would it be possible that so many relapses could take place out of any body of men, under common circumstances, in one year? I think not — and the inference appears to me direct, that there must be some oversight or inattention to the convalescent standing regulations, which may arise sometimes from one cause, and sometimes from another; for instance, men are frequently impatient of the restraint of an hospital, and declare themselves well long before they really are so. Many officers, suspect skulking, and dislike the idea of a crowded hospital, which is not unfrequently the cause of men being prematurely discharged from medical treatment. Medical officers themselves sometimes discharge men who declare themselves well, without thinking it necessary to examine them minutely; and this, without any intention of injuring the service, or the individuals belonging to it. 

It requires no force of reasoning to prove the evils that must arise from this inadvertency; and that it does exist, cannot, I think, be questioned from the data before us, because what I have already stated must be 



358 

REMARKS ON THE 

admitted, that the whole European force of this army could not, in the common course of things, have been twice in hospital during the year; and, more especially, as this year was not considered sickly. 

It is very far from my wish to impute neglect to any part of the medical establishment of India, feeling, as I do, that there is no class of men more imbued with sentiments of humanity, or more zealous in the performance of their duties, than those belonging to that community ; but, in order to correct an evil, we must point out its existence. This object has led me into such observations as may seem to imply carelessness in particular departments, and impatience in another branch of the service ; but these have been offered without the shadow of intention to offend the feelings of any person. 

From these observations, then, it appears to me that strict attention to a convalescent establishment is requisite, in order to rally the constitution after an attack of disease : and although it has come under my knowledge where a superintending surgeon has maintained, in a public correspondence, that " all 



GENERAL RETURNS FOR 1821. 

359 

who have been sick, or under medical treatment, can never from necessity be considered as convalescents, and subject to a further probationary course of recovery ;" yet, with all due deference to this authority, I must be permitted to say, that if this principle be acted upon, it cannot fail to produce all those evils which I have described, and which I wish to draw particular attention to. And, if further proof were requisite to shew the necessity and importance of convalescent establishments, let any individual consult his own feelings, whether he would be likely to be able to perform, on every or any occasion, his duties immediately after an attack of sickness, even after he is able to see his friends, and capable of taking exercise; but more particularly if that attack happened to be a severe one ? This is applicable to persons in the common circumstances of life, but it is infinitely more so to a soldier, whose habits render every precaution necessary, and whose duties in India expose him to such vicissitudes of weather and climate. Let us, for instance, suppose a soldier to be discharged from hospital, after having gone through a course of medical treatment of one week only, for any common disease — say a slight bowel complaint merely — and to be at once placed on duty, 



360 

REMARKS ON THE 

and obliged to walk as sentry backwards and forwards with his musket and accoutrements for two hours, the usual term of a soldier's duty, exposed as he is frequently in India to v hot sun, from 92° to 100° of Fahrenheit's thermomete — the probable consequences are, that he will return to his barrack fatigued, and if he can obtain a dram, or any of his friends can procure one for him, it will be his first resource, — and this, perchance, may be repeated, till considerable excitement is produced. Food is not always looked for; and, if it be, it may not be such as is suited to his state, after the diet to which he had been accustomed in hospital. Thus he becomes exhausted by fatigue, excited by liquor, overloaded with food, which, though good of its kind, may not be suited to the existing state of his digestive organs ; and what, I will ask, is likely to be the result but relapse ? which would, in all probability, have been prevented, by bringing him more gradually to his former habits. 

I could enter more at large upon this subject if it were necessary, but as my object is to benefit the public service, and the cause of humanity, I hope it will be considered quite 



GENERAL RETURNS FOR 1821. 

361 

sufficient to have stated the facts, from which I have been led to the following conclusions : viz. 

That to discharge men from hospital treatment and discipline before disease has been perfectly removed, or before they have sufficiently recovered their strength, must lead to frequent relapses ; and that frequent relapses will as surely lead . to chronic permanent diseases, disqualify from the active duties of soldiers, load the non-effective establishment, and cause the discharge of men from the service ! 

If these premises be admitted, and if it be true, as I have often heard it stated, that every European soldier who comes to India costs the government one hundred pounds sterling, the following statement will shew how much the service is injured, and the expense to government increased by a system, the defects of which appear to have been overlooked. 

Although I rest my present calculation upon the returns of the year 1821, it will be seen by the returns of loss by deaths, invalids, pensioners, &c. &c. which have been taken 



362 

REMARKS ON THE 

from the returns of each regiment for seven years, that upwards of 800 men have been lost annually to the service, (see Table XXXI.) and that not less than 500 of them were by death. 

I shall suppose that one fourth of the loss may be occasioned by this system of hospital discipline, viz. premature discharge from medical treatment. 

Two hundred men, at one hundred pounds each, will occasion a loss to government of twenty thousand pounds sterling annually, exclusive of a heavy and expensive non-effective establishment, and not including passagemoney for discharged men. 

It will be seen by the statement alluded to, that I have made a very low estimate of this loss ; my wish is to keep considerably within its limits, and to draw, with due moderation, attention to a system so pregnant with interest to the Indian government. 

If twenty thousand pounds a year is the loss upon a moderate calculation, in seven years it will amount to one hundred and forty thousand pounds for his Majesty's and the Honourable Company's troops. 



GENERAL RETURNS FOR 1821. 

363 

The following statement will shew the subject in a clearer point of view; and I shall not include time-expired men. 

General loss of European troops belonging to his Majesty's and the Honourable East India Company's service for seven years, is 

Men. Dead 5560 Discharged, invalided, and pensioned 3412 8972 

5560 deaths in seven years, is 794 in one year ; take one fourth of this as loss by bad system .... 198 J 3412 discharged, invalided, and pensioned in seven years, is 487 in one year ; take one fourth as above 121 J 320 At £100 each 100 Loss £32000 

Loss annually for King's and Company's troops : — £32000 7 In seven years £224000 



364 

REMARKS ON GENERAL RETURNS, &C. 

Honourable Company's troops alone :—: — 

1575 deaths in seven years, is 225 in one year; take one fourth as loss by bad system 66 883 discharged, invalided, and pensioned in seven years, is 126 in one year; take one fourth, as above . . . , 31 97 At £100 each 100 Annual £9700 

Annual loss for men belonging to the Honourable Company's European force alone :—: — 

£9700 7 In seven years £67900 



be ••>+-> g S" '8 v 2s2 s >: 2 Annual Average Annual S§. g?S »M y. • „ Regimental Loss, Loss of the «sh *•§>. £V> » "S S r*i c • ...„-«¦ calculatedon Army, CORPS. 542 *»„ S I § Statxons where each Corps was during the Year. the calculated on the tSS S 5 I 5 "§ "S « § I Total Strength. Total Strength. f January, February and March, marching in the Ceded) H. M. 22d Dragoons 705 93 798 33 2 20 -\ Districts ; April and May, camp on the Tombootlra ; V 6^ per cent. June to December, Bangalore ) 25th 840 840 43 1 14 Ijaulnah -[ 7 Royal Regiment... 1127 36 1163 107 9 35 i I 12ft 30th 889 93 982 48 7 19 Cannanore, Tomboodra, Mysore, Vellore, and Madras 71 34th 735 224 959 121 2 15 Seringapatam and Vellore 14& 53^ 841 841 13 ... Recently arrived and encamped near the Mount li 56th 902 8 910 15 6 ... Fort St. George, removed to the Isle of France 2^ 69th 778 778 41 1 35 Bellary 9^ }-9^percent. 80th 754 6 760 37 20 Quilon 7^ 84th 1209 7 1216 27 16 39 Karnaul, Bangalore, and Ceded Districts 6f a 86th 822 252 1074 66 3 79 Masulipatam 13^ 89th 804 46 850 21 2 24 Bangalore and Cannanore 5^ H. C. Horse Artillery 304 304 27 4 1 Jaulnah Force 7^ Ist Battalion 654 654 37 38 27 11 Mount 17^ 2d Battalion 714 714 45 28 32 2 Mount 14^ M. E. Regiment... 783 15 798 41 23 13 Trichinopoly 9^ ITotal 12861 780 I 13641 722 162 353 13 I have marked the Station of the Artillery at the Mount, because their Head Quarters were stationed there, and the general Returns dated from the Mount ; but it must be stated, that the Artillery are divided into various detachments, serving in the different Divisions of the Army, and that there are seldom more than two or three hundred men at the Mount : how they are distributed will be seen in the Returns of the different Divisions of the Army, where the numbers are stated belonging to each Station. 

Table XXIII. — General Return of Deaths, Invalids, Pensioners, Discharged, and Time-Expired Men, belonging to His Majesty's and the Honourable Company's European Service, for the Year 1815. 



g £" § £ c 3c 3 >: . I: Annual Average Annual ts» geS SeS Tg • y a Regimental Loss, Loss of the CORPS. 'SiS ."£>" «)¦£>« E? I S H Stations where each Corps was during the Year. calculated on Army, ™ "¦> rt & .§ » -3 5(u.230j the calculated on the IS I 6 | 5 1 -S -3 g | Total Strength. Total Strength. H. M. 22d Dragoons 710 8 718 20 2 ... 1 ... Bangalore 3ft per cent. " 25th 771 3 774 45 11 18 Centre Division 8& ... Royal Regiment... 1058 249 1307 79 24 43 Jaulnah 11^ ... 30th 924 99 1023 39 6 26 Madras 6ft ... 34th 835 53 888 44 1 22 Vellore 7^ ... 53d 851 283 1134 54 1 72 ... 1 Wallajahbad, Bangalore, and Trichinopoly 11^ ... 69th 724 1 725 53 8 33 ... 20 Ceded Districts, and Bangalore 12$ ... 80th 713 8 721 20 1 4 Quilon and Trichinopoly 3ffc ... ¦ 8^ per cent. 84th 1132 1 1133 37 7 52 ... 26 Ceded Districts 10^ ... 86th 950 1 951 49 ... 6 ... 2 Hydrabad and Masulipatam 5$ ... 89th 815 236 1051 34 13 20 Cannanore and Quilon 6^ ... H. C. Horse Artillery 361 127 488 7 16 Jaulnah 4^5 ... Ist Battalion 580 207 787 32 14 16 4 ... Mount 8& ... 2d Battalion 555 245 800 41 19 18 10 ... Mount 11 M. E. Regiment... 706 319 1025 48 6 1 2 ... Trichinopoly and Ceded Districts 5$ Total 11685 1840 13525 582 129 331 17 49 

Table XXIV. — General Return of Deaths, Invalids, Pensioners, Discharged, and Time- Expired Men, belonging to His Majesty's and the Honourable Company's European Service, for the Year 1816. 



=D 

«? 

to 

CO 

<4J 

->-~ 



g I* § . g 1 . . "§ Annua Average Annual CORPS. £§,; s«| % I ' * & Regimental Loss, Loss of the ?ls gift "I* fill Stations where each Cmps was during the Year, calcuktedon '•SH gSS'S'a f 1 g g Total Strength. Total Strength. H. M. 22d Dragoons 643 17 660 55 2 39 — — Camp, Ceded Districts, and Dooab 14ft per cent. " 25th 669 5 674 21 18 53 — 5 Centre Division 14ft Royal Regiment... 1166 3 1169 143 16 51 — 3 Camp Hydrabad Force 18A 30th 932 63 995 33 140 —Madras 17$ 34th 898 80 978 62 4 44— — Centre Division— VeUore lift 53d 1023 278 1301 76 8 35 — — Trichinopoly 9^ 69th 736 337 1073 39 23 18 — 4 Bangalore 7ft 80th 195 195 6 — — This Regiment was drafted 3 ?, T . mt 84th 1001 2 1003 23 10 26 — 13 Ceded Districts— Bellary 74 wiper van. 86th 935 7 942 45 7 2 — — Masulipatam 5£ 89th 849 172 1021 49 28 8 — — Quilon Bft H. C. Horse Artillery.. 456 133 589 32 — — 2 J Kandeish^ Dooab, Ellichapore, Jaulnah, Mahidpore, 1 -. \ and Nagpore ftf t^ s Ist Battalion 608 81 689 33 3 2 1 2 Mount sft 2d Battalion 632 5 637 39 2 4 Mount 7 M. E. Regiment... 891 314 1205 115 31 51 7 10 Karnoul, Hydrabad, and Mahidpore 17ft Total 11634 1497 13131 771 292 329 8 43 

TABLE XXV. — General Return of Deaths, Invalids, Pensioners, Discharged, and Time-Expired Men, belonging to His Majesty's and the Honourable Company's European Service, for the Year 1817. 



s 1 ¦g£"B £ §" >: . S Annual Average Annual 53;5 |^ 2c?g "2 y g. Regimental Loss, Loss of the CORPS. '§>' »¦§>• £? c H Stations where each Corps was during the Year. calculated on Army, >~>^ S5S 5 g •a -a g -s S. a -2 6 the calculated on the S« -2515 3 * p S Total Strength. Total Strength. tt v 00 , n „„„„ Kni - l nr o- , ol (Field Service in the Mahratta Country, from January) q8 „«--«,„? H. M. 22d Dragoons 591 5 596 37 1 21 - - | to June ; at Seroor, from June to December ../ 9.0 P^ cent. 25th 584 584 33 2 40 — 12 Bangalore and Arcot 14|j Royal Regiment... 957 — 957 150 — 37 — — Field Service 19^ 30th 866 205 1071 61 1 84— —Madras 13& 34th 895 20 915 139 2 26 — — Field Service— Bellary and Bangalore 19^ 46th 927 — 927 30 3 — — — Centre Division 3£ 53d 1245 30 1275 110 1 98— — Trichinopoly 16^ I ninMwnt 69th 1004 12 1016 96 1 40— 2 Bangalore 13ft > lOnjvruan 84th 920 6 926 69 10 25 — — Bellary 11^ 86th 912 3 915 82 1 — — — Masulipatam and Wallajabad : 9 89th 1078 6 1084 69 27 10 — — Quilon 9^ H. C. Horse Artillery 442 43 485 41 — — — — Field Service 8^ Ist Battalion 525 44 569 71 — 26 6 — Mount 18JL 2d Battalion 615 45 660 75 5 22 — — Mount 15^ M. E. Regiment... 987 162 1149 206 1 — — — Field Service — Kandeish and Nagpore 18 Total 12548 581 13129 1269 55 429 6 14 

TABLE XXVI. — General Return of Deaths, Invalids, Pensioners, Discharged, and Time- Expired Men, belonging to His Majesty's and the Honourable Company's European Service, for the Year 1818. 



