HB__HBl_i(BUK__H_______WSnara ANC E64 1866 Surgeon General's Office 1 N °-/^;*:. Ll / — — — - — - s, v ., vH oru'.i'v.vx.. ! o„^ * mi - ¦ - -VniLPk SOLOMON. A Compact and Practical Handy-Book. EPIDEMIC CHOLERA: ITS MISSION AND MYSTERY, HAUNTS AND HAVOCS, PATHOLOGY AND TREATMENT. With Kemarks on the Question of Contagion, the Influence of Fear, and Hurried and Delayed Interments. BY A FORMER SURGEON IN THE SERVICE OF THE HONORABLE EAST INDIA COMPANY. NEW YORK : Carleton, Publisher, 413 Broadway. M DCCC LXVI. Prrvr,-~.i_ 100 E~T \%io Entered, according to Act of Congress, in the year 1866, by GEO. W. CARLETON, ln the Clerk's Office of the District Court of the United States for the Southern District of New York. The New Yoke Printing Company, 81, 83, and 85 Centre Street, New York. To FRED. LAW OLMSTED, ESQ., ARCHITECT-IN-CHIEF OP THE CENTRAL PARK, AND LATE GENERAL SECRETARY OP THE TJ. S. SANITARY COMMISSION, ©Jim pajjtj. ar, jDrtrCcattir IN RECOGNITION OF _IS SAGACIOUS, HONEST, AND LIBERAL BENEFICENCE. CONTENTS. PAGE I. — The Mission and the Havocs of Cholera. 1 II. — Symptoms of Cholera — Premonitory Stage and Collapse IT 111. — Variations in the Symptoms 26 IV.— The Stage of Fever 33 V. — Recovery — True and Fallacious 38 VI. — Appearances on Dissection ? 41 VII. — Helps and Hints towards a Pathological Definition 46 VIII. — Pathological Conclusions 54 IX. — Epidemic Cholera and Cholera Morbus — The Difference : 62 X. — Treatment 66 In the Premonitory Stage "71 In the Stage of Collapse 16 Quinine 18 In Reaction 84 In the Stage of Fever 86 XL — Is Cholera Contagious? 88 Xll.— The Influence of Fear 101 XIII. — Hints to the Sanitary Boards 105 XlV— The Dead. 108 Moral 109 Appendix : Cholera — Its History and Localizing Causes 11l Cholera and Common Sense 115 EPIDEMIC CHOLERA. I. THE MISSION AND THE HAVOCS OF CHOLERA. Epidemic Cholera, like the Plague and the Yellow Fever, is a main branch of the Universal Sanitary Commission of Almighty God — armed with Herculean powers to turn a river of death through the Augean stables of the World's filth and lewdness and drunkenness and ignorance and waste ; and in the name of the King of Terrors, to compel from purple and fine linen and sumptuous fare a trembling recognition of their mortal brotherhood with nakedness and starvation and pitiful squalor. For, as Scott says, " the Beggar had no surgeon to dress, or ointment to mollify, or even a garment to hide his sores, so that the dogs, for very pity, came and licked them " — but his name, Lazarus, signified God my Helper. So Epidemic Cholera is a famous scourer of consciences as well as sinks, a masterly whitewasher of hearts as well as sewers, a potential disinfectant of " shoddy " and "petroleum" as well as garbage — moral as well as medical Inspector-General to the King of kings. THE MISSION AND THE HAVOCS OF CHOLERA. But it has had, in its time, some awfully heavy contracts on its hands, which, for the stubbornness, stupidity, and stench to be removed, we can compare with no known anti-nuisance movement, unless, perhaps, a job of New York street-cleaning in the dogdays. For instance: in 1762, according to Lebegue de Presle, the Cholera, in a visitation to Upper Hindostan, removed a nuisance consisting of 30,000 natives and 800 Europeans. From 1774 to 1781, it scoured the Coromandel Coast, and at one period destroyed above 60,000 people, from Cherigam to Pondicherry. As everywhere else in the world, the Pariahs were its first and favorite victims. In April, 1783, about a million and a half of devotees had assembled on the banks of the Ganges at Hurdwar, to celebrate a religious festival of peculiar popularity. Upon this frantic herd the Cholera burst in fury, and literally " cleaned out " 20,000 hysterical heathens in eight days. On the 19th of August, 1817, Dr. Robert Tytler, who practised medicine at Jessore, about a hundred miles north-east of Calcutta, was called to visit a Hindoo who had been attacked the night before with violent pains in his bowels, accompanied by purging and vomiting. Dr. Tytler found the man dying, and was about to report the case to the town authorities as one of poisoning, when he learned that, in the same part of the Bazaar, ten other natives had died with the same symptoms, and in 8 THE MISSION AND THE HAVOCS OF CHOLERA. another Bazaar, seven more, and that the disease had attacked many persons in the street. This was Asiatic Cholera, and in two months it had swept off more than 10,000 of the inhabitants of Jessore. Such was the origin of the "new pestilence," as it used to be called, which, after overrunning all parts of India, where it has prevailed endemically every year, and extending to Birmah, China, and Australia, Arabia, Persia, Russia, and the heart of' Europe, finally reached this Western Continent by way of Quebec and Montreal, in June, 1832, Jessore has. been styled " the cradle of the Cholera," because it was not until its irruption there in 1817, that the disease attracted anxious attention in Europe. Besides, Cholera did not appear as an epidemic at Calcutta until September, 1817 ; and for the ten years preceding, not a single case had been treated at the general hospital for Europeans in that busy mart. But that year it raged throughout the "City of Palaces," and 36,000 persons were attacked in the first three months of its visitation. It extended in almost every direction around Jessore, to the distance of 250 miles, and it has been computed that at least 600,000 persons died of Cholera in thirty-two cities, in 1817. At some of the towns and military stations, the invasion was so sudden that the roads were covered with the dead and dying, who had not time to regain their tents or houses. Men mounted on horses were seen to fall from the saddle, unable to rise again. "The first week in November it broke out in the grand army under the command of 1* 9 THE MISSION AND THE HAVOCS OE CHOLERA. the Marquis of Hastings, composed of 10,000 English and 80,000 Sepoys, and encamped on the right bank of the Betoah. On the fifth and sixth days, the mortality became so great that despair seized the bravest. To the usual uproar and gayety of a camp, succeeded a mournful silence, only broken by the groans of the dying and the lamentations of the survivors. The principal roads and fields around the camp were strewed with the dead bodies of those who had thought to escape by flight. No expressions can truly describe the spectacle of desolation which this army, but lately so brilliant, now presented. In twelve days, 9,000 men had died, and a still greater number had fled. Those who remained, overwhelmed by so frightful a disaster, disregarded the voice of their chief, and sought only to save their fives, or stun their fears by debauchery." We recall here the dreadful revelries of Captain Dowling's reckless verse — " The Song of the Dying :" " There's many a hand that's shaking, There's many a cheek that's sunk; But soon, though our hearts are breaking, They'll burn with the wine we've drunk. So ! stand to your glasses, steady ! 'Tis here the revival lies ; A cup to the dead already, And hurrah for the next that dies ! " There's a mist on the glass congealing, 'Tis the hurricane's fiery breath ; And thus does the warmth of feeling Turn ice in the grasp of Death. 10 4 THE MISSION AND THE HAVOCS OF CHOLERA. So! stand to your glasses, steady! For a moment the vapor flies, A cup to the dead already — Hurrah for the next that dies ! " Happily the Marquis of Hastings marched his army across the Betoah, and pitched his camp on dry and elevated ground, where the disease soon subsided. In 1819, the pestilence advanced from Madras towards the south; all along the coast numerous towns which had escaped the preceding year were now desolated by a frightful mortality. Hardly fewer than 150,000 people died in the Presidency of Bombay in 1819, from Cholera alone. Entire villages were depopulated, and so great was the panic, that the crews of many vessels, laden with cotton, deserted and fled in the night. At Bombay, nearly 20,000 persons were attacked. Bankok, the capital of Siam, lost more than 40,000 of its inhabitants. As the people attributed the calamity to the influence of an Evil Spirit, which, under the form of a fish, had sought refuge in the Gulf of Siam, the Sovereign authority ordered the celebration of solemn religious rites on the coast, in order to exorcise the finny demon ; but the gathering at one place of so dense a throng of human beings, redoubled the fury of the pestilence, and the mortality was frightful. The same year the island of Sumatra was devastated, and so terribly did the disease ravage the capital, that the King fled to the mouth of the river, where 11 THE MISSION AND THE HAVOCS OF CHOLERA. he formed a camp. But the Angel of Death followed them thither; and before the year was out had flapped his black wings over forty degrees of latitude and fifty of longitude. In 1820 the Cholera inspired the inhabitants of Manilla with so wild a terror that they broke out in an insurrection, in which many Europeans and a great number of natives perished. In 1821"it appeared at Jaggurnah on a missionary expedition. So furiously did it rage among the heathen during the annual monstrosities in honor of Juggernauth, that there were not left maniacs enough to drag the car of the idol around the temple, and that year not a single devotee enjoyed the luxury of being crushed under its wheels. The same year the scourge invaded Bassora on the Persian Gulf, and slew 17,000 out of a population of 60,000. Thence it passed to Bagdad, and destroyed one-third of the population. At Shiraz the mortality was awful; Batavia lost 17,000 inhabitants, and the entire island of Java 102,000. The scourge traversed forty-three degrees of latitude and seventy of longitude, sweeping and garnishing the unclean places. In 1822 the progress of the pestilence was in the direction of Europe. The Prince Royal of Persia, having attacked the Turkish army, saw his own array, a few days after the victory, swept away by the epidemic. In 1823 the Omnipotent Scavenger swept the Birman Empire, and not even the name of the heir to 12 THE MISSION AND THE HAVOCS OF CHOLERA. the crown, worn as an amulet around the neck, was awful enough to arrest its progress, or diminish the number of its victims. In China, also, the disease raged everywhere, " in consequence of the innumerable canals," and a population as the sands on the sea-shore. The Russian authorities urged the Mandarins to adopt preventive or preservative measures ; but the Mandarins (self-possessed philosophers !) replied that the deaths would allow more room in the world for those who survived ; and besides, that the Cholera chose its victims from among the filthy and the intemperate, and that no person of courage, who lived with moderation and cleanliness, would die of it. The Emperor, they declared, had said to his subjects, "Do not believe that the disease is stronger than yourselves. It only kills the scared people." Sagacious Emperor ! The same year the Cholera marched northward, as far as Orenbourg, on the confines of Asia and Europe, where numerous caravans arrive yearly from China and Hindostan ; it also made its appearance on the eastern shores of the Mediterranean, and created a lively alarm in Europe. In 1825 the Cholera returned to Bombay, and compelled the authorities to build hospitals, and burn great quantities of wood, tar, and gunpowder. In 1827 the epidemic again attacked Calcutta, and this time horses, cattle, elephants, swine, and dogs shared the fate of human pariahs. The Hindoos attributed the prolongation and universality of the 13 THE MISSION AND THE HAVOCS OF CHOLERA. scourge to the anger of the God of the Cemeteries, provoked by the absence of human sacrifices. "At Palcal, a Hindoo woman resolved to burn herself on the body of her husband, who had died of Cholera, but the Rajah refused to patronize, or even permit, the performance. The widow, however, was urgent in her suit, and declared that the pestilence would cease in five days if she were allowed to sacrifice herself." The Rajah yielded, and the woman burned — but it made no difference to the Cholera. In 1830 the epidemic prevailed all along the shores of the Caspian Sea, and on the 27th of July appeared at Tiflis, the capital of Georgia, nearly depopulating it by death and flight. Impatient of the limits within which it had hitherto been confined, it had, the year before, crossed the Ural Mountains, which separate Europe from Asia. On the 19th of July it reached Astrakhan, at the mouth of the Volga, and thence spread up that river, reaching Nischnei Novgorod about the last of August. On the 15th of September it appeared at Moscow, where it created a senseless panic, and 50,000 persons fled the city in a few days. The consternation was general throughout the Russian Empire, and the Czar offered a reward of 25,000 roubles for the best dissertation on the nature, causes, prevention and cure of Cholera. A Council of Health was convened at Moscow, composed of physicians from Paris, Berlin, Gottingen, and other cities. In 1831 it appeared at St. Petersburg — on the 26th of June — having previously visited Archangel, 14 THE MISSION AND THE HAVOCS OF CHOLERA. Warsaw, Riga, Polangen, and Dantzic. The Czar retired in dismay from the imperial city, and surrounded himself and his court with a cordon militaire, permitting no approach from without. In May it broke out in Mecca, among the innumerable pilgrims to the shrine, and " abated " thousands upon thousands of the foulest of those pious nuisances, with whom " it is a point of religion that no pilgrim shall change his clothes during the whole period of his pilgrimage, and that each pilgrim shall sacrifice at least one sheep, and leave the skins and offal to rot under an Arabian sun." Berlin was visited by the Cholera in the last week of August, and from the Ist of September to the middle of December, when it had nearly disappeared, the number of cases was 2,230, of which more than half died. On the 16th of August, the scourge entered Vienna from Hungary, in defiance of a double cordon, though the authorities refused to recognize its presence until the 15th of September, by which time it was raging with violence. It was remarked that, in Vienna, the Cholera destroyed more of the nobility and people of the higher classes than at any other time or place ; and here, likewise, was a most extraordinary fatality among physicians and other attendants upon the sick. The Cholera also prevailed this year (1831) at Constantinople. The Turkish Government declined to establish quarantines, but distributed gratuitously, throughout the empire, small pamphlets giving a history of the disease, and the most approved me- 15 THE MISSION AND THE HAVOCS OF CHOLERA. thods of prevention and treatment. Their good sense was rewarded with a mild visitation. " On the 26th of October, the Board of Health of Sunderland, in England, officially announced the presence of Cholera in that town. A few cases had been noticed in August, but it did not prevail epidemically until the last of October." On the 27th of January it appeared in Edinburgh, and soon afterwards reached London, where, contrary to all expectations, its ravages were inconsiderable. On the 24th of March it appeared for the first time in Paris, where it prevailed with great severity ; and shortly afterwards broke out in Dublin. Then it crossed the Atlantic, landed at Quebec on the Bth of June, was in Montreal by the 14th and New York by the 25th — since when its marches and its operations have been traced, observed, and reported with such anxious interest, both in Europe and America, as to call for no recapitulation here. 16 11. SYMPTOMS OF CHOLERA. The Diagnosis of Epidemic Cholera, especially in the stage of collapse, is, fortunately, as easy to acquire as the pronunciation of Italian. It has its peculiar features — its characteristic expressions, motions, signs, and sounds — which are the same, to be readily recognised all the world over. One case may differ from another in certain modifications and " accidents " proper to the individual, according to temperament, habits, and state of health, as one Chinaman differs from another in looks and ways ; but there will be no mistaking the Cholera or the Chinaman in either subject ; for there are the high cheek-bones, the flat nose, the pig-eyes, the perpetual cunning twinkle, and the "tail"; and here are the listless, sunken eye, the corpse-like features, the appalled expression, the plaintive whine, the blue, brown, or lead-colored skin, the cold, clammy, " dogs-nose " feel, the rice-water evacuations, the cramps, the " dead meat " tongue, and the chilled breath. That physician would indeed be eminently ignorant or stupid who should fail to recognize a case of Asiatic Cholera in the stage of asphyxia. Hydrophobia is not plainer. But let us imagine a case, and trace it from its SYMPTOMS OF CHOLERA. commencement to its close, which, since we shall " leave it to nature," will surely be death ; no man ever heard of an instance of true Cholera curing itself, after spasms, and the clammy blueness, and " washer-woman's fingers," and that ominous sinking, had set in. Nature, appalled and paralyzed by the stunning stroke of the fierce Angel of Reform, seems to slink aAvay and leave the field to him, retiring, like Achilles, to supineness and despair; and only the hopeful, patient, and sagacious calls of Science can rouse her to arms again. We will suppose that the Cholera, having flanked all the quarantine defences, has entered New York, and that its presence has been honored by official recognition. You have a friend with Cholera on the brain — nervous, anxious, scared — the eyes of his imagination continually turned inward upon his stomach and bowels, with a morbid fascination sufficient, by its very magnetism, to conjure a " cramp " there. Perhaps he has been dyspeptic, subject to indigestions and troublesome alternations of constipation and looseness. Perhaps he has domestic or business anxieties, that keep his spirits depressed. Perhaps his occupation is unwholesome — confining, exposing, or overtasking him, invading his hours of natural and necessary rest. Perhaps he is an intemperate man, given to spells of excess, followed by corresponding spells of "shakes," with loss of appetite and sleeplessness and vague alarms, and all the other reproachful shapes of nervous prostration. Perhaps, by habit or necessity, he is a keeper of 18 SYMPTOMS OF CHOLERA. bad hours — out in the chilly and damp air of night ; a man, too, familiar with wet feet and irregular and hurried meals. Perhaps, on the other hand, he is a pampered, gouty gourmand — committing slow suicide with the entire catalogue of French crudities, and flourishing in the face of Providence, cucumbers, radishes, and hard-boiled eggs. Perhaps — a hundred peradventures, all ending in the certainty that he is a ready-made case for Cholera, and that he is scared. Well, this cut-and-dried victim, who is neither filthy, nor lewd, nor naked, nor starved, nor houseless, nor squalid, but only respectably unfortunate, or a fool, "does not feel well this morning" — in fact his sensations are exceedingly queer, not to say alarming. "Do you know anything about Cholera ? and what are the premonitory symptoms ? " And then he goes on to describe them to you with an unconscious accuracy, impressive as a diagnosis, and touching by its melancholy portent. For several days, he says, he has had a vague feeling of uneasiness, accompanied by a sense of heat and disorder in the stomach and bowels, with loosenes — a simple feculent diarrhoea, with little or no griping, the " movements" steadily increasing in frequency day by day. At first there were but three, yesterday there were a dozen. He has occasional nausea, with more and more lassitude and languor. He is giddy, too, at times, and very weak, especially just after purging. "Has he headache?" Rarely, and never much. But he has an empty, 19 SYMPTOMS OF CHOLERA. hollow feeling, and this morning, at daybreak, he vomited thin, watery stuff*, mixed with a little bile, and some undigested food. " How did he pass the night ? " Badly. "He shivered some, his stomach and bowels were distended, and he was called to stool three or four times, passing a thin sort of whitish water, like whey, or the " rice-water " that his Cholera-book — he has been reading " Cholerabooks," you perceive — so often mentioned. There were starchy-looking flakes floating in it, with some bile at first, but that grew less. He was very restless, had some ringing in his ears, and a tingling sensation in his hands and feet, first in one and then the other, as if they were asleep ; and once or twice his foot was cramped. You feel his pulse — perhaps it is somewhat accelerated and weaker than in health ; you look at his tongue — not much alteration there — it is moist, and slightly furred ; but he says his mouth is dry, and he feels thirsty. You observe particularly that his features are sharp, and that his countenance wears an apprehensive, anxious expression. You advise him to go straight to bed, and send for a doctor. But he doesn't. Jones, who is also his friend, much " bosomer " than you ; Jones, who has all the common sense, and is such a practical, strong-headed fellow, you know ; Jones, who never felt uncomfortable an hour in his life, and don't believe in doctors and their nasty truck ; Jones says, " Nonsense ; you're only scared ! " Half right, Jones ! That sort of people are always half right. " Keep yourself quiet, and don't eat 20 SYMPTOMS OF CHOLERA. anything — then your bowels will have nothing to purge about. Guess conundrums, and leave this little shake to nature, and you'll do." Between Jones and nature, let us see what he comes to. An interval of twenty-four, or perhaps forty-eight hours, has elapsed before you see him again. Can this be the same man ? Ah, Jones, what have you done, with your conundrums and your nature? The hand of death is on him? You read his doom in his cadaverous countenance ; in the livid circles around his mouth, and his dull, sunken eyes ; in the sharp, contracted features ; in the blue lips, and the leaden, brown, or even purple, face and neck — according to the shade of his complexion, and the intensity of the attack; in the wrinkled, sodden, " washer- woman's " fingers, from which the rings have dropped off; in the bluish pearl- whiteness of the nails ; in the almost blackness of the lines tracing the larger superficial vein's ; in the labored, irregular, and broken respiration — "inspiration appearing to be effected by an immense effort of the chest ; while the nostrils, instead of expanding, collapse, and stop the ingress of the air, and expiration is hurried and convulsive." You call him by his name, and he answers with a helpless, wild, terror-stricken stare. You read his doom in that ; and that look, if you are a doctor, you will never forget; it is the very catastrophe of forlornness. You read his doom in his incessant tossing from side to side, and his agonizing travail and struggle for breath — the throes of a woman 21 SYMPTOMS OF CHOLERA. in the fierce pangs of labor. You read it in the shrunken toes, in the spreading, " dead-body " discoloration of feet, and legs, and thighs, and arms, and presently of chest and abdomen also. You read it in the withered hand laid piteously, appealingly, on stomach and breast. You feel it in the pulse, small as a thread, and hardly vibrating, soon to be totally extinct. You feel it in the deadly coldness and clammy dampness of the skin ; in the tongue, perhaps white and loaded, but always moist and flabby, and chilled, " like a bit of dead flesh " — the " dogs-nose feel." You hear it in the almost gone voice; in the plaintive whisper of that eternal "water, water, water ! " in the occasional weak, suffering whine ; in that dreadful low wail " which no man who has once heard it can ever forget — the lowest moan of the most wretched mendicant goes not to the heart more poignantly." If he tries to speak, it is by only one word at a time ; his lungs cannot retain air enough for even the shortest sentence; and oh, the weight and anguish at his heart; and oh, the fire in stomach, and bowels, and throat ! Strange, too, that with skin so deadly cold, and almost insensible to the action of chemical cauteries, he should yet complain at times of feeling too warm, and offer to throw off the bed-clothes ; his very sensations are beside themselves. If you could only feel him, you would surely think he had been dead a day or two ; and yet, from first to last, he has had nothing like a well-marked chill, only now and then a sort of nervous shivering. 22 SYMPTOMS OF CHOLERA. The attendants tell you that after you saw him last, the purging became more and more frequent — abundant, sudden, and " shot out " with foree — nothing but watery stuff, Sir, — sometimes dirty, sometimes with flaky, starchy matter floating in it — but always like barley-water. Every time he was purged his pulse would sink, and he would have a spell of cramps in his feet and legs, and get bewildered, and stagger like a drunken man, or fall down like a helpless child. Since he grew so weak he has not purged so often or so much — " seems like he hadn't life enough in his body even for that." The vomiting has not been in proportion to the diarrhoea — not so frequent or sudden or abundant— and now it has quite ceased ; what he did throw up was like the stools — barley-water or whey ; only once or twice it was quite green. " How did the spasms grow upon him, and in what form did they manifest themselves ? " Well, first of all, there was the thrilling and tingling in the toes and fingers, as if they were asleep ; then a quivering, rather strange than painful — a " funny feeling," he called it — in the hands and feet ; then a sudden twitching and stiffening and twisting of toes and fingers which seemed to alarm him greatly ; he held up his deformed hands in a helpless, pitiful way, and cried. Next the calves of the legs, and the muscles of the arms and thighs and loins were drawn up in excruciating knots — as if only particular sets of fibres were in spasm, and the tendons stood strongly out ; then, " the integuments of the abdomen were raised 23 SYMPTOMS OF CHOLERA. in irregular folds, and the belly itself violently drawn backward toward the spine, the diaphragm upward and inward toward the chest ; " here, too, were hardness and constant pain, and the parts felt sore to the touch. But though the cramps (which were invariably increased on moving) were agonizing, there was no convulsion. No urine appeared now — the kidneys were already dead ; no bile — the function of the liver was abolished ; he had ceased to expectorate — the salivary glands were withered ; and, touching climax ! the fountain of his tears was dry : surrounded by all that is endearing and heart-rending, wrung with anguish, unnerved, undone — he could not even weep. But the end is upon him. Colder, colder! That horrible clammy, corpsy sweat, smelling of the vault, burst forth afresh ; his lips and cheeks puff out and flap, in expiration, " with a white froth between them, as in apoplexy." The spasms have cramped his very vitals ; his pulse is gone forever ; fewer and fainter grow the broken heavings of his chest ; if you could draw blood from him now, it would ooze drop by drop, black and sluggish, tarry and cold. Now there is a quivering among the tendons of his wrist, and his weary breast is almost still. His mind has remained clear through all the rack and agony, and he is conscious yet ; yet he makes no sign — only a long, weary, convulsive sob, but no " rattle." It is painlessness and sleep that the lovely Angel Death has brought him, and the most delicious moment of his life is — the last. 24 SYMPTOMS OF CHOLERA. So that's what " Common Sense " and " unassisted Nature " did for a case of Cholera Asphyxia. As for us, all that we can do for it is to see that the dead body is not buried alive. 