Table XXVII. — General Return of Deaths, Invalids, Pensioners, Discharged, and Time-Expired Men, to His Majesty's and the Honourable Company's European Service, for the Year 1819. §£" ijJa cJa . S Annual Average Annual ,?"¦ B^ S^j "g . ,5 "S, Regimental Loss, Loss of the «§» usBu s8 « = • ff « c da Stations where each Corps was during the Year. calculated Army, CORPS. ?*»<-¦ 3'*>< -3 5^ • S 2 5 V on the calculated on the IS g-a -g-o "§ g "3 "g | Total Strength. Total Strength. H. M. 13th Dragoons 358 401 759 45 Just arrived from England, at Madras ss; per cent. ' „„¦¦ Aa . IQI „„„ .„ ._ Service in the Southern Mahratta Country till June, _, 22d 495 131 626 42 - 15 at Bangalore in July, and Madras in December H 25th 509 2 511 7 18 Drafted into other Regiments 8 Royal Regiment... 934 62 996 123 12 57 ... 6 Centre Division 19^ 30th 936 26 962 81 26 39 Hydrabad 13^ 34th 928 10 938 38 4 25 ... 11 Bangalore Bfg 46th 927 1 928 29 55 22 2 ... Madras Hi 53d 1045 4 1049 77 ¦•- 33 ... 2 Trichinopoly 101 11 1 11 A T/.cent. 69th 868 281 1149 65 2 23 ... 10 Cannanore B^, 84th 825 5 830 19 ... 11 ... 5 Drafted into other Regiments in July 4^ 86th 648 648 40 32 Ditto ditto in April ft» .. 89th 969 1 970 46 5 12 Quilon 64 H. C. Horse Artillery 426 109 535 43 8 14 10 ... Field Service 14 Ist Battalion 537 159 696 59 20 28 4 ... Mount \sf 2d 544 176 790 68 6 7 2 ... Mount 11^ M. E. Regiment... 798 261 1059 181 62 I 22 ... Mouthie, Ellichapore, and Asseer-Ghur 25-^ Total 11747 1629 13376 963 200 287 40 84 

B B 



Table XXVIII. — General Return of Deaths Invalids, Pensioners, Discharged, and Time-Expired Men, belonging to His Majesty's and the Honourable Company's European Service, for the Year 1820. g £• '3 4) gig -d ig.aJ5.S-,: , .2 Annual Average »sS Sms j»J St 3S t3 & • Regimental Loss, Annual Lossof CORPS. JJjS jft, |F I |. I J Stations where each Corps was during the Yea, calculated Army, M~ W° 2, « £ £ s S Total Strength. Total Strength. 11. M. 13th Dragoons ... 716 8 724 46 3 9 Centre Division 8 percent. 22d 95 95 2 5 11 ... ... Embarked for Europe 14ft Royal Regiment 816 243 1059 46 48 21 1 ... Trichinopoly 10^, 30th 895 51 946 73 10 Hydrabad 8^ 34th 888 5 893 37 15 20 Bangalore and Madras 8 46th 1023 76 1099 37 17 1 Madras and Bellary 5 53d 934 62 996 82 11 28 Bellary and Bangalore 12^ lO&percent 69th 1055 107 1162 61 20 5 Cannanore B^, 89th 1035 95 1130 30 12 26 Quilon 6 H. C. Horse Artillery ... 395 23 418 44 43 10 8 ... Field Service 25^ Ist Battalion 451 214 665 59 17 18 4 2 Mount 15 2d 576 192 768 43 48 22 3 ... Mount „ , 15^ M. E. Regiment 755 106 861 75 9 21 8 ... Asseer-Ghur 13^ Total 9634 1182 10816 635 258 202 24 2 



Table XXIX. — General Return of Deaths, Invalids, Pensioners, Discharged, and Time-Expired Men, belonging to His Majesty s and the Honourable Company's European Service, for the Year 1821. S3S 3 - 5 (Sbo* 1 "aiS -a • * Annual Average rnnpc «§£ 8 £e« m TR "8 * o ¦ ? „ ?, v Regimental Loss, AnnualLossof COK^fe. ""*" la^ 1 Ba s :§ Stations where each Corps was during the Year. calculated the Army, owe-B-g-o-o-S^-ig on the calculated on the sS"§ H B.2>g« Total Strength. Total Strength. H.M. 13th Dragoons ... 672 7 679 29 6 7 Bangalore 6^ per cent. ' Royal Regiment 950 93 1043 82 3 18 Trichinopoly 9f n 30th 868 115 983 66 2 26 Hydrabad 91 34th 851 6 857 44 2 35 Madras 9A 46th 961 2 963 58 12 11 Bellary 84 . 53d 890 56 946 37 5 28 Bangalore 74, 69th 1077 11 1088 42 22 31 Cannanore 8& f && per cent. 89th 962 46 1008 37 4 40 Quilon 8 H. C. Horse Artillery ... 475 36 511 64 5 4 Mount and Field Service 14& Ist Battalion 693 106 799 46 2 Mount 6 2d 533 233 766 35 3 Mount 4^ . M. E. Regiment 738 146 884 78 11 Nagpore 10 Total 9670 857 10527 618 77 200 



Table XXX. — Abstract of Annual Loss in the Army of European Forces, by Deaths, Discharges, Invalided, Pensioned, and Time- Expired Men, both in His Majesty's and in the Honourable Company's Services, under the Presidency of Fort St. George, for Seven Years, from 1815 to 1821, inclusive. Total Loss Grand Total I of Men by Loss by Annual Loss Annual Annual Invalids, Deaths, Rate of Loss by Total Rate of Effective in the Army Annual Loss Annual Loss Loss of Loss by Pensioned, Discharged, Rate of Loss Invalided, Loss by Deaths, YEARS. Strength of by of Men by of Men by Men by Time- and Time- Invalided, by Death, Pensioned, and Invaliding, the Army. Deaths. Discharges. Invalided. Pensioned. Expired Expired Men, Pensioned, per Annum. Time-Expired &c. &c. Men. in and Time- Men. Seven Years. Expired Men. 1815 13641 722 162 353 13 528 1250 sft per cent. 3,% per cent. 9ft per cent. 1816 13525 582 129 331 17 49 526 1108 4ft 3ft Bft 1817 13131 771 292 329 8 43 572 1443 5f 5 5^ 11 1818 13129 1269 55 429 6 14 504 1773 9^ 3ft 13 TT 5 S 1819 13376 963 200 287 40 84 611 1574 7ft ...... 4ft lift 1820 10816 635 258 202 24 2 486 1121 sft 4ft 10f g 1821 10527 618 77 200 277 895 sft 2ft Bft Total 88145 5560 1173 2131 108 192 3604 9164 44^ 28ft 72-& Average of Seven Years, 1 per Annum 12592^ 794 ft 107 ft 304 ft 15 ii 4 o 2U2 U 514 fo 1309^ 6ft 4 10ft Average Strength of the Army, upon 88145 Men in Seven Years, is 12592 per Annum. Average Loss upon 5560 Men by Deaths, in Seven Years, is 794f 5 Average Loss upon 3604 by Discharges, Invalids, Pensioners, and Time-Expired Men, in Seven Years, is 514 ft Total Average Loss of Men per Annum 1309^1 309^ Average Loss hy Death per Annum 6ft per Cent. Average Lsss by Discharges, Invalids, Pensioners, &c 4 Total Loss by Deaths, including Discharges, Invalids, Pensioners, and Time-Expired Men, per Annum 10ft Average Loss by Death of Diseases taken from the Medical Returns, 5191 in Seven Years, is 741 per Annum, or sft per Cent per Annum. 



Table XXXI. — Abstract of the General Loss of Men belonging to His Majesty's and the Honourable Company's European Troops, in Deaths, Discharged from the Service, Invalids, Pensioners, and Time- Expired Men, for a period of Seven Years, from Ist January, 1815, to 3lst December, 1821. Total Number m •. i -cor »• °f Recruits Total Effective rec eived from Grand Total Total Total Total Total Grand StX AZ? c England, from S of of In J^. p^U Time- Total im- Ist January, 1815, Deaths. Discharged. Expired. of Loss. lulo> to 31st December, 1821. 12861 8366 21227 5560 1173 2131 108 192 9164 





PART III. 

PRACTICAL OBSERVATIONS 

ON THE 

EFFECTS OF CALOMEL 

ON THE MUCOUS SURFACE AND SECRETIONS OF THE 

ALIMENTARY CANAL; 

AND ON 

THE USE OF THIS REMEDY IN DISEASE, 

MORE PARTICULARLY IN 

THE DISEASES OF INDIA. 





377 

SECTION I. 

Introductory Remarks respecting the Doses in which Calomel may be prescribed, Bsc. 

Although this preparation has been much employed in medicine during the two last centuries, yet practitioners seem not to have arrived at any determinate idea respecting the extent to which it may be advantageously given, or the mode of administering it. When calomel was first employed, under the terms of Draco Mitigatus, Manna Metallorum, Sublimatum Duke, Mercurius Dulcis Sublimatus, &c. it was used chiefly as an active purgative, either alone, or in combination with other medicines of the same class ; and we find, on reference to the medical authors of the seventeenth, and commencement of the last century, that it was chiefly resorted to when they wished to procure a full evacuation of the biliary and other alvine secretions, or to re-establish any natural evacuation, which had been prematurely put a stop to. But it is somewhat singular that the mode of administering it which these authors 



378 

INTRODUCTORY REMARKS. 

adopted, should have been so soon almost entirely forgotten, and that it was in every respect the same as that which has been suggested at the present day by several writers. 

I shall briefly refer to a few authors who seem to have entertained very correct views as to the mode of administering this remedy, and under whose authority, in addition to my own observation, I will shelter myself, when I at once state the proposition which it is the purpose of this article to establish, namely, that when the use of calomel is clearly indicated, it is most beneficial in large doses, generally at not less than twenty-four hours between the administration of each dose. 

Horstius* stated, that the " Mercurius Dulcificatus" may be given in doses of one scruple, or half a drachm, " ad viscidos humores magis attenuandos ;" and Deleboe Sylviusf recommended it in the same doses as an attenuating purgative. WepferJ prescribed it in doses of twenty grains, in combination with other purgatives, in affections of the head. 

* Opera Omnia, Vol. 11. p. 480. 1661. 

f Opera Francisci Deleboe Sylvii, p. 98. Amst. 1680. \ Observationes Medico-Practicse, p. 120 — 124. 1727. 



379 

INTRODUCTORY REMARKS. 

Dr. Friend* advised it in simple doses, in conjunction with purgatives and emmenagogues in emansio and obstructio mensium. Schroderf has expressly stated, that " Mercurius dulcis vulgaris, draco mitigatus, omnes humores noxios, sine perturbatione laude expurgat, unde vel infantibus exhiberi poterit. Dari potest ad sss. : cum aliis purgantibus a gr.viij. ad xv. et plures." JunckerJ has made mention of the exhibition of calomel in doses of twenty and thirty grains ; and Geoffroy || has recommended it to be given in doses of from five grains to thirty, according to the circumstances of the case. These authors seem, however, not ignorant of the mode of exhibiting this preparation in much smaller doses. But whenever they resorted to this manner of prescribing it, their object appears to have been to affect the system with the mercurial action. Whenever they were desirous of obtaining advantageously its purgative effects, they exhibited it in the large doses above 

* Opera Omnia, p. 112, et seq. 

f Pharmacopoeia Medico-Chymica, &c. p. 411. Lugd. Bat. 1672. 

| Conspectus Medicinee Theoretico-Practicee, p. 783. Halee. 1724. 

|| Tractatus de Materia Medica, Vol. I. p. 260. Paris, 1.741. 



380 

INTRODUCTORY REM A RK.S. 

stated, at considerable intervals between each — a mode of exhibiting it founded on their experience of its effects. 

Such were the ideas entertained at these epochs respecting the mode of prescribing this remedy, but the opinions since advanced upon the subject have been greatly changed. Since then it has been administered with greater timidity, and actually with greater risk of incurring the consequences dreaded from its more liberal exhibition. Two grains were found to irritate, five were, therefore, inferred to irritate more ; and the administration of ten grains was considered a most dangerous practice. Notwithstanding the encomiums lately bestowed upon the operation of scruple doses of calomel, those opinions still retain their hold on the minds of many practitioners, who have not witnessed the effect of this remedy when given in large quantities ; and others, who have witnessed the practice in the manner in which it has been revived, have very reasonable objections to the adoption of it. They very justly say, that they have seen twenty grains of calomel given every three or four hours, in acute diseases, and continued for several days, either without much sensible effect, or with very troublesome, and even dangerous consequences; — that they 



381 

INTRODUCTORY REMARKS. 

have observed, when the activity of the disease was subdued, violent effects occasioned by the manner in which this remedy had been exhibited, and the danger then most urgent was not that arising from the disease, but from the manner in which it had been treated. This, doubtless, has been the case in many instances in which the old practice of giving calomel has been modified by the revivers of it ; and is a serious and just ground of objection, not against the dose in which the remedy was exhibited, but against the unprecedented frequency with which it was repeated. What have been the consequences of this practice ? Older practitioners have been made firmer advocates of the propriety of prescribing this medicine in small doses, and of repeating it frequently in the same quantities, under certain circumstances ; whilst some modern innovators, witnessing the good effects of scruple doses of the remedy, when given after longer periods than those more frequently recommended by the revivers of the practice, think the benefit will be in proportion to the frequency of the dose, and thus overdo the practice, and bring discredit on the remedy, with those who exercise a cooler judgment of the matter. 