2 25 111. VARIATIONS IN THE SYMPTOMS. The general features — what one may term the contou — of Cholera Asphyxia, that compendium of the prominent phenomena from which, in all latitudes, seasons, localities, and classes, the disease may be easily and certainly made out, being sharply defined and uniform, the same symptoms, nevertheless, vary infinitely in the degree of their intensity, " according to circumstances " internal or external to the individual-^— from the simplest diarrhoea, with little pain and no cramps, and no graver derangement of the circulation and temperature of the surface than occurs from the operation of an ordinary purgative, up to the overwhelming attack of a prostration so paralyzing that the person stricken has scarcely become sensible of pain when the secretions are suppressed and the heart's action sinks suddenly. Sometimes the premonitory symptoms are protracted, and the patient has a week or more of warning, in the form of diarrhoea, uneasiness, and a sense of heat and " thrill " in the stomach and bowels ; in some cases, not diarrhoea, but obstinate costiveness, prevails. Sometimes he " falls dead in his tracks," like the men in the army of the Marquis of Hastings. At Bellamy, in India, a tailor was attacked while at VARIATIONS IN THE SYMPTOMS. work, and died in his working attitude, cross-legged on his mat ; and a merchant, concluding a bargain, vomited twice, and instantly expired. At Mecca, individuals in perfect health were suddenly stricken to the earth, vomited, turned cold, and died. Between these two extremes, the merciful admonitions are of various duration, from a few hours to a few days ; in the large majority of cases the disease takes from six to thirty-six hours to fully develop itself, and terminates by death or convalescence in from one to two days from the inception of collapse. Sometimes the patient sinks at once, after discharging a small quantity of colorless fluid by vomiting and stool ; sometimes the vomiting and purging are preceded by the spasms. Sometimes the matter vomited, instead of being colorless or whey-like, or like seething of oatmeal, is green, and the dejections instead of being thin, and whitish and muddy, are red and bloody ; or they may even consist of a greenish pulp, like halt-digested vegetables. We have described the cramps as usually beginning in the extremities, and thence creeping gradually to the trunk ; but in some cases they are simultaneously in all ; and sometimes the order of succession is reversed, the abdomen being first affected, and then the hands and feet. Generally, neither the vomiting nor the purging is a symptom of long continuance ; either they are checked by art, or the enfeebled body is no longer able to perform those violent motions ; so that they, together with the cramps, usually disappear some time before death. After the first 27 VARIATIONS IN THE SYMPTOMS. emptyings of the bowels, the stools have been observed to be yellowish, turbid, or frothy like yeast, and though generally inodorous, they sometimes emit a rank, fleshy smell. The dejections are seldom attended with much griping, and sometimes they are effected without effort or uneasiness, though generally the calls are sudden and irresistible, and the discharges expelled with alarming force. Tenderness of the belly, on pressure, is not among the most common symptoms, nor, we repeat, are the vomiting and purging by any means the most important or dangerous ; in a great number of fatal cases they have not been profuse, and have ceased, even without remedies, early in the attack. The cramps sometimes precede the vomiting and purging ; but in the low and most dangerous form of cholera, spasm is often absent, or is present in a very slight degree. Tetanic spasms of the legs, thighs, and loins have been observed, but there is no general tetanus (lock-jaw) or even trismus. Hiccough in Cholera is not indicative of danger ; on the contrary, when it occurs in the interval of struggle between death and reaction, it is a favorable sign, and generally announces the return of circulation. The spasm at the pit of the stomach is often very acute, and the belly is almost always drawn toward the spine by a remarkable permanent contraction of the abdominal muscles. The pulse occasionally, though rarely, keeps up tolerably for several hours after the disease has plainly declared itself. Generally it becomes small 28 VARIATIONS IN THE SYMPTOMS. and accelerated at an early stage, and on the accession of spasm or vomiting, suddenly disappears from the extremities. On the cessation of the vomiting or spasm, and sometimes, apparently, from the exhibition of remedies, the pulse will return to the extremities for a short time, and then again be lost. In the less severe cases it is not wholly extinguished, though much reduced in volume, and a thread of pulse, however small, is almost always felt at the wrist, where recovery from the blue or cold stage is to be expected. The sinking of the pulse in Cholera is a symptom not less characteristic than the cadaverous countenance, or the hoarse, plaintive whisper (vox cholerica), or the discolored skin, or the chilled breath ; when it can be felt, it is generally regular and extremely feeble, " sometimes soft, not very quick, usually ranging from 80 to 100." In the state of the skin, as in the other symptoms of Cholera, striking variations are found. The surface is sometimes observed to be dry, though cold ; and in a few rare cases, natural — " nay, of preternatural warmth." A rise of temperature has been repeatedly observed to take place just before death ; but the development of heat under such circumstances appears to be confined to the trunk and head, and in almost all cases may be regarded as a fatal symptom. It is not indicative of any restoration of the diffused energy of the arterial system, or of any improvement in the function of respiration. The heat, in such instances, has continued well marked for some hours after death. The skin, in 29 VARIATIONS IN THE SYMPTOMS. complete collapse, is generally insensible even to the action of chemical agents, and hence the usual vesicatories fail to blister. The application of mineral acids or of boiling water, in this condition of the skin, produces little or no effect, and now and then a patient is found who is insensible to the operation ; nor can leeches draw blood, from an early period of the attack. The blueness, so characteristic of Cholera in the East, has by no means been found an invariable, or even a very common phenomenon in England or the United States. Dr. White, one of the physicians to the Gateshead Dispensary and Cholera Hospital, states that in scarcely one case in ten, in his practice, did the discoloration assume that form ; but there is often a deep, brownish hue of the face and hands. This blueness or brownness can often be temporarily dissipated by energetic friction. Absence of the peculiar " cold sweat " is a rare, and, we believe, a decidedly unfavorable sign. The urine, from having been limpid and free, will become more and more scanty, and its passage will sometimes be attended with such difficulty as almost to amount to strangury ; but as the collapse advances, this condition gives place to that in w r hich the kidneys have ceased to perform their office, and there is no more secretion. Some patients complain of an urgent and painful desire to empty the bladder ; but the bladder is empty already, and after death is found to be dwindled to the smallest size ; the desire may ari^e from the contraction of the posterior disc 30 VARIATIONS IN THE SYMPTOMS. of the bladder, hard against the internal meatus, as disclosed in post-mortem examinations. The pains of Cholera are agonizing to the sufferer, and at times so pitiful as to move the attendants to tears. The patient tosses incessantly from side to side, and complains of intolerable weight and anguish at his heart. As he struggles for breath, his imploring looks and gestures make you almost feel the horror that is burning and gnawing, and wrenching and rending at his stomach and chest. At times, especially when the cramps are most severe, he rolls about and screams — and then there is that weary, weary cry for " water, water, water," and that heart-rending, haunting wail when the cold, bony grip of death is on him. Violent headache is far from being a common symptom in cholera — a neuralgic pain over one eye is less rare. The cramp is invariably increased on moving. In some cases the patient declares himself free from pain and uneasiness, just when the deadcold skin and the sharpened, anxious features, and the absence of pulse at the wrist, most surely portend speedy dissolution. During all this mortal struggle and commotion in the body, the mind remains clear and the perceptions unimpaired, almost to the final moment of existence. "The patient, though sunk and overwhelmed, listless, averse to speak, and impatient of disturbance, still retains the power of thinking and of expressing his thoughts, so long as his organs are obedient to his will." The mortal lies all down-beaten and dis- 31 VARIATIONS IN THE SYMPTOMS. trau ght, but the immortal is still master of itself. Dr. Lawrie, Professor of Surgery in the Andersonian University, who closely observed the epidemic as it appeared at Sunderland, Newcastle, and Gateshead, in 1832, commenting upon the declaration of the majority of medical men, that the mind is always unimpaired, says it appeared to him, in many cases, affected to a degree little short of what we find in concussion of the brain. He remarked this particularly in several children ; when undisturbed, they lay in a dull, sleepy, semi-comatose state, breathing with perfect calmness; when roused, they thought only of relieving their distressing sensations, and called vociferously for cold water. But he does not say that he found them irrational or incoherent, or that their condition was other than that which should attend upon congestion of the vessels of the brain. 32 IV. THE STAGE OF FEVER. A patient, having once fairly entered the stage of collapse, is rarely restored to health without passing through a fever closely resembling the typhus mitior of Great Britain. The system, under the influence of the peculiar and mysterious poison by means of which the Asiatic Cholera does its work, has been sunk into the lowest state of human existence. Those vessels that had ceased to pulsate, and all those muscular fibrils that had been for days convulsed, contracted, and, as it were, knotted and twisted in spasm, cannot at once resume their healthy action. The vis medicatrix natural, in resuming its efforts, seems over-eager for the restoration of the functions, and consequently sets up an exaggerated and dangerous action in every artery. After the "blue " cold period has lasted from 12 to 24, seldom to 48 hours, the vital powers begin to rally, the .circulation and animal heat to be restored, the cramps to relax, and the vomiting and purging to diminish, if they have not already ceased. The warmth returns gradually, the pulse rises in strength and fullness, and then becomes sharp, and sometimes hard. The patient now complains of headache, with ringing in the ears. The tongue becomes more 2* THE STAGE OF FEVER. loaded, redder at the tip and edges, and dryer; thirst continues, but there is less nausea. Highcolored urine is passed with pain, and in small quantities. The pupil is generally dilated, and soreness is felt on pressure over the liver, stomach, and bowels. The stools are no longer like water ; they first become brown and thin — then dark, or black, and pitchy ; and for some days the bowels continue to discharge immense loads of vitiated bile. A profuse critical perspiration may appear, on the second or third day, and leave the sufferer convalescent, but more frequently the quickness of pulse, and heat and dryness of skin are aggravated, the tongue becomes deeply furred, brown and dry, and sometimes hard, the eyes suffused and drowsy ; there is a dull flush on the face, with stupor and heaviness. Commonly, at this time, there is low muttering delirium, or other marked disorder of the brain; dark sordes collect on the lips and teeth, the patient is pale, squalid and low, catches his breath, is extremely restless, and moans " solemnly." The pulse becomes weak and tremulous ; on the skin rigors alternate with flushes of heat. Then comes a blessed insensibility, and the patient soon sinks under the prostrating effects of frequent pitchy alvine dischargesdeath arriving on the sixth, eighth or tenth day, or even later, to the very individual whom the most assiduous attentions had barely saved., in the cold stage. Constipation is not an uncommon symptom in the febrile stage, and the urine is often secreted abundantly— in fact, dangerous retentions are to be 34 THE STAGE OF FEVER. guarded against. It is probable that the duration of the consecutive fever is, in the majority of European cases, commensurate with the duration and seventy of the collapse, and not materially dependent on the kind of remedies employed. But sometimes a very mild case precedes a dangerous fever, especially in Europe ; and sometimes after the severest collapse, there is no fever at all, especially in India. In England the consecutive fever has been regarded as more frequently fatal, unless strictly watched, than collapse itself; and in cases of recovery from even mild forms of fever, relapses, more or less alarming, have not been very uncommon there. The points of difference between the phenomena of the European and the Indian forms of the epidemic, were intelligently stated by Drs. Russell and Barry, in a joint report to the British Government, dated "St. Petersburg, July 27, 1831," and by Dr. Lawrie, of Sunderland and Newcastle, in a communication to The Medico- Ghirurgical Review, in 1832. We believe that the same points of difference will be observed in the epidemic now advancing towards these shores : First. — " The premonitory stage occurs in a much larger proportion of cases in the English than in the Indian disease. In the latter . it is the exception, in the former it is the general rule." [The writer of the present article can verify, from personal observation, so much of this statement as relates to the phenomena of Cholera in Malacca, Burmah, and Hindostan.] 