It is singular, that after so many years' experience 



382 

INTRODUCTORY REMARKS. 

of the use of calomel, and after the great diversity of opinion that has been manifested regarding its salutary operation, and the doses in which it ought to be exhibited, some investigation should not have been entered upon as to its direct effects upon the coats of the stomach and bowels, and upon the secretions poured into them, whence a correct and safe practice might be deduced. 

At the present day, the opinions of practitioners, both in Europe and in India, are as various regarding the use or abuse of calomel, and the modes of exhibiting it, as at any former period. This is the more singular, as the points in dispute admit of solution to a certain extent by means of experiment, and cautious and close observation ; and yet the most experienced are still baffled to account for the operation of this preparation upon the animal economy, in health and disease, beyond a few of its obvious and ultimate effects, which are sufficiently demonstrable to the sight ; but this sense, although generally a safe, is not always a sufficient guide to those who are anxious to obtain a precise knowledge of the effects of whatever they use in disease. To this inconvenience we must submit, till we obtain correct information respecting the operations 



383 

INTRODUCTORY REMARKS. 

of remedies on the human body, which may direct us in the appropriate exhibition of them in disease. The attainment of such information should, I consider, be the object, as far as he may be able, of every individual belonging to the medical profession, who sees the value of that profession to the community, and is desirous of giving his unbiassed aid towards its improvement. The prejudices of early instruction are difficult to be overcome ; they lead us to draw conclusions from inadequate premises, and sometimes to reject useful inferences, because they accord not with preconceived or generally-adopted opinions. Ignorance, also, leads us to adopt, without examination, what is generally received, even although the most palpable objections may be found to it in our daily experience. 

Influenced, in some degree, by a similar partiality of judgment and indolence in research which I here condemn, I was in the habit of administering calomel only in moderate doses, until I perused the valuable work of Dr. Johnson, after which I began, in my hospital at Trichinopoly, to exhibit it in doses of one scruple each, to a patient in the advanced stage of dysentery : its action in this instance was so strikingly useful in procuring ease and comfort to the patient, 



384 

INTRODUCTORY REMARKS. 

that, although the case was not successful, I determined to give it a trial at the commencement of those acute diseases which we find most distressing and destructive in India, namely, in dysentery, hepatitis, and fever, — diseases which, in general, commence with great excitement, and excessive irritability of stomach. I accordingly adopted this practice, and have followed it for upwards of eight years, and in no instance have I had reason to be dissatisfied with its effects. 

Having been even at that time prepossessed in favour of large doses of calomel, it was not a difficult matter to make me a convert to the practice ; but I adopted it with very different views from those with which it was then recommended, and modified it accordingly, as will be seen in the sequel : nevertheless, so great were the prejudices that existed against this practice, even amongst men of professional eminence and reputation, that I have often doubted my own judgment in suggesting to those gentlemen who were placed under me, on their first arrival in India, the propriety of administering calomel in larger doses than are commonly thought necessary, although the result of my own experience was so decidedly in favour of the practice ; and I have sometimes felt great difficulty in meeting, 



385 

INTRODUCTORY REMARKS. 

and successfully resisting, the various objections which have been made to it. I consequently did not press its use, but gave the confident assurance that calomel could be used in large doses with perfect safety ; and established the fact by shewing its effects when so administered by me. A very short time convinced them of its advantages, and the practice became general from conviction, and not from persuasion. 

It is generally believed, and probably it may be true, that many constitutions in India are ruined by the use of calomel ; but I am disposed to consider this to be the consequence of continuing it in small doses, long after the necessity for using it ceases. 

There is a notion, and it has been inculcated with great industry, by those even to whom we are indebted for reviving the practice of exhibiting calomel in large doses, that where mercury is useful the mouth must be made sore, and that when the mouth is sore, the patient may be considered safe. This I conceive to be fallacious, and to have done serious injury to the constitution : for it must be well known to every medical man who 

c c 



386 

INTRODUCTORY REMARKS. 

has at all given his attention to the operation of mercury, that some constitutions cannot be affected in this way, and that any quantity of any preparation of mercury may be given without making the mouth sore. To continue, therefore, the administration of a remedy during an indefinite period, for an object that cannot be attained, must be attended with danger to the constitution, and loss of credit to the remedy so misused. 

This doctrine of the necessity of salivation, in the hands of a judicious practitioner, might, indeed, not be productive of so much injury, because they who practice with judgment, always having a defined object in view, discontinue the remedy after that object has been attained, whether the mouth become sore or not; but there are those who, from prejudice, inattention, or, perhaps, a want of knowledge, continue to use calomel till the mouth becomes sore, merely because it is a rule laid down — an absurdity which does not merit refutation. 

It is that class of practitioners too, who decry the use of large doses of calomel, who really give infinitely larger quantities, although in small and repeated doses. They probably 



387 

INTRODUCTORY REMARKS. 

suppose, that if three or four grains of calomel will purge, twenty grains will purge more, and hence carry off its effects by the bowels ; and that small doses will enter the system, and produce the expected effect — salivation. 

The very reverse of this is the fact : small doses of calomel, from two, three, to four and six grains, will purge, and keep up a considerable degree of irritation in the stomach and bowels, when twenty grains will not ; but, on the contrary, will allay the irritation of both, when it results from inflammation of their mucous surfaces. Thus, calomel, in large doses, appears to act as a sedative, as will be proved by the experiments I am about to adduce. 

I must, however, be permitted to say, that it would be as absurd as presumptuous in me to doubt that there are cases in which calomel, in small doses, has been and may be useful ; nor must it be supposed that I presume indiscriminately to condemn a practice that has been followed and supported by men of talent and experience : my wish is to condemn it only where it is employed without due discrimination, and where the sole end in view is, either to make the mouth sore, or to bring on 



388 

INTRODUCTORY REMARKS. 

salivation, without any satisfactory object, or therapeutical principle being fulfilled by the practice, and sometimes without a possibility of any benefit resulting from it. 

If the constitution is to be charged with mercury, to overcome any disease requiring its specific action — such as venereal disorders, chronic affections of the liver, &c. &c. — perhaps friction on the skin, or the blue pill internally, might be found the safest way of effecting that object: but I have no intention of entering upon this point of practice ; my object is, at present, to shew the direct effects of calomel upon the internal surface, and the secretions of the stomach and bowels, particularly in the more prevalent diseases of India. 

The various opinions which have been entertained on the use of calomel in these diseases, have induced me to try some experiments upon dogs, and the result has been so satisfactory, that I think they should not be withheld from the profession ; but finding that I have neither time nor means farther to prosecute the inquiry, I submit them, with full confidence that they will be received with indulgence ; and in the hope that other experiments 



389 

DETAILS OF EXPERIMENTS. 

will' be accurately made, which may farther illustrate the subject. 

SECTION 11. 

Details of Experiments, shewing the Effects of large Doses of Calomel on the Alimentary Canal, Bsc. 

About eleven o'clock, a.m., Dec. 1, 1823, I gave three healthy dogs the following doses of calomel, viz. 3j. 31J. and 3iij.: after they had taken the calomel they were kept in a room, and observed narrowly for twenty-four hours. 

The dog who took 3j. did not appear to feel any kind of sickness till night, when he vomited a little ; he was lively the whole time, and ate his food well ; had been purged two or three times ; dejections very dark grey colour. 

The dog who took 3ij. was likewise lively, and ate his food well ; vomited two or three times, and was purged more than the other : he passed tape-worms, and the dejections were black. 



390 

DETAILS OF EXPERIMENTS. 

The dog that took 3iij - was heavy, and apparently uncomfortable the whole day, but did not vomit at all. He was purged, and passed a very long tape- worm ; dejections also black. Although he looked somewhat heavy before he took the calomel, and was apparently dull and uncomfortable during the day on which the calomel was administered, he improved very much in his appearance on the following day, and was very lively. 

At ten o'clock, a. m., on the 2d December, twenty-four hours from the time at which the calomel was taken, the three dogs were hanged ; and as the largest dose was given with a view of ascertaining the worst effects of this preparation, I first examined the dog that took it, five minutes after he was dead. 

The veins were beautifully injected, the liver healthy, and the gall-bladder full of bile. 

The external coat of the stomach was of a pale colour, and seemed to be rather thickened. 

The small intestines had a peculiarly thickened feel, very similar to what is observed in cases of cholera; but I am not quite sure 



391 

DETAILS OF EXPERIMENTS. 

whether this thickened state is not natural to the healthy intestine of the dog. 

The stomach was laid open : its internal surface was considerably corrugated, and of a dusky red colour, but possessing neither the appearance of high arterial action, or of venous congestion. The corrugations were in a longitudinal, and not in a circular direction. 

The small intestines were laid open : their internal surface was loaded with thick, tenacious, cream-coloured matter, such as is generally found in the intestines of those who die of cholera. It appeared that the calomel, in this instance, had no other effect upon the dog than that of diminishing the vascularity of the stomach, as it did not seem to have mixed at all with the secreted matter of the intestines, or to have acted upon the gall-bladder. Probably the time was not sufficient for the purpose. 

The dog which was next opened, was that which took 3IJ. of calomel. 

The appearance of the stomach, both externally and internally, was infinitely more vascular 



392 

DETAILS OF EXPERIMENTS. 

than observed in the preceding experiment. The corrugations were, however, precisely of the same nature as those already described, and the venous system was beautifully injected ; but there was a. very considerable flow of bile in this dog, and the contents of the duodenum were more fluid, and less tenacious. 

The dog who took 3J. was last opened, and in him also the venous system was highly injected; but we were surprised to see a much higher degree of vascularity in the stomach of this dog, particularly at the internal surface, than in either of the two others. 

The bile, too, had flowed freely into the duodenum, and the contents of the bowel were highly coloured with bile, and not at all tenacious. The corrugations were of the same character, viz. longitudinal. 

Observing that the vascularity of the stomach was greatest in the dog which took the smallest quantity of calomel, I procured a healthy dog, and without giving him any of this preparation, had him hanged, and examined five minutes after he was dead, in order to see the natural state of the stomach — 



393 

DETAILS OF EXPERIMENTS. 

at least unoperated upon, # and unchanged by any medicine. I was greatly surprised to find that the stomach of this dog was infinitely more vascular than that of either of the three dogs already examined, and was in what I really would have considered a high state of inflammation. The corrugations were circular, and more or less vascularity extended throughout the alimentary canal, which was covered with a glairy transparent mucus. 

In order farther to ascertain the correctness of these inferences, the following experiments were performed. 

At one o'clock, a. m., December the 6th, 1823, I gave 3iij. of calomel to two dogs each, that had been kept in a separate room for two or three days previously, and had been fed upon rice and sheep's head. After taking the calomel they were sick and vomited, but seemed to suffer no other inconvenience, for they ate well, and were seemingly in good spirits. 

At eleven, a.m., the Bth December, fortyeight hours after taking the calomel, one of the dogs was hanged ; the other was preserved, to shew that no inconvenience attended the ingestion 



394 

DETAILS OF EXPERIMENTS. 

of so large a dose of calomel, and this was amply proved, as the dog continued well, and was in better condition a month after the experiment, than he was before. 

I examined the dog that was hanged as soon as possible after he was dead,, and the following were the appearances exhibited : — 

The veins, as usual, were beautifully injected; the liver was quite sound, and the gall-bladder rather empty. The external appearance of the stomach, which was very much distended with rice, was of a pale colour, with some large blood-vessels spread over it ; and, on being laid open, the rice near the pylorus was marked with bile, of a beautifully bright orange colour, while that in the upper part, near the cardia, was perfectly unchanged. On removing the rice from the stomach, it was found that its surface only was tinged with bile. 

The stomach, cleared of the rice, exhibited a beautifully corrugated appearance throughout its whole surface, with a peculiarly pale, pink blush ; but nothing like excitement or vascularity was evident. 



395 

DETAILS OF EXPERIMENTS. 

The corrugations were in the transverse direction, and were more marked near the cardia, but were less so at the lower part of the stomach, near the pylorus, where it was deeply tinged with healthy bile. The whole surface of the duodenum was covered with bile, without shewing the slightest trace of vascularity or viscid secretion. 

The jejunum was filled with digested food, well mixed with bile; in the lower part of the intestine the contents were more consistent, and of that peculiar blackish grey colour which is always produced by mixing calomel with the secretion of the intestine. 

The inner surface of the colon was in a high state of arterial vascularity ; the transverse ridges being not unlike the valvulae conniventes in the human small intestine. 

The rectum was likewise in an increased state of vascularity, with longitudinal corrugations. 

From comparing the state of this dog's stomach with those which I first examined, it seems that the first effect of calomel, in large doses, is not only to diminish vascularity, but 



396 

DETAILS OF EXPERIMENTS. 

also to produce a peculiar action of the fibres of the stomach, and that this organ requires a certain period to elapse before it can resume its natural function. 

The appearances, on examination of another dog which had not taken calomel, were as follow : — 

The stomach was found corrugated transversely ; it was in a much higher degree of vascularity than in the case of the stomach of the dog which had taken calomel, and this vascularity extended throughout the duodenum ; but the lower part of the intestinal canal was less vascular than the stomach ; its surface was covered with a viscid, glairy, and transparent secretion, adhering to and spread over the whole intestine. 