35 THE STAGE OF FEVER. Secondly. — "The evacuations, both upward and downward, seem to have been much more profuse and ungovernable in the Indian than in the European Cholera, though the characteristics of the evacuations are precisely the same." Thirdly. — "Restoration to health from the cold stage, without passing through consecutive fever of any kind, is far more frequent in India than in Russia or England, nor does the fever in India assume a typhoid type." [Recovery directly from the cold stage, without the fever, is the rule in India ; whereas, in England or in the United States, we believe that few, who have been once fairly collapsed, will escape the consecutive fever.] Fourthly. — " The proportion of deaths in the cold stage, compared with those in the hot, is far greater in India than in Western Europe." Fifthly. — " The head is more frequently affected in the British than in the Indian form of Cholera — as shown by greater mental oppression and insensibility during collapse." Sixthly. — According to Dr. Lawrie, "the discol oration of the surface is neither so frequent nor so extensive in India as in England." [The blus is the common discoloration in India, the brown in Europe ; though in many cases, in both England and this country, there has been a wellmarked purplish change.] When we come to consider the pathology of Cho- 36 THE* STAGE OF FEVER. lera, the reader's mind will revert to some of these variations and phenomena, as confirming our views of the nature and process of the morbid changes, and of the treatment scientifically and logically indicated. 37 V. RECOVERY— TRUE AND FALLACIOUS. When the more formidable symptoms of collapse have set in w r ith severity, the chances of recovery are in all cases precarious ; and if the constitution has been impaired by previous disease, or has failed by reason of age, the case has always been regarded as nearly hopeless. But in childhood, youth, and the vigor of life, a well-instructed, sagacious, courageous and persevering use of remedies will often be rewarded with complete success. A thread of pulse, however small, is almost always felt at the wrist where recovery from the " blue " or cold stage is to be expected. In much less formidable cases, it is never wholly extinguished, though much reduced in volume ; the respiration, too, is less embarrassed, and the oppression and anguish at the chest are not so overwhelming, although vomiting, purging, and cramps may have been more intense. Just where the favorable turn is taken, in the first feeble efforts at reaction, the return of circulation is often curiously announced by hiccough. Then the surface begins to grow warm, the pulse reappears at the wrist, and increases in strength and volume, and the natural hue of the skin is restored. Next, the vomiting and purging cease, or rapidly diminish (in RECOVERY — TRUE AND FALLACIOUS. certain cases of recovery from extreme collapse they even return for a time, after having quite disappeared) ; the cramps are relaxed ; fascal matter reappears in the stools ; bile, urine, and saliva are once more secreted and discharged ; the voice becomes stronger and more natural — the racked and broken wretch sighs, weeps, and lives. When the vital forces have begun to rally, the physician cannot be too vigilant; he must watch nature warily, suspiciously, to prevent the recurrence of collapse on the one hand, to repel congestions of the head and viscera on the other. Where the strength of the patient's constitution, or the curative means employed, are, although inadequate wholly to subdue the disease, sufficient to resist the violence of its onset, nature makes various efforts to "rally, and holds out strong but fallacious promises of returning health. Or when the restorative efforts are opposed by previous organic disease, general feebleness of constitution, or the worn-out energies of age, we must not calculate too confidently £>n any imperfect reaction that may be induced. In all such cases, the lost heat may be wholly or partially restored; if only partially, the chest and abdomen will become warm while the limbs remain deadly cold — a most evil omen ; the pulse, may return, growing moderate and full ; the vomiting and cramps may cease ; the stools may become green, pitchy, and even feculent; there may be a partial restoration of the natural excretions ; and yet the patient will suddenly relapse and sink, "not from 39 RECOVERY — TRUE AND FALLACIOUS. violent reaction or the development of any local inflammation, but from want of energy in the vital powers to carry forward the attempts at restoration which seemed so happily begun." The sufferer may have fallen into a flattering slumber ; but now anxiety and sleeplessness will return, and all the alarming symptoms be reestablished. These ignes-fatui of rallying sometimes flicker for two or three days, and all that time life and death will be poised in a sensitive balance. In some of the most rapidly fatal cases, warmth has partially returned to the surface, and the pulse has fluttered and flattered immediately before death. Be it remembered that the real danger is by no means in proportion to the quantity of matter discharged from the stomach and bowels. In some of the most trying cases this is not very considerable, and in some of the most successful it has been very great. Neither is cramp or spasm a sure criterion. The great danger arises from suspended or imperfect circulation. Restore and equalize this, and you have " cured the Cholera." 40 VI. APPEARANCES ON DISSECTION. The appearances disclosed on post-mortem inspections of the bodies of those who have died of Cholera, vary according to the duration and intensity of the attack, the age, constitution, and previous health of the " subject," and the remedies administered; but enough of uniformity is found in the reports of the most instructed and careful observers — especially as to the points most significant, and of the first pathological importance — to serve the purpose of a description addressed to the unprofessional multitude ; enough, too, we think, to afford an accurate definition of the disease, in place of the bewildering guess-work of the text-books. In the language of the Medico- Ghirurgical Review, "The man who would treat disease successfully, must not consider his only aim and object to be the knowledge of the various morbid changes which take place in the structure of the different organs, and of the symptoms by which they are distinguished ; his researches must be directed beyond this — to the laws of vital actions, to the manner in which they are disordered, and to those agents capable of restoring them to their healthy state." The bodies of those who have sunk in the earlier APPEARANCES ON DISSECTION. stages of Cholera exhibit hardly any unhealthy appearance ; the stomach and intestines are apt to be paler, and more distended with air than usual, and some explorers have discovered, fancifully perhaps, a "characteristic foetor" from the abdominal cavity. But in the more protracted cases, a greater or less degree of injection of the mucous membrane, with occasional ecchymosis, is the most frequent appearance. It has also been observed, in cases where the violence of the spasms proved the most prominent symptom, that the mucous membrane presented that appearance which approaches nearest to inflammation. The large intestines are sometimes filled with whitish and flaky-turbid fluid, sometimes with greenish, yellow, or tarry matter — in other words, with the characteristic discharges, or with vitiated bile, just as the patient may happen to have died in the earlier or later period of the attack, in collapse, or in the struggle for reaction. In like manner the stomach contains either the ingesta in an unaltered state, or the same " veal-soup-like " stuff that the patient has been vomiting ; or its contents may be green or dark. So, likewise, as to the vascular appearances presented by the alimentary canal, the varieties seem to correspond, with instructive regularity, to the duration, the stage, and the intensity of the attack. The mucous membrane is generally somewhat softened ; sometimes of an unusual paleness throughout, "but oftener having various portions tinted of various hues," from the pale rose to the dark brick-dust and slate-colors, as venous or 42 APPEARANCES ON DISSECTION. arterial injection predominates; patches of ecchymosis and arborizations of the larger branches are frequent ; but the most common appearances have been a red or purplish speckling of the mucous membrane, generally over the whole surface, but more apparent in some parts than in others. Sometimes these different appearances are scattered throughout the entire extent of the alimentary canal ; at other times the stomach alone is colored and the intestines pale, or the stomach pale and different portions of the intestines darkly injected. The venous trunks of both stomach and intestines are generally found remarkably engorged. The rule, divested of its numerous exceptions, or rather modifications, dependent upon circumstances and conditions which the intelligent physician will not fail to take into the account of each individual case, is : Where the patient has not lingered, but succumbed early to a rapid attack — no striking vascular change, beyond general venous congestion, and turgidity of the prominent vessels. Where collapse, in its completest form, has been developed, repelling and damming the current of the blood — universal dark engorgement, with deep discoloration of the internal surface of the stomach and intestines. Where the disease has been protracted, and has reached the stage of consecutive fever — every degree of arterial injection, in addition to the congestion, from the lightest blush to the angry flush of exaggerated action and incipient inflammation. These are the keys to the stages ; the mad malady rings many a change on them. 43 APPEARANCES ON DISSECTION. The liver is commonly found enlarged and gorged with blood, but not always. In some cases it is soft and light-colored, and not very turgid; in others it is even collapsed and flaccid. The gallbladder is, almost without exception, full of dark green or black bile. The spleen and kidneys are not always surcharged with blood ; quite frequently they present a perfectly natural and healthy appearance. The bladder is always empty and contracted. The lungs have often been found in a natural state, even in cases where there has been much oppression of respiration. Much more commonly, however, they are either gorged with dark blood, so that they have lost their characteristic appearance and have rather assumed that of the liver or spleen, or they are remarkably collapsed, their bulk so much reduced that they lie in the hollow on each side of the spine, leaving the cavity of the thorax nearly empty. In the majority of cases the heart and its larger vessels are distended with very dark blood. All the cavities of the heart are filled with a thick, blackish treacle ; and blood so dark that, when extended on a white surface, it resembles in color the juice of the darkest cherry, is often found in the arch of the aorta and in the other great arterial trunks. The principal venous vessels are usually found engorged — the most forcible injection could not have more completely filled them — and the contained blood is dark and sirupy. The vessels and membranes of the brain are frequently turgid with blood, particularly towards the base. A fluid is 44 APPEARANCES ON DISSECTION. sometimes found effused into the convolutions in considerable quantity, with more or less serum in the lateral ventricles. The blood-vessels of the vertebral column and spinal cord may be noticeably congested, and in some cases there are marks of inflammatory congestion in the larger nerves. But the cases in which the brain presents a natural appearance, and those in which the sinuses and the veins leading to them are stuffed with almost black blood, are of equally common occurrence. 45 VII. HELPS AND HINTS TOWARDS A PATHOLOGICAL DEFINITION. The consecutive fever of Cholera is not an integrant and necessary part of the disease. It cannot be distinguished from an ordinary continued fever, except by the rapidity and fatality of its course. It is the result of nature's effort to recover herself from the stunning shock that has prostrated her, and the oppression that keeps her down. Cholera is only cognizable with certainty during the cold or " blue " period ; of the three stages, the collapse alone is true Cholera. Where medical measures have been promptly, energetically and successfully employed, the essential and diagnostic symptom, sudden sinking of the circulation, has often not developed itself; and there are cases where an excited vascular action has accompanied the first tumult of the system in Cholera. These are precisely the cases which yield most certainly and promptly to the remedial measures. In India it has been observed that these favorable indications chiefly appear among the European soldiers, who usually imbibe spirits freely at the commencement of the attack. During an invasion of Cholera in Malacca and Burmah, in A PATHOLOGICAL DEFINITION. June and July, 1852, the writer of this had medical charge of an East India Company's war steamer in the Bay of Bengal and the Straits of Malacca. The ship's company was composed of Europeans and natives — Malays and Mohammedans —in about equal proportion. Under the peculiar treatment, to be described further on, not a single case of collapse occurred among the Europeans, all of whom " indulged " liberally, the officers in wine and toddy, the men in their regular grog, twice or three times a day, and in irregular " drinks " as often as they could get them ; whereas, among the natives, most of whom were abstemious by reason of " piety" or vows, every case was collapsed ; but the recoveries, even from the cold stage, amounted to eighty-five per cent. If the superficial veins and arteries be opened in the cold stage, the contained blood may flow out ; but their walls then collapse, and no more blood can be drawn, There is no authentic fatal case of Cholera on record where the circulation has not been arrested, in the extremities at least, long before death. An increase of temperature is often observed, just before dissolution ; but the development of heat in such instances is partial, being confined to the trunk and head, and is a fatal symptom. This mocking warmth is generally appreciable for some hours after death. The application of boiling water to the skin, in the worst cases of collapse, produces little or no 47 A PATHOLOGICAL DEFINITION. effect, and some patients are insensible to the operation ; but it is certain that in a body but just dead of some other disease, boiling water will vesicate readily. So extreme is the diminution, or so complete the destruction, of the nervous energy of the skin in the cold collapse of Cholera, that there is less vitality there in such cases, the patient being still alive, than in the skin of a body recently dead of a different disease. The writer has applied boiling water to the feet and legs of patients in India, without eliciting a tone or gesture of complaint. The change in the condition of the blood — " dark, black or tarry, thick, ropy or sirupy" — is fully proved to be in the ratio of the duration of the disease, the blood more or less rapidly changing from a natural to a morbid state as the disease advances; such is the general rule. Observe that the blood is usually found to be less changed in those cases of Cholera Avhich are ushered in with excitement, than where collapse has occurred at an early period of the attack. The blood is sometimes found, on dissection, to be of as dark a color in the left as in the right side of the heart, affording reason to believe that in the whole arterial system it is equally changed. In many cases the temporal artery has been opened, after attempts to procure blood from the brachial or jugular veins had failed, and the blood in the artery was found dark and thick, like the venous blood ; it flowed in a languid, ropy stream, and then the artery collapsed. 48 A PATHOLOGICAL DEFINITION. Hiccough is a favorable sign, and seems to announce the return of circulation, especially when it occurs in the intermediate moments between the threatening of death and the beginning of reaction. While burning thirst, pain at the stomach, cramps, asphyxia, clammy sweat, cadaverous coldness, and aphonia, may all be present, vomiting and purging may be absent, and " yet " the case will rapidly run to a fatal termination. The fact is, the vomiting and purging are not only " far from being the most important or dangerous symptoms " — it is not only true that " the danger of the case is by no means dependent on the quantity of matter discharged from the stomach and bowels," and that "in some of the worst cases this is not very considerable, and in some of the most fortunate it is very great " — but it is our conviction that the vomiting and purging are, in their original intention, genuine efforts of nature to relieve the engorged vessels, and restore the equilibrium of the circulation ; that they constitute nature's safety-valve to the congestion ; that their presence, in collapse, is generally a favorable, and their sudden disappearance a very unfavorable sign. They almost invariably cease a short time before death in the cold stage ; they frequently return in a notable degree at the beginning of reaction. Mr. John Fyfe, of Newcastle, England, attended 579 cases of Cholera ; and in all these, he says, collapse never came on " until after profuse serous discharges from the bowels." Was not nature, by those discharges, struggling to prevent the collapse ? 3 49 A PATHOLOGICAL DEFINITION. — in the language of Dr. James Johnson, Physician Extraordinary to the King of England, was she not making " violent, but too often unsuccessful, efforts to restore the broken balance of the circulation, and to reestablish the secretions, by sickness and purgin — the ejected fluids being exudations, not secretions ?" Here nature cries to us for help, and shows us how to help her — disclosing to us the inner mystery of Cholera. If we do not make haste to aid her in the direction she points out, she will exhaust herself by her own tremendous efforts. In Cholera there is every reason to believe that every species of secretion, in all parts of the body, is abolished. No known function of the mucous membrane of the alimentary canal could form matter like that w r hich is discharged ; and as there is no circulation going on in the skin, but rather a complete state of asphyxia there, there can be no secretion of perspiration. The " cold sweat " of collapse is not true perspiration (like the critical perspiration of the consecutive fever), but exudation; and, viewing the skin and the mucous membrane as one continuous surface, it is just to conclude that this exudation is homogeneous throughout. " Whence, then, and how, come these discharges ? On the skin, certainly not from circulation, for there is none there ; and it is more than probable that the capillary circulation of the mucous membrane of the intestines is equally absent. It would seem as if the elements of the body, composing the parts nearest to the surfaces, became subject to new affinities, 50 A PATHOLOGICAL DEFINITION. forming a new substance, incapable of being retained by the membranes, but rapidly oozing through them. Two facts go to support such a hypothesis : First, the abundant new formation transuded, where no circulation exists ; and second, the rapid amaigrissement of the body. This wasting of the body is not merely apparent, it is real ; the usual roundness of the parts is taken off, and tendons and other salient points become strikingly prominent." We quote from the report of Dr. Robert Nelson, member of the Medical Board, and Commissioner of Health at Montreal. Of the two great classes of functions performed by the organs of which man is composed, one only is primarily paralyzed by the poison of Cholera. The operations of the senses, and of the intelligence, are either left untouched or are affected but in a secondary manner. It is the animal that dies ; the intelligence, awe-stricken, surveys the scene of death, and trembles and wonders. Those functions by which mere existence is preserved — those complicated powers by means of which we are forever appropriating, and converting into a part of ourselves, portions of the matter around vs — are, all at once and all together, deranged and disabled by the blow of this terrible angel. Nutrition is annihilated ; respiration becomes difficult, irregular, and inefficient ; the involuntary muscles no longer perform their offices ; the voluntary are contracted in painful knots by other powers than the will ; the blood ceases to circulate ; its physical properties are altered, its 51 A PATHOLOGICAL DEFINITION. serous element suddenly thrown out upon the intestinal mucous surface of the body ; the secretions are all arrested, and animal heat is no longer produced. After the first, or premonitory stage, bile ceases to be formed. We always find the gall-bladder full ; but this filling has taken place before collapse set in. There are no signs of bilious absorption. The victim of Cholera does not die "solely of starvation, caused by vomiting and diarrhoea," as certain doctors hold ; but by paralysis of a portion of the nervous system, and consequent chemical and organical decomposition of the blood. During the prevalence of Cholera, there are often observed among persons otherwise healthy various anomalous affections of the nervous system — such as cramps, cold sensations of the hands, feet, and legs, a peculiar thrilling in the extremities of the fingers and toes, and an oppressive feeling of anxiety in the region of the heart. Adult age exhibits a much more lively susceptibility to the Cholera poison than early life ; great numbers of children escape it, simply because they are less subject to the predisposing influence of Fear. The idea of bleeding, in the stage of collapse, has its origin in a hydraulic theory totally inadmissible in Cholera. There is not too much blood in the whole body, but too much at the centres and too little at the surfaces. A return to healthy distribution and circulation will not result from abstracting, 52 A PATHOLOGICAL DEFINITION. any more than from adding, a portion of the dammed-up mass. The cessation of arterial action is not owing to the state of the fluids, but to determinate derangement in the nervous power, by which the machinery of circulation has been stopped. Besides, in most cases you cannot bleed ; thickened and stagnant in the vessels, the blood cannot be made to flow ; and if a few ounces be squeezed from the orifices, it hangs from them in long tarry strings •to no purpose. The experiment of galvanizing is a kindred absurdity. The desideratum in Cholera is not the supply or restoration of vital or nervous power, but the propulsion of that power to the surface from which it has receded. 53 VIII. PATHOLOGICAL CONCLUSIONS. "Not in the world of Light alone, Where God has built llis blazing throne, Nor yet alone in earth below, With belted seas that come and go, And endless isles of sunlit green, Is all thy Maker's glory seen ; Look in upon thy wondrous Frame — Eternal Wisdom still the same ! "The smooth, soft air, with pulse-like waves, Flows murmuring through its hidden caves, Whose streams of brightening purple rush, Fired with a new and livelier blush, While all their burden of decay The ebbing current steals away, And red with Nature's flame, they start From the warm fountains of the Heart. " No rest that throbbing slave may ask, Forever quivering o'er his task, While far and wide a crimson jet Leaps forth to fill the woven net "Which, in unnumbered crossing tides, The flood of barning Life di/ides; Then, kindling each decaying part, Creeps back to find the throbbing heart. " Then mark the cloven sphere that holds All Thought in its mysterious folds, That feels Sensation's faintest thrill. And flashes forth the sovereign Will ; Think on the stormy world that dwells Locked in its dim and clustering cells ! The lightning gleams of power it sheds Along "its hollow, glassy threads I " Holmes. In 1831, Dr. James Johnson, whose clear-sighted deductions have thrown so much informing light on the nature of Epidemic Cholera, and who was at that time editor of The Medico- Ghirurgical Review, PATHOLOGICAL CONCLUSIONS. and Physician Extraordinary to the King of England, submitted to the Westminster Medical Society a series of propositions, embodying his views of the pathology of the disease — views that have never since been contravened, and to the convincing completeness of which no later observations have materially added. We extract the essence of those propositions : " I. That in Epidemic Cholera, as in most other epidemics, a poison or sedative principle — whether emanating from the earth, from animal or vegetable matter on the earth, or engendered in the air — strikes a predisposed individual, and, after an uncertain period of incubation, produces a train of phenomena, forming the subject of subsequent propositions. In Sporadic Cholera (that is, common cholera morbus), the general or diffusive cause is absent; but when the common exciting causes are strong, and the subject highly predisposed, severe or fatal cases will occur (even in that less formidable malady), where the symptoms cannot be distinguished from those of the malignant Epidemic Cholera." [That "Asiatic" Cholera arises from "atmospheric distemperature," and is diffused through, and conveyed by, the air, is evident from the fact that its appearance in any place is usually preceded by cases of cholera morbus, and the general prevalence of disordered digestion ; and when the disease does appear as an epidemic, scarcely a single individual in the same locality escapes having some disorder of the stomach and bowels. Almost every one complains of diarrhoea. Moreover, this atmos 55 PATHOLOGICAL CONCLUSIONS. pheric distemperature is often so powerful as to affect animals. In January, 1827, in Calcutta, cattle, and even elephants, experienced the epidemic influence to such a degree that they died in great numbers. Everywhere in India, .cattle and dogs have died of Cholera, goats and camels in Persia, monkeys in Burmah, chickens and turkeys in Moscow, and in Prussia multitudes of fish. Within a week after the outbreak of the pestilence at Constantinople, in July last, the birds of all kinds, from the sparrow and swallow to the sea-gull and kite, absolutely disappeared from the capital, and by their return, early in September, announced with reanimating certainty the restored salubrity of the atmosphere. It was also said that the gilding on the caiques in the Golden Horn and the Bosphorus was tarnished, especially in those localities where the Cholera had raged most severely.] "11. This poison manifests its effects according to the evidence of our senses : first, on the nervous system, as evinced by the prostration of strength, by