The corrugations of the colon had precisely the same appearance as those in the stomach — they were transverse. The rectum was not at all vascular, and the corrugations in its inner coat were in the longitudinal direction. 

The accompanying drawings, taken from the subjects at the time, will shew the actual state of the internal surface of the stomach 



397 

DETAILS OF EXPERIMENTS 

and intestinal canal more clearly than any description ; and from them it will appear that calomel, even in these excessive doses, has the effect of diminishing vascular action, rather than of exciting it, which will account, in some degree, for the scruple doses of calomel at once allaying irritability of stomach and vomiting — a circumstance I have witnessed with astonishment, and for which I never could account till now. 

These experiments were followed up by the performance of others, and the results were always the same. lam led, therefore, to the following inferences, the former of which is confirmed by Dr. Yelloly's interesting paper on the vascular appearance of the human stomach, read to the Medico - Chirurgical Society, July 27, 1813, — that the natural and healthy state of the stomach and intestinal canal is high vascularity ; and that the operation of calomel in large doses is directly the reverse of inflammatory. 



398 

INFLUENCE OF CALOMEL 

SECTION 111. 

Of the Influence of Calomel on the Secretions of the Intestinal Canal, and on those of the Liver and Pancreas. 

The immediate influence of calomel upon the secretions lining the mucous surface of the intestinal canal, seems to be peculiar, and of a nature which deserves more attention than has been directed to it. It appears to me that this preparation produces a chemical action on these secretions, and that, in consequence of this action, their mechanical properties and appearances become greatly altered. I have often tried its effects upon the dead subject, and have always observed, that the tenacious secretion which is frequently found covering the mucous coat, is completely changed by the admixture of a small quantity of calomel with it in situ : this secretion assumes a dark grey colour, becomes more fluid, much less tenacious, and is easily detached from the mucous surface. It is singular, that the colour of the mucous secretion is nearly that produced by a combination of calomel and ammonia. It seems to 



ON THE INTESTINAL SECRETIONS, &C. 

399 

me probable, that this secretion occasions a partial decomposition of the calomel, and that a portion of the mercury is left in a state of a dark grey oxide, and imparts its colour to the secretion with which it is mixed. 

The dark grey appearance communicated by the calomel to the secretion covering the mucous coat of the intestines, is only remarked when there is no admixture of bile ; and it is remarkable, that this appearance is precisely the same with that which the alvine dejections assume after the administration of a full dose of calomel, in the acute diseases of India, and before the biliary secretions appear in the stools ; thus shewing the effect of the calomel upon the mucous secretions, in conjunction with its purgative operation, before it has succeeded in procuring the flow of bile either from the gall-bladder, or immediately from the liver itself. 

If, then, it thus separates the tenacious matter covering the mucous coat of the intestines, may not its operation upon this secretion in the duodenum be the means of removing such obstruction from the common duct, as this secretion may be considered to occasion ; and thus it may effect a discharge of bile 



400 

INFLUENCE OF CALOMEL 

into the intestine, which was only prevented by the mechanical obstruction placed in its way. In this case, the dose of calomel may be considered as acting chemically upon the mucous secretion, and mechanically as respects the duct. But this is only one mode of operation, as respects the biliary secretions, which we may reasonably bestow upon this remedy. Having shewn that the first operation of calomel is upon the mucous secretions of the intestines ; that it attenuates, changes, and detaches them from the surfaces to which they adhere, it seems not unreasonable to infer, that these surfaces are thus left more exposed to the influence of such other doses as may be subsequently administered, particularly when the secretions, which have been acted upon by the previous dose, have been more completely carried off by a cathartic draught, by which the first dose of calomel ought to be followed. These effects having been produced, the influence of the subsequent doses will be more immediately exerted upon the mucous surface of the duodenum, and this influence more readily propagated thence along the canals of the ducts, to the gallbladder, and to the liver itself; and hence, according to the state of the duodenum, and of the biliary apparatus at the period of employing 



ON THE INTESTINAL SECRETIONS, &C. 

401 

the remedy, will the effects of the calomel upon the hepatic secretion be more or less immediate. The same explanation will hold equally with respect to the pancreatic secretion, and satisfactorily account for the immediate and overpowering flow of bile which often follows a single dose of the medicine, as well as for the frequent exhibition of the remedy before the desired effects are produced by it. 

It can scarcely be expected that calomel will at once be absorbed, so as to act by its immediate presence upon the liver and gallbladder. If it does occasionally thus act, and in this manner increase the biliary secretion, whilst the common or cystic duct remains obstructed, considerable distress must arise from the increase of the quantity of bile in the gallbladder, which must be the result. As obstruction of the common and cystic ducts occur sufficiently often to make us prepared to expect it, and as its existence is sufficiently marked by the symptoms, and by effects of remedies, the mode of employing calomel which will most immediately act upon the obstruction ought, therefore, to be adopted. Now, from what has been already said, large doses of calomel, followed by cathartic draughts, are more likely to effect this than small doses often repeated, 

D D 



402 

INFLUENCE OF CALOMEL 

which will become absorbed, thus act immediately on the liver, and, by increasing the secretion of the bile, also . augment the disorder, without removing the obstruction. • 

Distension of the gall-bladder, from the accumulation of bile, is a frequent occurrence, but it is more often met with as a result merely of inactivity of the organ, and want of tone and energy of the duodenum and neighbouring viscera, or of viscidity of the bile itself, or of the tenacity of the mucous secretion occluding the opening of the common duct, and intercepting the action of irritating matters upon its mouth, than of obstruction of a more permanent nature. 

When a loaded state of the gall-bladder is inferred, from the presence of weight and oppression at the epigastrium, with a sense of coldness at the stomach, and various dyspeptic symptoms, then the purgative operation of calomel will succeed in procuring the discharge of the bile, unless there be a total obliteration of the canal through which it has to pass; and this and other purgatives ought to be employed until dark or dark green motions are procured — a colour which indicates that the flow of bile has taken place ; as shewn by several trials I 



ON THE INTESTINAL SECRETIONS, &C. 

403 

have made of the appearance which the matters contained in the intestines of recently dead subjects assume, when their tenacious mucous secretion, and a small quantity of calomel, are mixed in situ, and the bile lodged in the gall-bladder is poured upon the whole. In the first instance, as already pointed out, the admixture of calomel with this tenacious, mucous secretion and the feculent matter, produces a dark grey and pultaceous compound, similar to the first dejections proceeding from the exhibition of calomel before the flow of bile has taken place ; in the second instance, a dark green and more fluid compound is formed, similar to the character of the motions, when the biliary evacuation is occasioned by the use of this remedy. 

When, therefore, we see the change from dark grey — the colour which calomel alone gives the mucous secretion — to dark green, we may rest satisfied that the ducts are emulged, and that the calomel and cystic bile are acting conjointly upon the bowels. Hence, the propriety of continuing this remedy till healthy action be produced will appear evident. 

I consider the viscid secretion, already described as covering the mucous surface of the digestive canal, to be mrobidly increased 



INFLUENCE OF CALOMEL, &C. 

404 

during* many acute derangements, and particularly during those prevalent in India ; and I believe, that in some of them it is not only thrown out from the mucous service in increased quantity, but also in a deranged or altered condition from that which characterises it in health. When this is more particularly the case, the intestines, viewed externally, upon dissection of fatal cases of disease, seem thickened in their coats, and they communicate a pultaceous and doughy sensation to the touch. In some cases, this is even evident during the life of the patient, upon a careful examination of the denuded abdomen. Upon laying open the intestines, the quantity of this tenacious secretion seems often surprising, and it is chiefly observed in those wherein active purgation had been neglected during the treatment. It is upon this morbid and accumulated secretion, that the action of calomel is particularly manifested. This medicine prepares it to be acted upon by other purgatives, renders it more fluid, and less adherent to the contiguous surface ; and thus leaves the mucous coat in a cleaner and more suitable condition for the influence of whatever remedies may be subsequently administered ; and the functions of exhalation, secretion, absorption, &c. unobstructed by the thick coating which lined the surface in which these functions take place. 



405 

ON THE USE OF CALOMEL IN DISEASE. 

The experiments shew, that, in addition to these effects upon the mucous and other secretions, full doses of calomel tend to render the mucous surface of the stomach less vascular, whilst it seems to excite the arterial capillaries in the mucous coats of the colon. These effects should be kept" in recollection, and should have an important influence in regulating the indications with which calomel ought to be prescribed, and in adapting them to the pathological condition existing at the time of prescribing it. These experiments may serve to explain several phenomena hitherto imperfectly understood, and may, it is hoped, lead to farther research. 

SECTION IV. 

General Remarks on the Use of Calomel in Disease. 

It is not the intention of these observations to recommend the indiscriminate use of calomel ; but I maintain, from very extensive experience of its effects, and from the experiments already stated, that in many acute diseases, and particularly in those of India, it may be given boldly, 



406 

ON THE USE OF CALOMEL 

and without risk ; and that injurious effects are more likely to be produced by frequently repeated small doses, which keep up a certain degree of irritation and nausea, than by a full dose, given at once, and discontinued when the objects looked for are gained. These objects I conceive to be to allay irritability, diminish vascular action, and to cleanse the intestinal canal of the tenacious matter which often lines it, and, in many cases, almost completely obstructs the passage through it. 

In these diseases, therefore, in which we have reason to suppose, from the great irritability of the stomach, the state of the tongue, and the functions of the abdominal viscera, that increased vascularity of the digestive canal is present, with a deranged state, and accumulation of the mucous and other abdominal secretions, as in all the types of fever, dysentery, liver complaints, &c. — calomel, in doses of from ten to twenty grains, either alone or variously combined, according to the circumstances of the case, is an excellent remedy. 

In these diseases, I have been generally in the practice of giving, at bed-time, twenty grains of calomel, with one or two grains of opium, and sometimes without the opium, and 



407 

IN DISEASE. 

a smart purgative draught the following morning. This practice I have repeated daily, until the excretions assumed a healthy hue. A tonic laxative was then exhibited, and continued till the natural functions of the bowels were completely restored. In these diseases, I never wished to see the mouth in the least degree affected ; whenever this happened, I considered the salutary effects of calomel interrupted, because its use must be then discontinued ; and it was my object to act upon the secretions of the intestines, to diminish vascular excitement in the intestinal canal, and not in the most remote degree to act upon the salivary glands. 

It is evident from the preceding, that calomel is not a suitable medicine in those cases wherein an opposite state of the digestive canal and of the secretions to that described exists, and that it is calculated to prove injurious under such circumstances. Judgment, and an experienced discrimination, are requisite to the beneficial administration of this remedy under most circumstances ; and I consider that it is chiefly owing to the want of this, that it is so often used with little advantage, and that so much diversity of opinion exists amongst 



408 

ON THE USE OF CALOMEL 

medical men respecting the administration of it in various diseases. 

Although I was for many years fully aware of its effects in allaying irritation of the stomach, and in procuring abundant discharges of tenacious and morbid matters from the bowels, yet it is comparatively much more recently that I was led to analyse more closely its effects in disease. I always observed, that the frequent repetition of small doses of calomel generally produced nausea and uncomfortable feelings, and completely deranged the functions of the stomach, which was not the case with full doses of this preparation, when given at considerable intervals, and in such a manner as to act decidedly upon the secretions and functions of the bowels, and more particularly when aided by a purgative on the following morning. 

When it is desirable to affect the constitution with the mercurial action, and to keep up that action, in order to remove any glandular obstruction, I cannot advise this object to be attempted by means of the exhibition of small doses of calomel, given at short intervals. I have always found this practice attended with 



409 

IN THE TREATMENT OF FEVERS. 

unpleasant effects, and the digestive organs not unfrequently injured by it. I therefore recommend the blue pill in preference, and that the use of it, even, should not be pushed farther at any time than the production of a slight soreness of the mouth, and even not so far as that, if decided benefit follow the exhibition of the remedy, short of this effect. 

SECTION V. 

Of the Employment of Calomel, in the Treatment of Intermittent, Remittent, and Continued Fevers. 

Calomel may be given in the different forms of fever, in order to fulfil three distinct indications. The first of these is to diminish the irritability of the stomach, when that state exists, and more particularly, when it evidently depends upon increased vascular action in the internal coats of this viscus. The second intention with which this remedy may be exhibited, is to correct and to promote the discharge of the secretions on the internal surface of the digestive canal, and those of the large secreting organs, which are generally deranged in this class of diseases : and the third indication is 



410 

EMPLOYMENT OF CALOMEL 

to procure, by its means, under certain conditions which will come under consideration, increased action of the great secreting organs, and to excite the functions of the vascular system generally, without, however, inducing its specific operation on the salivary organs. This last indication is the one which ought more rarely to be resorted to, and when adopted, it should never be with the view of affecting the salivary organs ; because I believe, from extensive observation of its effects, that when calomel is given in the febrile diseases of warm climates, to such an extent as to excite these glands, it is then carried too far — so much so, as to occasion injurious effects upon the system. It then generally lowers the powers of life rapidly, and the state of excitement produced by it upon the vascular system has then commenced its termination in exhaustion. In order to elucidate the application of this remedy to the treatment of fever, I will consider it, first, as respects the cure of intermittent fever ; secondly, as regards the treatment of remittent fever ; and thirdly, as to its use in the continued fever of India ; and state, as briefly as I can, my own experience respecting it — which has been not inconsiderable — and the mode I pursue, and the indications I endeavour to fulfil in prescribing it. 



411 

IN THE TREATMENT OF FEVERS. 