the arrest of the secretions — dependent on nervous energy — and, in fact, by a depression of the whole of the sensorial functions, as well as those of organic life." [Symptoms curiously resembling those of Cholera are frequently observed to attend that sudden prostration of nervous energy, that shocking annihilation of tone, which follows upon a protracted debauch, especially in subjects of highly nervous temperament — that extreme depression into which 56 PATHOLOGICAL CONCLUSIONS. persons so constituted usually sink from extreme excitement — that painful nervous back-springing and unbalancing from excessive physical or mental stimulation. In such cases there are often extreme weakness, sudden diarrhoea, cold sweats, shiverings, sinking of the pulse, blue discoloration of the nails and lips and around the eyes, excruciating cramps creeping from the extremities to the trunk, distortion of the fingers, tingling and thrills in the muscles of the feet and hands, a sensation as if the balls of the fingers were applied to cold metal buttons, agitating anxiety about the region of the heart, tones and gestures of imploring helplessness, suddenly altered countenance, an expression of wandering apprehension, and even the hoarsely whispering voice. In like manner, the influence of extreme or prolonged fear upon the nervous system, often manifests itself in phenomena strikingly resembling what are called the premonitory symptoms of Cholera.] "111. The secondary effects of the choleraic poison ane shown in the vascular system. The heart acts feebly, the circulation recedes from the surface, and the blood accumulates in the vessels of the internal organs ; decarbonization and calorification cease, or are greatly diminished ; the temperature of the body falls to that of surrounding inanimate substances; paleness is changed to blueness ; and the influence of the ganglionic system of nerves seems to be nearly suspended, if not annihilated." [The reader has but to revert to what has already been noted in relation to the post-mortem appear- 3* 57 PATHOLOGICAL CONCLUSIONS. ances, and the changes in the distribution, quality, and color of the blood, to appreciate the clearness of this proposition and the accuracy of its statement. The recession of circulation from the surface, and the utter loss there of all that elasticity which depends upon nervous vitality or tone, are evinced by the peculiar " pudginess " or dough-like quality of the skin, when it is pinched up between the thumb and finger.] " IV. It is at this period that nature appears to make violent, but too often unsuccessful efforts to restore the broken balance of the circulation, and to reestablish the secretions by sickness and purging, the ejected fluids being exudations rather than secretions." [It is in this view of their intention or tendency that the vomiting and purging are to be regarded as natural rallying exertions.] "V. We are not, in our present state of knowledge, certain whether the spasms are merely the effect of the poison on the nervous system, or an effort of nature to resist it; but they, like the vomiting and purging, tend ultimately (if not seconded) to exhaust the powers of fife." [The writer was led, by his observations in India, to the conclusion that the spasms do constitute such an " effort to resist" the paralyzing influence of the choleraic poison, by restoring the continuity of the obstructed nervous current.] " VI. If nature (by which I mean the constitution), whe- 58 PATHOLOGICAL CONCLUSIONS. ther with or without aid, be able to resist the first or depressive shock of the poison, and institute a reaction in the system, that reaction, in a great majority of cases, becomes a fever, exhibiting a new train of phenomena, and demanding a different mode of treatment. If this view be correct, it would lead to the inference that the choleraic symptoms constitute the first or cold state of a choleraic fever." [Or, a more logical definition, that the true choleraic symptoms are confined to the cold stage,, and that from the moment that reaction is substantially set up, the disease ceases to be Cholera, and becomes continued fever.] " VII. If reaction, with restoration of circulation, secretion and oxygenation do not take place, the patient dies in a state of asphyxia, the intellectual powers often remaining but little impaired till the last glimmer of the lamp of fife is extinguished. This has been often witnessed in concentrated miasmal fevers, both within and without the tropics." " VIII. All the changes which present themselves in the dead body are effects, not causes of the disease ; with the exception of the congestion of black blood in the internal organs, which is almost the only phenomenon observable when Cholera terminatc-s fatally in a few hours. The traces of inflammation in various organs after death, indicate the causes or effects of the reactive fever rather than of the Cholera which precedes that fever." [This is not so well put. Why the exception ? The course of the disease being in three stages — 59 PATHOLOGICAL CONCLUSIONS. the premonitory, the cold, and the febrile — -the second stage only being true Cholera, and the poison manifesting its effects first on the nervous system, it is clear that the congestion of black blood is the mechanical effect of paralysis of the nervous extremities primarily, and secondarily and consequently of collapse of the superficial vessels, whereby the whole volume of the blood is suddenly repelled from the surfaces to the centres, from the finer filaments to the larger branches, and so on to the great trunks, which are found loaded with thick black blood after death. This is the whole process and sequence of engorgement and congestion, and therefore the congestion should be regarded as the effect of the Cholera proper, and the traces of vascular excitement and inflammation as the effect of reaction, and the cause of the consecutive fever.] "IX. As we have no means of expelling or neutralizing the poison, we can only endeavor to counteract its effects, and to assist nature in her remedial movements." [The primary or essential indication is to restore, not " the equilibrium of the circulation," as Dr. Johnson has it, but the impaired nervous vitality, the paralyzed nervous energy, whereby that equilibrium was lost. The balance of nervous power restored, the balance of circulation follows, of course, and then — " secretion, calorification, oxygenation." This is the signal that nature makes in the cramps, and the key-word is Revulsion. The galvanizers tried to answer it, but their error was the same in 60 PATHOLOGICAL CONCLUSIONS. principle as that into which the bleeders fell ; for the galvanizers insisted upon adding something that was not wanted, and which could not have been added if it had been ; while the bleeders insisted upon taking away something that could not be spared, and which could not have been removed.] 61 IX. EPIDEMIC CHOLERA AND CHOLERA MORBUS— THE DIFFERENCE. British Cholera and Asiatic Cholera, Common Cholera and Malignant Cholera, Sporadic Cholera and Epidemic Cholera, Cholera and Cholera Morbu — these are terms commonly employed to mark the distinction between the two diseases. For our own part, w r e regard it as a fact established that, in their kind, they are one and the same ; that the difference is of degree, of intensity and fatality, merely, and the presence or absence of the diffusive cause. In the characteristic phenomena, we find the family likeness very strongly marked : vomiting and purging, pain and cramp in the stomach and bowels, dejections at first thin and watery, afterwards bilious, great sickness and distress at the stomach, spasms in the muscles of the abdomen and extremities, intense thirst and craving for cold water, sinking of the pulse, cold arms and legs, dead-pale countenance, distressed expression, cold sweat, and extreme prostration. Sydenham described an epidemic Cholera Morbus that prevailed in England in 1669. In his opinion the disease did not differ from the Common Cholera, except that, that year, it prevailed epidemically. EPIDEMIC CHOLERA AND CHOLERA MORBUS. The Bombay Medical Board have declared that Sydenham's description applies exactly to the Cholera of India. " Therefore the people of India might attribute their disease to importation from England." A Report of the Royal Academy of Medicine of Paris says, " The Cholera of India is, as to its symptoms, the Cholera of the ancients ; and except in intensity and danger, differs but little from ordinary Cholera." The most accomplished physicians of England have indorsed this opinion. The physicians of Montreal regarded the epidemic of 1832 as differing in no respect from the endemic Cholera of the United States and the Canadas, " save that now it is epidemic ; the same organs are affected, and the same symptoms exhibited." The common Cholera Morbus of the United States is usually considered a not very dangerous malady ; but most writers declare that it often is so, and that it frequently destroys life in a few hours. The descriptions of this disease, found in old medical works, always included the vomiting, purging, cramps, sweats, and most of the symptoms of Asiatic Cholera. Sydenham describes the first discharges as thin and watery ; and Frank says, "At first the egesta are like water — then as if flesh had been recently immersed in them ; sometimes they are white ; " and adds, "in the worst cases of Cholera the patients, exhausted by profuse discharges, and their torments, become collapsed in five or six hours, and look no longer like themselves." Observe that it is of Cholera Morbus that he is writing. 63 EPIDEMIC CHOLERA AND CHOLERA MORBUS. No symptoms have been described as characteristic of Epidemic Cholera that do not sometimes present themselves in Common Cholera. Much stress has been laid by certain observers on the difference in the discharges. On this point The Medico-Ghirurgical Review remarks : "If the fluids are colorless, it is considered a proof that the disease is Asiatic — if any bile, or other colored fluids appear, the disease is English. Yet the India Boards, and indeed all careful observers, have acknowledged that the discharged fluids form no criterion of the disease. The Bengal Board, for example, tells us that ' the fluid ejected from, the stomach was watery, mostly tasteless, transparent, or of a whey or ash color. Sometimes it was sour, green, dark, like infusion of tea, starchy, mixed with mucus, and viscid. In very rare cases, pure bile was thrown up.' In respect to the alvine evacuations, 'they were generally watery, colorless, white, or muddy — sometimes red and bloody — sometimes greenish and pulpy, like halfdigested vegetables.' Is it not preposterous, after this, to make the distinction between the Asiatic and the English disease to consist in the color of the motions ? Nimium ne crede colori ! " Dr. Jarvis, a very intelligent physician of Northfield, Mass., communicated to Dr. Brigham of Hartford, Conn., a description of " a very singular and malignant disease" that prevailed at Warwick, a hilly town in Franklin County, Mass., in 1831. The disease made its appearance in July, and in five weeks thirty-two 'individuals were attacked, of whom 64 EPIDEMIC CHOLERA AND CHOLERA MORBUS. 65 sixteen died. The malady manifested itself, in the first instance, by distress at the stomach, extending to the bowels ; then by nausea, and vomiting, and frequent calls to stool ; the discharges were white and watery. If the disease was arrested here, the dejections became bilious ; but if not arrested, the vomiting increased ; nothing could be retained on the stomach but opium ; the discharges from the bowels were constant, and of a thin fluid, resembling rice-water ; there were cramps of the muscles of the abdomen and extremities, with intolerable thirst ; the skin became cold, shrunken, and of a leaden hue ; the pulse weak, and often imperceptible ; the mind not weakened or disturbed, the patients manifesting but little anxiety about their condition, and conversing freely to the last. These are but a few from the convincing array of facts that might be marshalled to prove that the Epidemic Cholera of Asia differs from the Common Cholera Morbus of the United States in intensity and fatality only ; and that when the latter, by reason of its violence and favorable local circumstances, assumes an endemic character, there may remain but the difference of a letter between the two diseases. X. TREATMENT. Salt, mustard, vinegar and oil, pepper, red and black, everything the casters afford, except tomato catsup and Jockey-club sauce — as if Cholera were chicken salad ; wine, whisky, rum, and brandy, Apple Jack and Old Tom — everything the decanters, and nothing that the pitcher, supplies ; rhubarb, senna, and castor-oil; scammony, colocynth, jalap and aloes ; ipecacuanha, tartar-emetic, and sulphate of zinc ; calomel in all stages and in doses of all sizes, from the homoeopathic mite to the allopathic monstrosity ; opium in all its forms, and by every imaginable mode of administration ; ether, camphor, musk, castor, aromatic and stimulating tinctures; essential oils of peppermint, clove, and cinnamon ; extracts of hyoscyamus and cicuta, prussic acid, subnitrate of bismuth, colchicum, cinchona, serpentaria and capsicum ; oil of vitriol, spirits of turpentine, and for all we know, petroleum; brandy injections, soap injections, tobacco injections, warm drinks and ice water; tepid baths, cold baths, hot baths, vapor baths, hot sand, friction with irritating rubefacients, blisters, scalding water, mineral acids, red hot irons, cold water pumped on the spine and the pit of the stomach, bleeding, cupping, leeching, oxygen gas, TREATMENT. laughin gas, injections of saline solutions into the veins, electricity, galvanism, chloroform, clairvoyance, hasheesh, inhalation, Perry's Pain-killer, Radway's Ready Relief, Mrs. Winslow's Soothing Syrup, Phalon's Night-blooming Cereus, Constitution Life Syrup, and Mrs. Allen's Hair Restorer. For heterogeneousness and promiscuousness, and elaborate and complicated stupidity and nastiness, we know of nothing in the whole range of English literature with which to compare the run-mad list, unless it be Mr. Timothy Tickler's description of the spots on a steamboat table-cloth, in the JVbctes Ambrosiance. Enough, that it represents every degree of " sagacity and energy," from the most timid imbecility to the most self-sufficient recklessness, from "leaving the disease to Nature," to murder with aggravating circumstances ; and that it stands for the practice of all the gentlemen who have got themselves inoculated with other gentlemen's theories — who have ripped with this Euripides of Venesection, or socked with that Socrates of Vesication. Even if this were the place, and the time and space were ours, to explore and discuss the bewildering budget of notions, the labor were in vain. Our readers will thank us for proceeding at once to our demonstration of the method of treatment at which we long ago arrived, by way of the pathological conclusions already plainly stated, and by which eighty-five out of every hundred of the collapsed cases, and all of the premonitory cases, were recovered, in the Bay of Bengal in 1852. 