1 . In Intermittent Fever. — I have been in the habit of prescribing calomel in the agues of India, in order to fulfil the three general indications above stated ; but I must remark, that, although I have considered it an important means of cure, I have not trusted to it alone, but have either combined it, or alternated the exhibition of it with other remedies, more particularly with other purgatives, and with large doses of bark in the intervals. 

As the intermittents of India occur both as primary and secondary diseases, the treatment of them must be varied accordingly. In the primary form of ague, i. c. when it appears either in a quotidian, tertian, quartan, or double tertian and quartan form, and not as the sequelae of remittents, I prescribe a scruple dose of calomel at bed-time, with a view of fulfilling the second general intention with which I resort to it, namely, to correct and to discharge the deranged secretions. I generally order it to be taken at bed-time, with a view of allowing it to operate its effects undisturbedly till the following morning, when it is desirable to procure full and copious evacuations of the morbid secretions which load the gall-bladder, and the internal surface of the stomach and intestines ; and which the previous 



412 

EMPLOYMENT OF CALOMEL 

dose of calomel has rendered more copious, and more easily operated upon by means of the subsequent purgative. The cathartic draught, which seems to be the best suited to procure the full discharge of the vitiated secretions, after the exhibition of the calomel on the previous night, consists of the infusion of senna, with salts and the tartarized antimony. Cases will occasionally occur, wherein it will be advisable to commence the treatment with the exhibition of an emetic ; and where there is little or no affection of the head or stomach, this remedy may be given, and, if possible, in the forenoon : but, even then, the scruple dose of calomel ought also to be taken at bed-time, and followed up the next morning by the purgative draught. 

On the second night of the treatment, the scruple dose of calomel may be repeated and followed by the morning purgative; or ten grains of calomel may be given, with five or six of aloes, and the morning purgative, as before, according as the state of the patient, and the appearance of the tongue and of the excretions, may guide the practitioner. As soon as the tongue begins to become clean, and the excretions assume a healthier character, the cinchona bark, combined with aromatics, 



413 

IN THE TREATMENT OF FEVERS. 

may be given in decided doses shortly before the expected paroxysm ; but, during the exhibition of the bark, calomel with aloes must be taken at bed-time, and an aperient draught in the morning. The bark ought not to be commenced with until the secretions have assumed a healthier character, and until hepatic bile is seen in the excretions ; and it ought never to be exhibited whilst pain, tenderness, fulness, and oppression, are felt in the hypochondriac and epigastric regions ; if these instructions be not attended to, and if the bark be exhibited before the deranged secretions are carried off, and whilst symptoms of deranged action of the liver are present, there will be great risk of inducing chronic inflammation of the liver and spleen, which, if not immediately attended to, will terminate in obstructions and permanent disease of these viscera. As soon as the disorder yields to this treatment, calomel may be given in much smaller doses, (if given at all,) and it may be combined with aloes ; but, in this stage of the disorder, I prefer the blue pill, with aloes and myrrh, and tonic laxatives through the day. As I have observed the dependance of the disease, in many instances, upon the full and new moon, the bark may be exhibited more liberally just previous to, and during the lunar 



414 

EMPLOYMENT OF CALOMEL 

changes ; attention being at the same time paid to the state of the secretions and excretions. 

It will frequently happen to the Indian practitioner to meet with cases of ague, wherein there have existed much functional and even structural derangement of the liver, previous to the attack of ague under which the patient is suffering at the time. In such cases, calomel may be given in from five to twenty grains, combined with opium and tartarized antimony, with a view of fulfilling the third indication laid down for the exhibition of this medicine, namely, that of exciting the vascular and secreting functions, of determining to the skin, and producing a deobstruent effect upon the liver. In cases of this description, the calomel should be alternated with tonic aperients and occasional laxatives, in order to keep up a regular and gentle action of the bowels and secreting organs ; but, at the same time, care should be taken not to push the calomel so far as to act upon the salivary glands ; for as soon as this effect is produced, it may be considered that the vascular excitement occasioned by it is about to terminate in the exhaustion of the tonic powers of the system, and that it will, if not immediately left off, do more harm than 



415 

IN THE TREATMENT OF FEVERS. 

benefit to the patient. It will also appear evident to the experienced practitioner, that, in cases of this description, bark cannot be exhibited, if at all, until the derangements of the glandular viscera have been almost, or entirely removed by the practice already pointed out. And even when this is accomplished, I prefer the adoption of tonic vegetable infusions, combined with gentle laxatives, to the use of the bark ; or, if lat all adopt the latter, I prefer it in the form of infusion or decoction, in combination with rhubarb, or any other tonic laxative. 

As great irritability of the stomach is often present with the paroxysm of ague, scruple doses of calomel, with one or two grains of opium may be given, in order to allay this symptom ; thus fulfilling the first indication for its exhibition, without interfering with the other objects kept in view during the administration of this medicine. 

The observations which may be offered on the use of calomel in the cases of ague which commence as remittents, will be made more appropriately under the following head, ague being merely the sequela of the remittent disease. 



416 

EMPLOYMENT OF CALOMEL 

2. In Remittent Fever. — The mode I have adopted of exhibiting calomel in this type of fever, will be best explained by the following brief detail of the general treatment of it which I pursue, and which, from long experience of its beneficial effects, I venture to recommend. 

In the first place, I endeavour to relieve the most urgent symptom, which is headach, by bleeding, either local or general, according to the habit of body of the patient, and the time he has been in India. I then give an emetic, or a full dose of calomel, according to circumstances. If the tongue be foul, and the patient complain of a bitter taste in the mouth, I generally prefer the former, giving also the latter at bed- time, after the operation of the emetic ; and following it up by the exhibition of a smart purgative on the next morning. If these have not the effect of producing very copious evacuations, cathartic enemas are administered; the saline mixture, with the spiritus setheris nitrosi, and the tartarized antimony, is continued throughout the day. Urgent symptoms, such as congestion in the viscera of any of the great cavities, are narrowly watched, and local bleeding, if necessary, had recourse to, more particularly with a view of relieving determination to the head, liver, or lungs. 



417 

IX THE TREATMENT OF FEVERS. 

Calomel is again repeated at bed-time, a purgative in the morning ; and this plan is followed, until the more urgent symptoms are subdued, and more complete intermissions and 

regular paroxysms are produced. An alterative and laxative course of medicine is then commenced, and the cinchona bark thrown in to prevent the return of the paroxysms, which are more particularly expected at certain periods of the moon, as the full and change. When it is ascertained at what time of the moon's age the paroxysms supervene, the bark is given two three days previous to that, and continued until the period has elapsed, when it is discontinued, and the alterative course again commenced and pursued until the next change of the moon, and so on till the patient recovers. Under this plan of treatment, I have never observed any instances of those enlarged abdomens, arising from chronic obstruction of the contained viscera, which are common in India, and which are referred to in my reports. .In the remittent type of fever, as well as in the intermittent form into which the fever thus passes, it will be seen that calomel may be required to fulfil, according to circumstances, its three general intentions. It is sometimes necessary to exhibit it in scruple doses with opium, in order to allay the irrita- 

E E 



418 

EMPLOYMENT OF CALOMEL 

bility of the stomach occasionally attending the paroxysm. It is always necessary to give it in order to fulfil the second intention, and then it should be exhibited in the manner, and combined and followed up according to the plan, already detailed. When there exists chronic disease of the glandular viscera of the abdomen, in complication with this type of fever, calomel may be prescribed, so as to fulfil the third indication, in the manner already noticed ; and after it has satisfactorily accomplished this, tonics, combined with aperients, and occasional laxatives, may be given in order to complete the cure. 

3. In Continued Fever . — The continued fevers of India, as I have remarked in my reports, are of a decidedly inflammatory character in their first stage. The tongue is generally white,* coated with a glairy mucus, the papillae large and prominent, and somewhat dry. There is much determination to the encephalon, oppression at the praecordium, and fulness about the pit of the stomach. The bowels are generally costive, the abdomen full, and the 

* This state of the tongue is what I have generally expressed by the term " excited," as it indicates excitement of the system, and that the patient can bear bleeding and other evacuations, which always remove it. 



419 

IN THE TREATMENT OF FEVERS. 

skin hot and dry. The stomach and intestinal canal partake largely of this increased action, and their mucous surface may be considered as being covered with a similar morbid secretion to that observed on the tongue and fauces, which accumulates, and becomes more and more viscid and tenacious, and consequently more difficult to be removed, in proportion to the time it is allowed to remain undisturbed. I consider that this viscid matter keeps up considerable irritation in the system, and contributes greatly to increase the derangement of the chylopoetic viscera, and to prolong the fever. These circumstances are evinced by the copious discharge of vitiated matter from the bowels by means of appropriate purgatives, and the effects following its expulsion. 

Calomel, in full doses, by means of mixing with, dissolving, and separating viscid matter of the above description, as shewn by the experiments already detailed, facilitates its expulsion from the bowels, upon the subsequent action of a brisk cathartic. Nor is the operation of the calomel limited to the mucous surface of the stomach and intestines, diminishing the vascularity of the former, and exciting capillary action in the large intestines ; it also promotes the discharge of the contents of the 



420 

EMPLOYMENT OF CALOMEL 

gall-bladder into the duodenum, and corrects and increases the secretions of the adjoining viscera, and of the mucous surfaces with which it comes more immediately in contact. I consider this to be its primary and principal effect in this stage of the disease ; it should therefore be continued as long as the dejections are viscid, or unnatural either in consistence or in colour, and without reference to the quantity taken ; because, so long as the dejections are morbid, calomel alone, and in combination with aloetic purgatives, is the only medicine I have found decidedly effectual in clearing the intestinal tube from this morbid and accumulating matter. In the inflammatory stage of the fever, the practitioner runs but little risk of its producing its specific effects, which ought certainly to be avoided ; for although it is given in such cases generally after venesection, yet the excitement of the system is too great to allow this effect to be produced. But it must be recollected, that I recommend calomel, in this type of fever, entirely with a view of fulfilling the first and second general indications only, and that here, as in the former types of fever, I advise it to be alternated with active doses of cathartics ; and often also to be combined with aloes, thus preventing its absorption into the circulation. 



421 

IN THE TREATMENT OF FEVERS. 

When there is much irritability of the stomach, calomel should be given in full or scruple doses, with opium,* in order to allay that unpleasant symptom ; but, when irritability of stomach is not present, it ought to be prescribed at bed-time, as in the former cases, either in similar doses, or in smaller ones, combined with aloes. The purgative draught should never be omitted to be given in the morning, regulating its activity in such a manner as to render it unnecessary to repeat it throughout the day, without pushing its cathartic operation too far. 

When there seems to be sufficient reason to suspect any degree of spasmodic constriction about the gall ducts, preventing the flow of bile into the intestines, it will then be advisable to give a scruple of calomel, with two or three grains of opium, at bed-time. If, how- 

* The addition of opium to the calomel will not tend to impede the purgative operation of the latter, when given in the dose above recommended ; but, on the contrary, will promote its action, by allaying the spasm which, in the diseases under consideration, is generally present in parts of the small and large intestines, and prevents the full operation of purgatives. Its operation in this way being secured by the opium and the purgative draught, there is but little risk of affecting the mouth by the calomel. 



422 

EMPLOYMENT OF CALOMEL 

ever, from the thick coating of the tongue and fauces, and the appearance of the dejections, the flow of bile seems to be prevented by the obstruction which the morbid secretions covering the duodenum may offer to the mouth of the common duct, I then prefer a combination of calomel with aloes ; giving, also, in both instances, a cathartic draught in the morning. If either of these means fail, an emetic ought to be immediately prescribed, and, if there be occasion, it should be followed by either of the means already detailed, appropriating them in the way now described. By this plan of treatment put in active operation during the acute stage of the disease, the subsequent state of exhaustion is generally prevented; but when the disease has advanced to this latter stage, and the typhoid symptoms are present before the patient comes under treatment, the secretions are then much more vitiated, and accumulated to a much greater extent than in the former stage. The fuliginous coating of the tongue, teeth, fauces, and lips, and the appearance of the motions, sufficiently prove this; but it is evident, that whilst these remain in the prima via, cordials and tonics can avail but imperfectly. The obvious intention is to procure their expulsion from the body by such means as will effect the object most 



IN ACUTE DISEASES, &C. 

423 

readily, without lowering the energies of life. With this intention, from five to ten grains of calomel, in conjunction with rhubarb, aloes, or jalap, should be prescribed, and repeated according to circumstances ; whilst the energy of the system must be supported with wine and beef-tea, or other appropriate means, carried to an extent which the state of the patient requires, attending also to his wants and wishes in the choice of them. 

SECTION VI. 

Of the Use of Calomel in the Acute Diseases of the Liver and Gall-bladder. 

Calomel ought to be employed, next to general and local depletion, in the acute derangements of the biliary organs, in order to produce its purgative effects. But whether the disease be seated more particularly in the membranes and towards the surface of the liver, or in its secreting or parenchymatous structure, or in the gall-bladder or ducts, this medicine should always be exhibited as a purgative only, and never in such a manner as may give rise to its absorption, and consequently to its constitutional effects. When 



424 

CALOMEL IN ACUTE DISEASES 

prescribed as a purgative, in the dose of about ten grains, with aloes, &c, and followed by the cathartic draught, as formerly pointed out, it operates as an active derivative to the mucous surface of the large intestines, and elicits the discharge of the biliary secretions from the hepatic ducts and gall-bladder, which, if allowed to remain, would prove a source of irritation to the inflamed parts in the vicinity. 

I am anxious, in acute affections of the biliary organs, to avoid the constitutional effects of calomel, because I believe, that when these are produced, the energies and vital resistance of the system are thereby impaired, and the presence of this mineral in the circulation tends to keep up, in the inflamed part, a degree of excitement and irritative action which would otherwise subside, and which, I am persuaded, tends in many instances, when allowed to proceed, to occasion chronic derangements of this viscus, and even to give rise to abscesses, if the inflammation be seated in the glandular structure of the organ. 

The observations already offered equally apply to inflammation of the gall-bladder and ducts. These derangements are more generally complicated with acute disease of the 



425 

OF THE LIVER AND GALL-BLADDER. 

liver, but they occasionally occur alone. Their existence may be inferred from the presence of pain, constriction, and oppression about the pit of the stomach, occasionally darting to the dack and shoulder blade; and from the irritability of the stomach, particularly after the injection of cold fluids. In such cases, general and local depletions, followed by warm poulticing and fomentations, must be first put in practice, and afterwards calomel and purgatives ought to be prescribed, as already pointed out. It occasionally happens, that, when the inflammation is seated in the cystic or common duct, considerable obstruction is thrown in the way of the discharge of the cystic bile, owing to a partial or complete occlusion of the canal, by means of the lymph thrown out from its inner surface, or owing to the spasm which accompanies the inflammatory state. In these cases, the bile remains pent up in the gallbladder, occasioning, in addition to the more characteristic symptoms of the disease of the ducts, various phenomena referrible to the stomach, with some degree of jaundice and hypochondriasis. In these cases, although the inflammatory state may not be well marked, yet the experienced practitioner will be led to recognise the derangement existing from the assemblage of symptoms present, and will 



426 

USE OF CALOMEL IN 

employ a decided and efficacious plan of cure. He will resort to general depletion whenever the habit of the patient can admit of it, but more particularly to local depletion, repeated according to its effects, to warm-poulticing and fomentations, or to counter-irritation on the surface of the body ; and to the administration of calomel in active doses, combined or alternated with cathartics, so as to produce a decided effect upon the secretions, and upon the functions of the intestines. 

SECTION VII. 

Of the Use of Calomel in Chronic Disorders of the Biliary Organs. 

The simplest form of chronic disorder of the liver is that consisting of imperfect discharge of its functions. This is often the first stage of liver disease, and may lead to acute hepatitis, as well as to chronic forms of this disease ; but I believe that the latter are the more frequent result. Imperfect function of the liver generally depends upon debility of the constitution, especially upon debility of the digestive canal. It may be treated by the usual means employed to remove this state, with the addition, or the occasional use, of calomel as a purgative, joined 



427 

CHR-ONIC DISORDERS. 

with aloes and myrrh, or with the blue-pill, similarly combined. But in this form of disorder mercurials ought not to be prescribed, so as to occasion ptyalism. 

When this simple form of deranged function continues long without correction, it generally terminates in congestion of the portal veins, and engorgement of the duets conveying the bile from the secreting structure of the liver, and Lb also occasionally complicated with a loaded state of the gall-bladder. 

This more complicated form of chronic deranged function may be inferred from a muddy or yellowish cast of countenance, with a heavy expression of the eye, and a dirty yellow tinge of the tunica albuginea. The digestive functions are usually much impaired, and the alvine motions either pale, of a clayey colour and consistence, or particularly dark and offensive. The patient complains of no pain in the region of the liver, but he feels a sense of oppression and fulness at the epigastrium ; he loses flesh and strength, his pulse becomes languid and feeble, and his spirits depressed. 

In these cases, the treatment may be advantageously commenced by the exhibition of 



428 

USE OF CALOMEL IN 

calomel, either alone or with aloes, or the compound cathartic extract, at bed-time, and of the usual purgative draught the following morning. These remedies ought to be continued until the stools assume a healthy appearance, when the blue-pill and aloes may be given at night, and tonics, with laxatives, through the day, until the digestive functions are restored, and the system returns to its accustomed vigour. When these fail in accomplishing their object so readily as may be desired, the nitro-muriatic acid bath should be resorted to ; and a blister may be applied over the region of the liver, in addition to the foregoing means. 

The derangement now described may be neglected, or it may be partially removed, in which case it generally returns. In either instance it will terminate, in a longer or shorter time, according to circumstances, in more serious disorder. It will give rise to vascular action, of a sub-acute kind, in the substance of the liver, which, whilst tending to overcome the obstruction previously existing, also gives rise to the effusion of lymph in the structure of the part where such reaction supervenes. Thus, enlargements of parts, or of the whole of the liver, take place ; or the formation of tubercles and schirrous hardness is the result, 



429 

CHRONIC DISORDERS. 

even although the patient may not have been the subject of previous acute disease of this viscus. It ought, however, to be remarked, that this, as well as the other chronic derangements of the biliary organs, are often the result of a previous attack or attacks of acute hepatitis ; but whether occurring as the sequelae of the acute form of the disease, or as the primary disorder, either in a patient who has enjoyed previous good health, or in one who has suffered under some other disorder, as intermittent, or remittent fever, &c. the symptoms and the treatment will be nearly the same in most of their important constituents. 

The form of chronic disorder now under consideration is indicated by the^ presence of the greater number of the symptoms already detailed, with the addition of a dull pain under the blade or top of the right shoulder, with uneasiness, and occasional pain and fulness in the region of the liver, or at the epigastrium, with a white or foul tongue, dry harsh state of the skin, occasional slight paroxysms of fever, &c. This form of disorder requires the exhibition of calomel in the manner already pointed out, in conjunction with local depletions, blistering on the region of the liver, warm poulticing, and the nitro-muriatic acid bath. In this form of disorder, the alternate use of large 



430 

USE OF CALOMEL IN 

doses of calomel, and the cathartic draught, is required for a longer period, and the subsequent employment of aperients and laxatives should also be longer persisted in. More caution is requisite in resorting to the exhibition of tonics, and these should never be prescribed uncombined with aperients or laxatives. 

In addition to the congestion of the portal veins, with a loaded state of the biliary canals, and sub-acute action in parts of the viscus now alluded to, producing enlargements and tubercles where such derangements are seated, we not uncommonly find upon dissection an engorged state of the gall-bladder, with great distension of Jhe hepatic ducts. In these cases, the bile contained in the gall-bladder is generally dark green, of a thick consistence, and extremely viscid ; at other times it is almost as black as tar, and scarcely can be made to pass through the ducts. Occasionally, the bile accumulated in the gall-bladder is of a straw colour and gelatinous consistence, and with difficulty can be squeezed through the cystic duct. In many instances, wherein a loaded state of the gall-bladder — such as is now pointed out — 'has been observed, in dissections of those who have died either of fever, dysentery, icterus, or of hepatitis itself, the ducts 



431 

CHRONIC DISORDERS. 

have been more or less diseased. In some cases, they seem to have been spasmodically contracted ; in others, they have been almost impervious, most probably from previous inflammation. In other instances, they seemed only to have been plugged up by the thick and viscid nature of the secretion ; and in a few cases, lymph seemed to have been effused from the internal surface of the inflamed canal, and to have obstructed the passage of bile. These derangements, as far as my own observation goes, have generally been confined to the cystic duct. 

Although these pathological conditions of the biliary apparatus have been most unequivocally shewn in dissections of fatal cases, wherein there existed evidence during life of hepatic disorder, yet I have had sufficient proofs of their existence in cases wherein medical treatment has proved efficacious, inasmuch as the symptoms characteristic of these derangements were equally present under both circumstances. These symptoms are, in addition to those already pointed out, a sensation of distension and tightness about the epigastrium and praecordium, and a feeling of coldness at the stomach, with flatulence. The tongue is generally foul, and covered by a glairy mucus. The pulse is 



432 

USE OF CALOMEL IN 

not affected. The stools are deficient in bile, and the bowels generally irregular, sometimes constipated, at other times relaxed. The urine is muddy, dark coloured, and deposits a brownish sediment. There is frequently jaundice, although not always, and the countenance is generally muddy and sallow. 

These derangements require the purgative operation of calomel, alternated with the exhibition of the cathartic draught, as already pointed out, and combined, as circumstances may require, with aloes, colocynth, cathartic extract, and occasionally with opium. This treatment should be continued for some time, but it ought not to be trusted to alone. I have generally employed at the same time, various stimulating liniments on the hypochondriac and epigastric regions, warm poulticing, blistering, and, if the patient at all complained of pain, I never omitted local blood-letting. 

It is possible that the inexperienced practitioner may mistake a loaded state of the colon for these derangements; but attention to the evacuations, and to the operation of the purgatives prescribed, will be sufficient, independently of other appearances, to point out the actual nature of the disorder. 



433 

ACUTE DYSENTERY. 

SECTION VIII. 

Of the Use of Calomel in Acute Dysentery. 

The acute dysentery of India is almost exclusively confined to the caecum, colon, and rectum, as respects the existence of inflammation of their internal surface; but functional derangement is general throughout the whole digestive canal, even for several days before the dysenteric symptoms become fully formed. It is from attention to this primary derangement, that the experienced practitioner is enabled to foretell the consequences, and is led to adopt measures which frequently succeed in averting the disease that would inevitably supervene if it were neglected. Hence it will appear, that confirmed dysentery may often be considered as the result of previous disorder, which might have been checked by judicious treatment, but had been either neglected by the patient, or overlooked by the medical attendant. As the disease becomes developed, the functional disorder runs into vascular derangement, particularly in the large intestines, and this derangement is soon productive of serious alterations of the structure of the interior of this part of the canal. 

F F 



434 

USE OF CALOMEL 

During the early period of disorder, the state of the tongue, fauces, and stools, generally betrays the existence of an accumulation of the same kind of tenacious secretion on the villous coat of the digestive canal as has been already described, and the same remedies as those already referred to are required to remove it. In the stage of the disease under consideration, before the dysentery becomes fully formed, much advantage will result from the exhibition of a scruple dose of calomel at bed-time, and a cathartic draught on the following morning. These remedies not only act upon the morbid secretions, but also have the effect of allaying the irritability of the upper part of the canal, and of imparting a stimulus to the vessels of the villous coat of the large intestines, which tends to subvert the disordered action which is commencing in them, — modes of operation which are evinced by the preceding experiments, and the observations which I have been enabled to make. 

It often appears, from the state of the tongue and of the excretions, and from the appearances observed upon the dissection of the fatal cases, that the morbid secretion already alluded to is thrown out in great abundance upon the internal surface of the stomach and small 



435 

IN ACUTE DYSENTERY. 

intestines, through the whole of the progress of the disease. The propriety of removing it, therefore, must be obvious, so that its accumulation, and the changes which would result therefrom, might not become a source of irritation to the inflamed surface of the caecum and large intestines in the advanced stages of the disease. And I think there is great advantage derived from removing this disordered secretion, by the means already indicated, inasmuch as the calomel seems to change its character in the course of operation, whilst this medicine itself appears to be in some degree decomposed in the course of its admixture with this secretion, and rendered more mild in its action upon the inferior parts of the canal. 

These inferences being admitted, more particularly the undoubted effect which the calomel produces upon the secretion which lines the internal surface of the duodenum, and which often obstructs the mouths of the ducts that open into this intestine, it must follow, that a very beneficial operation of calomel in dysentery, consists in the removal of the obstruction thus placed in the way of the secretions which flow from these ducts. It appears, in conformity with the laws and objects of nature, that the combined operation of the biliary and pancreatic 



436 

USE OF CALOMEL 

secretions upon the intestines should be necessary to the healthy discharge of the functions of these organs) and that their entire or partial obstruction must be followed by disorder of those parts, for the purposes and healthy condition of which they are intended. Hence the propriety of endeavouring to remove every obstruction which may stand in the way of the biliary and pancreatic fluids, in order that their salutary operation upon the diseased surface of the lower intestines may be exerted ; and that obstructions are often placed in the way of the flow of these secretions, in cases of dysentery, is a fact which is sufficiently well established, and one which so far merits particular attention, as it forms the basis on which we must often place the most important indications of cure in this disease. Indeed, the presence or absence, and the healthy or disordered appearance, of the biliary secretion in the stools of the dysenteric patient, will prove to the Indian practitioner the most important guides which he can follow in the treatment of this malady — guides which he can never follow too closely, nor. with disadvantage. He will often have cause to know, that whenever healthy bile appears in the stools of the dysenteric patient, much advantage will result from it ; whilst, on the other hand, whenever 



437 

IN ACUTE DYSENTERY. 

the bile is either deficient or disordered, as it very frequently is in this disease, that the patient will never derive permanent advantage from medical treatment until these disordered states shall have been removed. It seems as if the natural stimulus of healthy bile were necessary to the due discharge of the intestinal functions, and that a morbid condition or deficiency of this fluid, if not always one of the efficient causes of dysentery, often at least disposes to its supervention. 

From what has been said in my remarks upon the treatment of disorders of the biliary organs, and from what has been now stated, it will appear sufficiently obvious that the use of calomel, continued in the manner already pointed out until the disordered state of the biliary secretions generally present in dysentery shall have been corrected, is one of our most efficacious means of cure in this disorder. 

In addition to a scruple of calomel given at bed-time, and a purgative draught the following morning, in order to carry off the diseased secretions lining the internal surface of the intestines, to remove biliary obstructions, and to procure a flow of healthy bile, it will often be necessary to exhibit calomel through the day, in order to act upon the skin, and upon 



438 

USE OF CALOMEL 

the liver, through the medium of a partial absorption ; but care must be taken not to continue the remedy in this manner until it shall affect the mouth, which ought not in any case to be made sore by it, for the reasons I have assigned when treating of the use of calomel in fevers, (see p. 410). When I have given calomel in this way, I have usually prescribed three grains of it, in combination with three or four of ipecacuanha, and one of opium ; and this combination I have generally directed to be taken three times in the course of the day. 