67 TREATMENT. But first, in this connection, it seems but fair that we should call attention to a fact which has been everywhere observed, and which may serve to explain the honor in which certain remedies have been held in certain localities and seasons, only to fall into contempt at other times and places. The causes that produce Cholera are always most violent at first ; and after an early climax of fury, the disease is observed to become more mild and manageable. Remedies then appear to have more control over it, and the hope is entertained that the method of treatment adopted has lessened the mortality and triumphed over the scourge ; but all such hopes are almost sure to be blasted on a recurrence of the invasion, or on trial of the same remedies in other places at the commencement of the attack. Dr. Lefevre, physician to the British Embassy at St. Petersburg, and who enjoyed the amplest opportunities of observing the disease and ascertaining the most successful modes of treatment, remarks : "The Epidemic Cholera, on its first invasion, baffles all attempts to conquer it ; but it gradually loses its intensity, and towards its decline, becomes as tractable as other diseases of the alimentary canal." And Dr. David B. White, one of the physicians to the Gateshead Dispensary and Cholera Hospital, says : " When Cholera first rages, its inveteracy is greater than at any subsequent period, and remedies which utterly fail in the first instance, acquire a renown and celebrity when nature herself is at work to assist them." 68 TREATMENT. So, what is true of the period of the invasion is equally true of the stage of the case : thus calomel, before reaction, has been pronounced all vanity and foolishness ; and bleeding, after reaction, has seemed all wisdom and virtue. Mr. William Scot, in an old Report to the Madras Medical Board, on the treatment of Cholera in the Presidency of Fort St. George, says : " The suppression of the excretion of bile being only a link in the common chain of symptoms, and the partial or occasional removal of that excretion, or even its total absence, having been proved to be of little consequence in the general course of the disease, to attempt to excite it by particular means, may be considered as premature and injudicious. Whenever a favorable change takes place, indicated by a renewal of the ordinary functions, then the exhibition of the appropriate stimulus (calomel) seems to be clearly indicated, and not till then." And Dr. Kinnis, in an account of the treatment at Port Louis, Mauritius, in 1820, anticipates the intelligent objections (to blood-letting) of many later observers, in the following words : " The impression produced on me is, that when only a few ounces of blood can be obtained, their abstraction accelerates the fatal event ; and when bleeding can be carried to syncope, the disease is curable without it." In other words, it is folly to bleed with the object of " restoring the circulation," since if you can draw blood, it is because the circulation is already partially or completely restored; and if there is not circulation already, you cannot draw 69 TREATMENT. blood, and your cutting and squeezing only weaken more and more the half-dead patient, and thwart and cripple nature. The fact is, nature is trying to do her own bleeding in her own way, and doing it in excess — by the profuse evacuations, we mean. In the language of Dr. Kirk : " When was it proposed, till the present day, to relieve a condition of the extremest depression, and of no arterial excitement, by the abstraction of the principal vital fluid ? Will the removal of a small column of venous blood change the condition of the rest of the sanguineous stagnance, or impart energy to those nerves which, under a poisoned influence, have ceased to perform their important functions of giving life and action to the whole system ? " No ; the practice of bleeding, especially in the stage of collapse, admits not even of that similia similibus defence which may be set up for the tobacco injections, of which it has been said that when dogs are poisoned by them, the symptoms produced are precisely those of Cholera — purging, vomiting, cessation of the pulse, complete collapse. But in spite of our promise, we have digressed into debate, and with a thought of apology to the reader, we come back to the treatment which we believe has been conclusively proven to be the logical and natural end to which the true pathological paths infallibly converge, and for which any one must be prepared who has followed us thus far on the. trail of clear-sighted and keen-scented explorers. There are usually three stages to a case of Cholera 70 TREATMENT. — first, the premonitory or warning stage ; second, the " cold-blue," or stage of collapse, which alone is true Cholera ; and finally, the stage of consecutive fever, which is the result of reaction, and differs in no respect from a common continued fever. The first and last stages may both be absent — that is, a man may be suddenly struck down with collapse, and as suddenly be restored to perfect health, without passing through the stage of fever. The writer has observed this phenomenon in its completeness, again and again, on the coast of Siam; but it is of extremely rare occurrence in Europe or the United States. " The poison of Cholera, in Great Britain," says Dr. Kirk of Scotland, " does not seem sufficiently energetic to destroy the constitution in a moment, as it is said it sometimes does in India. Nature here struggles for emancipation, generally for days together, and institutes new actions, and various discharges, to relieve herself of her load." TREATMENT OF THE PREMONITORY STAGE. This is simple enough — only be prompt. Whatever you do, waste no time ; for Cholera is the time of failing forces, and the tide of circulation that is going out, and it waits for no man. You may have three days of warning — act as if you had but three hours ; and from the moment that you take hold of what threatens to be a case of Cholera, keep constantly in view the following indications, in their order : 71 TREATMENT. I. To allay irritation in the nervous expansion of the stomach and bowels. 11. To excite the vascular system, and to restore fluidity, motion, and heat to the blood, by restoring the impaired nervous vitality. 111. To reanimate the suppressed secretions. IV. To obtain healthy evacuations from the bowels and kidneys. V. To control and moderate reaction, and obviate congestions, local determination, or organic inflammation. When the patient comes under treatment in this stage of the disease, before the pulse and animal heat have failed, his recovery may be calculated upon with much confidence — especially if he be young, of vigorous constitution, and with a reactive vitality unimpaired by previous organic disease. Therefore, while the symptoms are confined to simple diarrhoea, nausea, or imperfect vomiting, flatulence, vertigo, headache, and pain in the abdomen or pit of the stomach, thrilling sensations of heat through the bowels, and probably occasional cramps or quivering in the legs —to any or all of these symptoms — send him at once to bed, and insist upon strict repose. If he can use a bed-pan for the purpose of evacuation, so as to avoid rising from his bed even for that occasion, so much the better. Many persons have experienced the full development of Cholera, and have even died, for having, in the beginning, refused to take to the bed for a simple looseness; and a diarrhoea which would surely 72 TREATMENT. have degenerated into Cholera has often been cured by the mere repose and warmth of the bed. Keep him warmly covered, and make him wear a flannel band around his belly. An excellent application to the abdomen is a bag filled with ashes, or bran, very warm, and often changed. At the same time, if the weather be cool, let the temperature of the apartment be kept moderately high. Administer internally nothing, as yet, except half an ounce of castor oil with 25 drops of laudanum, in a cup of strong coffee. But if the nausea and diarrhoea continue — especially if the oil and coffee are rejected — if the pain in the abdomen and pit of the stomach becomes more distressing, and the vertigo and flatulence, and thrillings of heat in the bowels increase, apply a large mustard poultice over the whole surface of the abdomen, so as to cover the pit of the stomach, and administer a draught consisting of a tablespoonful of salt, dissolved in a large tumbler of warm water. If the pulse has begun to sink, the extremities to grow cold, and the cramps to be painful, repeat the salt and water, doubling the quantity of salt, and adding a teaspoonful of red pepper. This will act as a free emetic, and will probably bring up a considerable quantity of dark bile — perhaps thick and vitiated ; but that will depend, to some extent, on the intensity of the attack. The administration at this time of an active emetic is in accordance with the admirably expressed views of Dr. James Johnson, who says : 4 73 TREATMENT. "Of all the means which nature or art can bring into operation, the act of full vomiting is the most powerful in driving the blood from the trunk to the capillaries — from the internal organs to the periphery of the body. It is also the most universal excitant of secretion in every glandular structure of the living machine. Nausea and retching are quite different in their effects from the operation of full vomiting; for they depress the power of the heart and nervous system, and prevent the blood from flowing to the surface; while full vomiting impels the circulation with such force into the superficial vessels that it is extremely difficult to stop the flow of blood from the orifice of a vein during vomiting. I have seen the blood come from a vein, under such circumstances, with all the character, or at least the appearance, of arterial blood." But this is the only time when it is surely an advantage to administer emetics; in the more advanced stages they are of doubtful propriety. If these measures prove ineffectual — if the pulse continues to sink, and the surface to grow colder, if the cramps increase in violence, and the discharges from the bowels are losing their natural faecal color and odor, and assuming the " rice-water " characteristics, it is quite time to begin with stimuli — equal parts of laudanum and spirits of camphor, a teaspoonful in half an ounce of brandy every half hour ; for collapse is almost upon you, and you have no time to spare ; but don't have recourse to stimuli until the pulse is decidedly sinking, and the surface growing cold ; then nature needs them, and their force is expended where it is needed. 