It may be proper to mention, that in full and robust subjects the treatment ought to be commenced by one or two copious bloodlettings, and, if necessary, by the application of leeches upon the abdomen, whenever the disease is fully formed. When the patient's strength and habit cannot admit of one large bloodletting, the application of leeches ought not to be neglected, and they should be followed by semicupium, pediluvium, poultices laid on the abdomen, small anodyne and emollient injections, and afterwards by flannel bandages. 

After the acute symptoms are removed, the calomel, in the manner now recommended, should be either altogether discontinued, or 



439 

IN ACUTE DYSENTERY. 

given only occasionally, when its operation may be assisted by mild, oleaginous, or saline aperients, as circumstances may require. It will generally, however, be found, in this stage of the disorder, that the blue pill, with aloes and myrrh at night, and tonic laxatives in the morning, will promote convalescence, and avert the chronic form of the disease. 

The reader will recollect, that it is not my object to give, under the head of these remarks, a full account of the treatment of dysentery, but merely my wish to point out the manner in which, according to my experience, calomel may be most advantageously used in the cure of this destructive disease. 

It has been considered by several physiologists, that the decarbonisation of the blood takes place to a great extent in the internal surface of the large intestines, and particularly in the caecum. If such be actually the case, the blood circulating there must be in a highly carburetted state ; and, owing to the effects of this kind of blood upon the vessels containing it, congestion must be a frequent consequence whenever the decarbonising process is impeded or interrupted, or whenever the great mass of this fluid is thrown in upon the internal viscera 



440 

USE OF CALOMEL 

by means of cold applied to the surface of the body, or whatever lowers the energy of the heart's action. Congestion, carried to any considerable extent, will frequently be followed by inflammatory action, either of an acute, sub-acute, or chronic character ; and hence will often result confirmed dysentery, attended by destruction of parts in its more advanced stages. There can be no doubt that the caecum, where it is supposed that the decarbonising process is chiefly effected during health, is the part particularly diseased in dysentery. This fact is sufficiently proved, on dissection of fatal cases of the disease ; and seems to indicate, that the derangement of the functions of this part quickly proceeds to produce alterations of its structure, owing to the particular nature of these functions, as above explained. 

If it be allowed, that one of the effects of large doses of calomel is to occasion increased capillary action in the internal surface of the large intestines, the propriety of prescribing it in this manner, in the various forms of dysentery, cannot well be disputed, inasmuch as we give a remedy which, independently of its effects upon the secretions, tends directly to remove the congestion in the caecum now 



IN CHRONIC DYSENTERY, &C. 

441 

alluded to, to stimulate the overpowered vessels, and by imparting to them a new action, supersedes the morbid one existing at the time when it is exhibited. 

SECTION IX. 

Of the Use of Calomel in Chronic Dysentery and Diarrhoea. 

Chronic dysentery, and occasionally diarrhoea, arise from neglected or ill-treated acute dysentery. The state of the tongue and of the stools must be our guide in the exhibition of calomel in these complaints. When the tongue is coated and foul, and the dejections small, difficult, and consisting of blood and mucus, a scruple of calomel with two grains of opium, or ten grains of calomel with five of antimonial powder and one of opium, may be given at bed-time, and followed by the exhibition of an aperient the next morning. If these act, they generally bring away clay-like and tenacious motions, which shew the necessity of continuing the treatment until healthier evacuations are procured. If these means fail on their first exhibition, which is often the case, they ought nevertheless to be continued until they produce 



442 

USE OF CALOMEL 

their effects ; but not to the exclusion of other means, as the warm bath and antimonials, so as to determine to the surface of the body, emollient and anodyne injections, — the latter in small quantities, in order that they may remain in the rectum, and warm bandaging. These means having answered their purpose, and the motions having assumed a healthier character, an alterative treatment ought to be adopted, consisting of the blue pill, with aloes, myrrh, &c. and vegetable tonics, with gentle laxatives; and these should be persisted in until the system resumes its vigour, and the digestive and alvine functions are completely restored. 

The Indian practitioner will seldom meet with cases of chronic dysentery or diarrhoea, unaccompanied by chronic disease of the biliary organs. The evacuations are usually deficient in healthy bile, and if there be any of this secretion in the stools, it generally presents a morbid appearance. In these cases I prefer the use of the blue pill, alternating it with a combination of calomel, tartarised antimony, and opium at night, and the usual purgative draught the following morning. As it is an important object to excite the healthy action of the liver in these cases, and to procure the flow of bile into the intestines, the application 



443 

IN CHOLERA. 

of a large blister over the right hypochondrium, in conjunction with the means already pointed out. will prove an efficacious means of accomplishing this object. This plan should be persisted in, without regard to the quantity of medicine exhibited, until the wished for effect is produced. Calomel, in the doses above recommended, is particularly efficacious in bringing away the viscid and clay-like secretion which lines the intestines and cells of the colon, and in procuring a flow of healthy bile ; but in these cases, saline purgatives ought not to be selected, as they produce watery motions, exhaust the patient, and have little or no effect upon the biliary and other glandular secretions in this form of the disease ; although, in some instances, the Epsom salts may be combined with the bitter aperient mixture* with advantage. 

SECTION X. 

Of the Employment of Calomel in Cholera. 

It is unnecessary at this place to enter into any details respecting the exhibition of calomel in the epidemic cholera, after the full 

* See page 278 for this mixture. 



444 

USE OF CALOMEL 

exposition I have given of the treatment of this disease in the first part of this work, and after the particular mention I have there made of the use of calomel, and of its operation upon the secretions in that disease. I may, however, state, that I have found it an excellent remedy in combination with opium, and, occasionally, with aloetic purgatives, or alternated with them and other medicines of the same class, in fulfilling the first and second general intentions with which I resort to the use of this remedy, (p. 409). The same general indications have led me to employ this remedy in the common or sporadic cholera of India : and in this form of disease, whether it has been characterised by an unusually copious discharge of the bilious secretions — constituting it the bilious cholera of some authors ; or by spasm of the gall ducts, and an absence of this secretion from the matters ejected from the stomach and bowels —as in the mort de chien of other writers, I have generally derived much advantage from its decided exhibition. In the dose of twenty grains, with two or three grains of opium, I have found it successful in allaying the inordinate action of the stomach in the former variety of the disease, and carrying downwards the biliary secretions, particularly when aided by the subsequent 



445 

IN DISEASES OF CHILDREN. 

exhibition of a purgative draught, or of emollient diluents, as circumstances may have required. In the latter variety, which has received the name of mort de chien, the same combination seems to act upon the biliary ducts, relaxing spasm, or removing obstruction from the mouths of these canals. These ends being obtained, and the general commotion of the system being allayed by means of the combination of this medicine with opium, the second general indication, namely, that of correcting and discharging the disordered secretions, is best answered by combining it with such other remedies as circumstances may require — • as a few grains of it, with ipecacuanha and opium, and alternating its exhibition with gentle alteratives and tonic laxatives. 

SECTION XI. 

Of the Use of Calomel in some of the more Prevalent Diseases of Children. 

Ist. In Constipation. — The intestinal canal of children is often loaded with a viscid pultaceous matter, which, when neglected and allowed to accumulate, often leads to farther 



446 

USE OF CALOMEL 

disease of a more serious nature, and not unfrequently to the most fatal maladies. Under such circumstances, calomel, exhibited in the manner already described, is the most suitable remedy, as it detaches this matter from the mucous surface of the intestines, and prepares it for the more full operation of a suitable aperient, subsequently exhibited. When this loaded state of the intestines exists, calomel may be given in a very full dose, and repeated, until we are led to conclude, from the appearance of the tongue and of the motions, that this state is removed, and that a healthy discharge of the biliary and other secretions has been established. 

If we endeavour to analyse the operation of calomel in constipation, we shall be led, by a close observation of its effects, to conclude, that this operation is first exerted upon the accumulated secretion in the bowels, which tends to prolong the derangement whence itself not unfrequently sprung; secondly, upon the mucous surfaces themselves, and through the medium of them and of the nerves supplying the bowels and adjoining viscera, upon the secretions of the mucous follicles, upon the muscular tunics of the intestines, and upon the secretions of the liver and pancreas. 



447 

IN DISEASES OF CHILDREN. 

Having exhibited, and repeated according to circumstances, a full dose of calomel to children, namely, from five to fifteen grains at bed-time, and given a dose of castor oil, or any other purgative, in the morning ; and having thus secured the immediate effects of the treatment — the removal of constipation, and a natural appearance of the motions and of the tongue; our next endeavour ought to be to prevent the functions of the intestinal canal from relaxing into their former state of inactivity, and the mucous secretions from accumulating upon the inner surface of this canal. This end is best obtained by exhibiting, immediately after the calomel has performed its purposes, gentle doses of alterative aperients at bed-time, and active doses of tonics through the day. By these means, the general health and strength of the young patient will rapidly improve, and the functions of the prima via gradually assume a regular character. 

2. In Worms. — There is no state which leads more directly to the formation of worms than constipation, and the accumulation in the intestines of the viscid mucous secretion already noticed, which is both co-existent with, and consequent to the want of action of these 



448 

USE OF CALOMEL 

viscera. This secretion forms the nidus in which they are generated ; whilst the want of action of the parts enclosing them allows them an undisturbed possession of their tenement. The decided benefit resulting from the exhibition of large doses of calomel in disorders of this kind, is not so much owing to the effects of this preparation upon the worms themselves, as to its influence in detaching the viscid matter in which they lodge from the intestinal surfaces, and thus enabling these viscera, upon the subsequent exhibition of a cathartic, more particularly to exert their action both upon the worms and the matter in which they burrow, as upon foreign substances. 

Whilst the stools are deranged, in cases of worms, the use of calomel in large doses, at bed-time, ought not to be relinquished, the patient having abstained from food for five, six, seven, or eight hours, according to his age and strength ; for whilst the motions are either slimy, or of a tenacious and putty-like appearance, or whilst they are otherwise unnatural, either in colour, consistence, or odour, it should be inferred that the deranged secretions lining the villous coat are not entirely brought away, and that while any of it remain, it may 



449 

IN DISEASES OF CHILDREN. 

contain some of those animals which we wish to remove, and which will soon generate a numerous offspring, if allowed to lodge in the bowels. 

When, on the other hand, the motions present a natural appearance, then it may be concluded that the deranged secretions are brought away, and that all obstruction has been removed which formerly impeded the flow of the biliary and pancreatic juices, and the discharge of the secretions of the mucous follicles into the viscera, whose healthy functions they all are destined to promote. This having been effected, light and nutritious diet should be given, and tonic and gently aperient remedies exhibited, with a view of restoring energy to the functions of the digestive and assistant digestive organs, and of preventing the accumulation of the secretions which are so abundantly thrown out from the mucous surface of the bowels of children, which, when allowed to remain undisturbed and to accumulate, become vitiated, cause various derangements, particularly in organs intimately associated in function with the intestines, and sympathising in their disorders, and which furnish a nidus for the generation of those parasitic animals which prey upon the weakened constitution. 

G G 



450 

USE OF CALOMEL 

3d. In Marasmus. — At the commencement even of this disease, the abdomen of children is generally tumid, frequently of a doughy kind of hardness, and the state of the bowels is always irregular. In marasmus more particularly, and indeed in the majority of the disorders of children, the stools are often green, slimy, dark brown, and variegated ; and even when they are of a healthy appearance as respects colour, they will be found, on a closer examination, viscid and tenacious. Sometimes they have a clay-like appearance, at other times they are like glazier's putty ; occasionally they contain shreds of coagulable lymph, giving rise to the suspicion that the mucous membrane is coming away in places ; and not unfrequently they even resemble the green matter which accumulates on the surface of stagnant water. Whenever motions of the kind now noticed are observed, whether they occur in marasmus or in any other disease, calomel, in the manner recommended, is obviously indicated. These varied states of intestinal derangement frequently arise from functional disorder of the liver, and occasional obstruction of the gall-ducts. The biliary derangements are generally attended with an interrupted flow of bile into the duodenum, with engorgement of the gall-bladder, 



451 

IN DISEASES OF CHILDREN. 

in which this fluid acquires new properties, and with sudden discharges of the accumulated fluid into the intestines, as soon as the distension of the gall-bladder occasions reaction of its parietes, and the removal of the obstruction which prevented for a time the regular flow of bile into the duodenum. Hence partly result the varied states of the stools, as respects odour, colour, and consistence ; but, in addition to the biliary disorder, there is generally a morbid condition of the mucous surface of the small and large intestines. This surface is evidently loaded with the disordered secretion already noticed, which, existing in the duodenum, may be considered as one of the causes of obstruction to the regular discharge of the biliary and pancreatic fluids into that viscus, and which obstructs the functions of the lacteal absorbents, and, when it has become vitiated from its long detention in the intestines, produces irritative inflammation of the mucous surface itself; and this inflammation gradually extends to the mucous follicles, and even to the mesenteric glands. Hence, also, the deranged state of the motions may be readily explained, and the shreds of coagulable lymph, resembling pieces of membrane, which are occasionally seen in the motions, are easily accounted for. 



452 

USE OF CAL6MEL 

In all the diseases of children, and of adults also, but more particularly in those in which the nutrition of the patient is especially deranged, and the dejections unnatural, the naked abdomen should be carefully examined, particularly in the situations of the caecum, the sigmoid flexure of the colon, and the right hypochondrium. If tenderness and fulness be observable in any part of the abdomen, and in these situations more particularly, and especially if, in addition to these states, a feeling of pulpiness or doughiness be furnished, instead of the natural elasticity of health, the practitioner must not content himself with half measures. He should resort to the decided use of calomel, in the manner pointed out, until the evacuations assume a healthy appearance; when deobstruent laxatives and aperients may be combined with tonics, in order to restore the vital energy, and promote the functions of the organs of digestion and assimilation. 

In disorders of this description, palliatives ought never to be resorted to; otherwise disease, which at first was more or less confined to the digestive organs, will extend itself to the absorbent and secreting glands, and even to the brain and nervous system. It should 



453 

IN DISEASES OF CHILDREN. 

also be kept in recollection, that accumulations of viscid matter often form in the cells of the colon in these complaints. These are difficult to remove in proportion to the time that they have been allowed to remain ; and they often produce much constitutional disturbance, which is frequently attributed to other causes. These accumulations frequently do not prevent the operation of purgatives, but the motions are generally fluid, and somewhat offensive, even although the colour may not be particularly unnatural. This ready procuration of stools upon the exhibition of a purgative, is apt to prevent the real nature of the disorder from being suspected ; but, whenever the state of the bowels and the stools, the appearance of the tongue, and the tumidity and tenderness of the abdomen, with the continuation of debility, emaciation, and constitutional disturbance, lead us to suspect this condition of the large intestines, — purgatives, as calomel and aloes, must be exhibited, and soap injections thrown up the rectum. After these have produced the desired effects, alteratives and tonics, as formerly recommended, ought to be prescribed, and continued until the patient's recovery is complete, when change of air, and active exercise should be recommended. 



454 

USE OF CALOMEL 

Before I quit this subject, it may be observed, that as soon as we perceive the motions assume a dark grey colour, resembling a combination of quicksilver and chalk, we may conclude that the calomel is producing its beneficial effects. This colour of the motions, which arises from the admixture of the calomel with the morbid matter accumulated in the bowels, should be distinguished from the diseased excretions themselves ; and the same plan of treatment which gave rise to it ought to be continued until a dark green colour of the stools is observed. This latter appearance of the motions generally proceeds from the flow of the cystic bile into the duodenum, and its admixture with the matters contained in the bowels. The exhibition of the calomel ought not to be put a stop to upon this appearance of the stools, but should be continued until they assume either a bright orange colour, or a natural character and consistence ; when the tonic and aperient after-treatment already recommended may be pursued. 

4th. In Convulsions. — Convulsions in children assume various characters, and more frequently result from a disordered state of the bowels, similar to what I have already alluded to, than 



455 

IN DISEASES OF CHILDREN. 

from disease seated within the head itself. The observing practitioner will readily conclude respecting the immediate seat of derangement ; but whether it be in the bowels, or in the encephalon, or the consequence of the irritation of worms, or of teething, the exhibition of a full dose of calomel at bed-time, to be followed in the morning by a purgative draught, will be generally beneficial. The only difference which the exact seat of disease will require, respects the longer or shorter continuance of this treatment, and the addition of other remedies, either during its operation or subsequent to it. If the convulsions arise from the disordered state of the bowels, the plan of treatment inculcated must be followed until the functions of these viscera assume a healthy character : if the convulsions result from the irritation of worms, this treatment must be put in practice until they are expelled : if from the irritation of dentition, attention to the state of the gums, and early scarification of them must also be practiced : and if from effusion upon the brain, as in hydrocephalus and the last stage of some acute diseases, calomel ought to be given, chiefly as a purgative ; and other means, such as mercurial inunction, and remedies calculated to excite the function of absorption, ought to be employed at the same time. 



456 

USE OF CALOMEL 

sth. In Acute and Chronic Hydrocephalus. — The exhibition of calomel in acute hydrocephalus forms an essential part of its treatment. This disease often originates in disorder of the bowels, and in an obstructed or otherwise deranged state of the abdominal secretions ; whilst the derangement of the functions and secretions of the bowels and of the biliary organs, if not the primary disorder, and the cause of the disease of the brain, is generally co-existent with its earliest stages. To correct, therefore, the secretions and functions of the bowels and their allied viscera at the time when we are also directing our measures immediately to the organ most affected, is one of the most important indications which we can propose to ourselves in treating the disease. 

But this attention to the functions of the bowels ought neither to be of a secondary kind, nor should it be of short duration. The exhibition of calomel, in the manner so often alluded to, should be most active, and continued until a most decided effect be produced, both upon the state of the motions and upon the disease itself: but it must be kept in recollection, that the use of calomel cannot alone cure the disease. Other active means must 



457 

IN DISEASES OF CHILDREN. 

be also employed, and carried to an extent which the circumstances of individual cases will suggest to the practitioner. These means are various, but, with the exception of local depletion, not any of them admits of such a universal application as the decided use of calomel. 

To the treatment of the chronic form of hydrocephalus, many of the precepts are applicable which have been now stated ; and the same remarks which were offered at the conclusion of the paragraph on convulsions, will be found to apply to the treatment of this form of the disease. 

6th. In Croup. — Calomel has been recommended in croup in doses of from five to ten grains, given at very short intervals, until spinage-like stools are procured from it. I have certainly found this treatment efficacious, and it agrees with the results of my experiments, and with the views I entertain of the operation of this medicine ; but I think this mode of prescribing calomel frequently interferes with the employment of other remedies which are equally beneficial, and more suited to the urgent circumstances and symptoms so frequently apt to supervene in the course of the disease : 



458 

USE OF CALOMEL 

I allude to the employment of emetics, particularly when the paroxysms of suffocation threaten the life of the patient. I prefer, in this disease, to give not less than ten grains of calomel at once, and preferably at bed -time, prescribing also a cathartic draught the following morning ; or, if circumstances seem to require the exhibition of this medicine through the day, I think that benefit will generally be derived from the exhibition of an emetic an hour or half an hour before the calomel is given. My own experience is decidedly in favour of this practice ; and I have often adopted it previously to the exhibition of the dose of calomel at bed-time. 

The chief advantage of this mode of using calomel in croup consists in the circumstance of its yielding all the advantages which can be expected to be obtained from the remedy, in whatever manner it may be given in this disease, and certainly as much benefit as I have seen accrue from any other mode formerly recommended ; whilst it by no means stands in the way of the use of other very efficient remedies, but acts, as it were, jointly with them. Indeed, its efficiency is promoted by the previous exhibition of an emetic, and by active depletions, &c. 



459 

IN DISEASES OF CHILDREN. 

7th. In Chorea. — The deranged state of the secretions of the bowels in chorea has been generally remarked by medical writers ; and the dependance of this disease upon the derangement of the prima via has been as generally admitted. Without, however, attempting to inquire whether or no chorea actually originates in the disorder of the digestive canal, or whether both derangements are co-existent, I believe it will not be denied by the attentive observer of the relations and progress of this disease, that the stomach and bowels are not the only abdominal organs which are deranged in their functions at a very early period of the malady. The state of the stools, the appearance of the tongue, the condition of the abdomen, evinced upon a close inspection of it, and the colour and state of the integuments, all prove that the mucous surface of the digestive canal is lined with a viscid and otherwise morbid secretion, which obstructs the functions of the absorbing, and. exhaling, and secreting vessels seated in this surface ; and that the functions of the liver and pancreas are insufficiently and irregularly performed, and their secretions irregularly discharged into the duodenum, either owing to obstruction at the mouths, or in the course of the ducts, or to 



460 

USE OF CALOMEL 

deficiency of vital action in the organs themselves. The immediate consequences of these states of derangement are imperfect assimilation, diminished nutrition, and deficient energy of the nervous and muscular systems. 

The advantages arising from the continued use of purgatives in chorea, have been frequently stated, and are well known to the profession ; but I believe that I have found a more decided and a speedier effect produced by the exhibition of large doses of calomel at bed-time, and warm cathartic draughts in the morning, than by the usual way of prescribing purgatives. In addition to these, tonic medicines may be given through the day; but it will be better not to commence with the exhibition of them until the stools begin to assume a natural appearance, when vegetable tonics, and afterwards the preparations of iron may be prescribed. Alteratives at bedtime are generally required in this disease, even after the necessity for the use of the full doses of calomel no longer exists : and aperients, combined with tonics, are generally required to promote the vigour of the digestive and assimilating functions, and to excite the action of the secreting viscera. 



461 

IN DISEASES OF CHILDREN. 

Bth. In Eruptive and other Fevers. — With respect to the administration of calomel in the eruptive fevers and other febrile diseases of children, I may remark, that the mode of employing this medicine which I have adopted, is also applicable to them generally. In most cases it will be advantageously preceded by an emetic, especially at an early stage of the disease. 

As soon as either scarlatina or measles manifest themselves, or indeed any other febrile disorder, an emetic may be given in the forenoon ; and from five to twelve, or even fifteen grains of calomel, according to the age and strength of the patient, at bed-time. A purgative draught ought to be exhibited early in the morning, and diaphoretics, consisting of the liquor ammoniee acetatis, camphor julap, and spiritus aetheris nitrosi, combined with whatever medicines the circumstances of particular cases may require, should be administered through the day. The calomel, either in the same or in diminished doses, must be continued every night, and the aperient draught in the morning, until the motions become natural in appearance. 

When the abdomen is full, and the motions 



462 

USE OF CALOMEL 

very offensive, and unnatural in colour and consistence, this treatment will be found particularly beneficial. 

The prejudices which exist respecting the exhibition of calomel, have led me to enter more fully into the subject of its use in diseases, than may appear to many to have been necessary ; but I conceive that these prejudices have arisen from the inefficient and hurtful manner in which it has been usually prescribed during the preceding half century, and from the views which have guided practitioners in exhibiting it. There has been too general a desire to produce the constitutional effects of this mineral, and too little attention paid to its operation as a purgative, when given in large doses ; and to its influence upon the secretions, the functions of the bowels, and the condition of the stools, when exhibited with the intention of producing cathartic effects. And even when it has avowedly been given as a purgative, it has usually been prescribed in small, irritating, and inefficient doses ; and practitioners have generally contented themselves with resorting to it once or twice, or at most occasionally ; and hence they have had no 



463 

IN DISEASES OF CHILDREN. 

opportunity of experiencing the effects arising from its more protracted use, when given in large doses, and alternating it with purgative or aperient draughts, and such other remedies as the nature of the disease, and the circumstances of particular cases, may have required. 

Erroneous notions respecting the operation of calomel have also been long entertained, and a timid mode of exhibiting it has been the consequence. The dose of the medicine has been assigned by authors of modern dispensatories, and other writers, with a precision and a limitation which were by no means requisite ; and those who merely followed the recommendations of others, without thinking and acting for themselves, either blindly adopted the same practice, or, if they did attempt to modify it, proceeded no farther than to exhibit the medicine more frequently; and thus they actually resorted to a more hurtful mode of prescribing it than any other they could have pursued. 

The experiments which I have detailed, but still more decidedly, my extensive experience of the effects of large doses of the remedy, when given in the way I have described, shew its propriety ; but even this mode, although the safest which can be adopted, requires 



464 

USE OF CALOMEL, &C. 

judgment and tact in the practitioner for its efficacious employment. The empirical and indiscriminate use of the best medicines, and the inappropriate application of the most efficient practice, have been the frequent causes of their unmerited neglect, and of the most erroneous notions respecting them — causes, however, which can operate only for a time, and which will gradually disappear before the more general diffusion of professional science, and a more accurate and enterprising spirit of inquiry. 

THE END. 

* 

LONDON : 

I'IUNTED BY ,T. MOVES, BOUVERIE STREET) 





POG^S STOMACE THAT HAJ> TJ^TKEW THRIBB IJ)TRA.CIIMS O^ C^ILOMISL 









¦/i,i~/ ' . lOAae yrirtf&d-fy <P.JfaZtr>uin*tZ 

ZSTATITILAIi ATPZABIAJfCS Of THE DO^'S STOMACH.. 



EXPLANATION OF THE PLATES. 

PLATE 1. 

Natural appearance of the dog's stomach. 

PLATE 11. 

Dog's stomach that had taken three drachms of calomel. 

PLATE 111. 

Fig. 3. The large intestines of a dog, to which three drachms of calomel were given. A. Part of the Ilium. B. The Colon, in a state of inflammation. C. The Rectum, also, more vascular, but much less so than the colon. 

Fig. 4. The large intestines of a dog in their natural state. D. The Rectum. E. The Colon. F. Part of the Ilium. 



/ 



I 



EXPLANATION OF THE PLATE 

PLATE 1. 

Natural appearance of the dog's sto 

PLATE 11. 

Dog's stomach that had taken three drachms 

PLATE 111. 

Fig. 3. The large intestines of a dog, to which three drachms oi mcl were given. A. Part of the Ilium. B. The Colon 

state of inflammation. C. The Rectum, 

>re vascular 

but much less so than the colon. 

Fig. 4. The large intestines of a clog in their natural state. 1). Th Rectum. E. The Colon. F. Part of the Ilium. 



ERRATA ET CORRIGENDA. 

Page 13 line 24, for lacerating read lancinating. , 48 12, for crunlies read cumlies. 53 25, for can read could. 63 4, for after-part read other part. 84 14, after last insert report. 87 1, dele soft. , 134 5, for quiet read quick. 156 20, for Marcellus read Marcellinus. __ 165 » 8, dele clear and. 166 14, dele of. 172 18 and 19, for no ship, however well supplied she may be, read few trading ships, however well supplied they may otherwise be. 177 13, after cannot, insert as vised in India. 184——. 1, for our own personal, read what is derived from personal. 189 9 and 10, dele disqualified and. 279 18, for are read were. 294 14, for at read in. 353 15, for follows read follow. 379 I, for simple read scruple. 388 21, for is read more. 404 4, for service read surface. 



Preparing for Publication, 

IN ONE LARGE QUARTO VOLUME, 

RESEARCHES INTO THE 

PATHOLOGY AND TREATMENT 

OF THE 

PRINCIPAL DISEASES OF INDIA 

> 

And more particularly into those of the LIVER and ALIMENTARY CANAL : illustrated by numerous Copperplate Engravings of Morbid Structure, finely and accurately coloured after Nature. 

JAMES ANNESLEY, Esq. 

ETC ETC.