74 TREATMENT. Cloths wrung out in hot water, and laid on the abdomen, are very useful in alleviating the pain, or any griping that may attend the diarrhoea. The following is an excellent formula for pills to arrest the diarrhoea, especially in persons destitute of the comforts and conveniences of life, or whose occupations keep them stirring or exposed : R. Pulv. Opii — gr. xv. Hydrarg. Submur. — 3j- Pulv. Bacc. Capsici — 3 ij. Confec. Rosas — q. s. So as to make 40 pills. One to be given every two hours, till the diarrhoea is checked. They produce a degree of constipation, which, if necessary, may be removed on the second day by any mild laxative. Physicians will find it convenient to carry a box in the pocket, for the way-side emergencies of a cholera invasion. In a few cases, not diarrhoea, but obstinate constipation prevails, " after a longer or shorter duration of which the disease suddenly appears." For these, castor oil, or rhubarb and magnesia, assisted by injections of warm water, are to be preferred, whilst, from first to last, drastic purgatives are to be strongly deprecated. Active friction of the abdomen with warm flannels, or the bare hand, will materially promote the action of the laxatives. If the patient has already begun to suffer from thirst, toast-water, beef-tea, and thin sago, are the safest drinks — a little at a time ; and the diet should 75 TREATMENT. be confined to chicken and mutton-broth, and well boiled rice. Should recourse be had to the stimuli, of brandy, laudanum and camphor, their action should be seconded by the application of steady dry heat, and energetic and persistent friction. Let the upper and lower extremities be surrounded with bags of heated ashes, bran or sand, or with hot bricks and bottles of hot water, wrapped in woollen cloths ; heat common platters of metal or earthenware, and lay them, wrapped in flannel, on the pit of the stomach and the abdonfen ; at the same time, assiduously rub the legs and arms with warm flannels, sprinkled with dry mustard. So much for the treatment of the premonitory stage, down to the point where it begins to pass into collapse. The prompt and vigilant application of these various measures will infallibly ward off the " cold blue " stage, in ninety cases out of a hundred. In this place, by the by, we remember the importance of enjoining cheerfulness, as far as may be, in the attendants and surroundings of a patient in the premonitory stage of Cholera. TREATMENT OF THE STAGE OF COLLAPSE. We will now suppose that all our efforts to shield the patient from the icy grasp of true Cholera have been unavailing, and that he is fast sinking into complete asphyxia — his pulse no longer to be felt, his skin brown or leaden, and doughy and clammy and 76 TREATMENT. cold, like that of a dead body, his tongue cold, even his breath cool, his features pinched and shrunken, his expression anxious and woe-begone, his fingers and toes withered and puckered, his eyes sunken, his voice hoarsely, piteously whispering, — wrenched and torn with cramps, and maddened with thirst ; it is a frightful picture ; our readers should be shockingly familiar with it by this time. Well then, what now ? Courage and Perseverance ! — Heroic treatment and indefatigable pertinacity ! — You have this dreadful encouragement, that the case is clearer than it was before, the " situation " simpler ; you know your foe now, and you confront him face to face ; you have nothing to hope for from nature, and nothing to fear from experiment, and nothing to lose ; you may cripple or exhaust your patient in striving to save him, but the Cholera, if it break down your guards, will surely slay him outright. It is a fair stand-up fight between you and your giant ; your patient's vital subsistence, and your own scientific ammunition, are running very low ; if you waver or parley, you are lost. Remember — that " the organs, during the collapse, probably owing to deficient vitality, often give no indication of having been acted upon by repeated doses of certain powerful medicines, which, under other circumstances, would have produced the most decided effects." But forget ihe " therefore " — that it is suggested (by some irresolute and short-sighted practitioners, who do not recognize an analogy even -when it is held before their eyes) "that this temporary insensibility 77 TREATMENT. of the system should not inculcate the administration of such quantities as could, by accumulation, when the organs begin to recover their vitality, give rise to unfavorable results." If you administer to a man who has been bitten by a rattlesnake, two or three quarts of whiskey or apple brandy, you have no fear that he will die " dead drunk," as soon as he begins to recover his vitality ; nor do you find it difficult to understand why, in cases of Cholera that have been treated with free doses of calomel in quick succession, salivation is so rarely produced. Now, then, is the time to bring all your forces into action, and engage them all together, with intrepidity and elan. Begin by giving a large enema — from three to four pints of as hot water as the hand can bear, with six ounces of brandy, and two drachms of laudanum. At the expiration of an hour, withdraw this enema by a tube introduced into the rectum — it will come off quite cold — and immediately throw in another, without the laudanum and brandy. At the same time administer by the mouth, every half-hour, the equal parts of laudanum and camphor, a teaspoonful in half an ounce of brandy, already prescribed. One hour after the last injection of hot water alone, repeat it — this time adding the brandy and laudanum — and so on by alternate hours. Between the doses of laudanum and camphor, give five grains of Quinine, in any mode of administration least disagreeable to the patient ; if it be immediately rejected, immediately repeat it. If the means of injection are not at hand, double 78 TREATMENT. the doses of camphor and laudanum, until some simple apparatus can be procured ; though it is reasonable to expect that, in time of Cholera, every family not absolutely destitute will be provided with one, and that no physician will go abroad without it ; it should also be in the power of every police officer to furnish one at the shortest notice. Still, though a great advantage, and the best of all possible modes for applying heat, the enema is not imperatively indispensable, the patient's life does not depend upon it; and if you cannot inject, you may make the double doses of laudanum and camphor serve your purpose, especially if you have your great gun, the Quinine, engaged. If he rejects the laudanum and camphor, give him a grain and a half of dry opium every hour, until he ceases to vomit. All this while it is to be presumed that you have been pursuing your external treatment with redoubled assiduity and care ; that your bricks, your bottles of water, your bags of ashes or bran or sand, are in their places and kept hot, worsted stockings, filled with hot sand constituting a simple and effective appliance ; that you are keeping your patient in a strictly horizontal position, and in as complete repose* as may be practicable; that you have his chest and arms clad in thick flannel, and his abdomen and thighs and legs covered with sinapisms, and that you are applying cloths wrung in very hot water to his feet ; or that you are vigorously rubbing him with dry warm flannels wherever and whenever p>u can get at his legs or arms or trunk ; that you 79 TREATMENT. cause his bed-covering, and his warming appliances, to be carefully replaced as often as, in his restless, tossing agony, he may throw them off; and that you have made your assistants sensible of the importance of avoiding all unnecessary disturbance of the patient, and of confining him to the horizontal position until the heart shall have recovered its action, by reminding them that an erect, or even half erect position during the collapse, has been often observed to produce instant death; indeed, any muscular movement is more or less dangerous. For this reason alone, the use of the warm bath, once in decided favor, is to be positively condemned. In its time it probably killed five cases for every one it saved; baths of all kinds are painful and dangerous. The patient ought never to be left, for a moment, without an attendant firm enough to guard and control him, and sufficiently well instructed to be capable of acting according to circumstances, and taking advantage of every change. The application of evaporating liquids, or indeed of any moisture, to the general surface, should be forbidden, for obvious reasons. When the frictions with dry warm flannel, powdered with mustard, can be maintained by four persons rubbing all at once the whole surface fcf the body, the advantage is great. Mustard plasters should be applied to the spine, when that can be done without disturbing the patient too much ; and the vomiting is often allayed by linen cloths dipped in hot water and laid on the pit of the stomach. When the cramps are excruciating in the muscles of 80 TREATMENT. the arms and legs, the roller bandage, firmly applied, will often afford decided relief; the patient commonly cries out for extension and pressure, " strong pressure," there. For that inappeasable fiend of thirst, the sufferer may suck or swallow whole, small lumps of ice, the size of a hickory-nut; no drink will afford him such grateful relief; if you are compelled to give him cold water, it should be colored with brandy, and slightly acidulated, and he should be allowed to sip it only. And now, if you must be afraid, be afraid of the Collapse, and not of your remedies. Not of the stimulants — for if you have understood what we have so conscientiously and particularly endeavored to demonstrate, as to the true nature of the disease, and the pathological procession of the phenomena, any defence of the stimulant treatment is unnecessary; and if you have not understood that, such a defence were useless. Not of the opium — for the vomiting, the purging, the cramps — originally honest efforts of nature to relieve the engorgement and congestion, and restore the secretions, by giving a new impulse to the circulation, and new energy to the insensible nervous extremities, having failed of their intention, have now become simply exhausting, and must be stopped. And who needs an argument to prove that that may best be done by an astringent, an antispasmodic, an anodyne, a stimulant, all in one ? Only, give enough. When the Cholera first appeared in Russia, the French Government sent an agent to St. Petersburg 4* 81 TREATMENT. to investigate the nature of the disease; and he wrote : " The brilliant success mentioned by English physicians has been of very rare occurrence, and due only to the very large doses which they have had the courage, or rather the temerity, to administer." Remember, that collapse almost never comes on till after profuse serous discharges from the bowels. Not of the Quinine — for of all the medical agents, whose aid fair science has invoked for the relief of collapsed and congested, stagnant and dried-up humanity, there is not one more direct, more consistent, more clear in its great office of distributing and equalizing the circulation, and leading the vital current back from its bursting dams to its remote, deserted channels, than this simple, faithful, noble tonic. Moreover, you have, in the asphyxia of Cholera, a true tonometer. Watch those puckered, blanched, and withered fingers, and ply your quinine without fear ; for so long as they remain withered, blanched, and puckered, you may be sure that the peculiar virtue of the drug fails before the paralyzing potency of the poison, with the inertness of bread pills ; but so soon as they begin to plump out rosily with the returning genial heat — Its faintest, feeblest stir Slow-spreading, strengthening long, at last Vibrating full in them," — then stop ; so you will have nothing to fear from " the accumulative effects of the drug ;" on the contrary, you will probably find the consecutive fever 82 TREATMENT. mildest and briefest in those cases of which the col\apsed stage has been treated with quinine — as from ihe analogy of its modus operandi in intermittent fever, you might expect. It has even been argued in objection to the treatment by quinine, that neither that " nor any other medicine " can produce any effect whatever in the collapsed stage, because the absorbents are paralyzed. But it must be evident that the remedial measures here recommended to precede, accompany, and cooperate with the quinine, forcibly tend to revive the function of the absorbents, by promptly restoring vitality to that portion of the nervous system from which such functions are derived. Of no disease in the whole dire catalogue is it truer than of Cholera, that "while there's life there's hope." Keep on saying " Never say die," with the pertinacious iteration of Barnaby Rudge's raven. Stick fast to your patient, and fight for him, in spite of extreme unction, almost in spite of a charnel odor ; and never give him up until the coffin-lid is screwed down. It is not easy to say just when people do die, according to " Crownners' 'quest law," in Cholera asphyxia ; for they are often colder and more insensible than any dead man some hours before they give up the ghost, and sometimes they are warmer than many a living one, some hours after. At the Mission San Dolores, near San Francisco, where many cases of Cholera occurred in 1849, the writer saw a living Mexican " laid out." 83 TREATMENT. TREATMENT IN REACTION. Unless your patient's constitution has decayed with age, or been broken by previous disease or depraved habits, he will, in a few hours, have rallied under the treatment here prescribed. Now is the time to bring up your "mercury " reserve. As soon as the pulse returns to the wrist, and begins to acquire volume and strength — as soon as the natural warmth and color begin plainly to return to the skin, and the spasms to abate — at once, without waiting for other signs of reaction, stop the injections, double the intervals between your doses of quinine, and be. tween those of laudanum and camphor ; that is, that there may be an hour from quinine to quinine, and an hour from laudanum to laudanum — and immediately give twenty grains of calomel. If, at the expiration of two hours, the evacuations have not become bilious and faecal, repeat the dose. If they have, stop the quinine, laudanum, and camphor, and give ten grains of calomel ; which should be followed up, at the expiration of two or three hours more, with a full dose of castor oil. If by this time he has passed urine, and dropped into a restful slumber, as will probably be the case, your patient is saved ; the Cholera has passed, and what remains is either common continued fever, or direct convalescence. In June, 1852, Tobee, tindal of the Malays, on board the Hon. East India Company's war-steamer Phlegethon, went ashore at Aracan, at 9 in the morning, in perfect health. At 1 o clock he was 84 TREATMENT. brought back completely collapsed — cold and blue. The treatment employed was precisely that which has been prescribed in these pages, especially as to the brandy, camphor, quinine, and calomel. At 7 o'clock the same evening the natural heat and hue had returned to the skin ; after passing considerable quantities of thick, black, vitiated bile, his stools had become faecal and nearly natural; he had passed urine, and was sleeping quietly. Twenty-four hours afterwards he was on deck, comparatively well, and on the third day he was discharged from the sicklist at his own request. He was a man of about twenty-five, with an unimpaired constitution, and of great personal strength and courage. He had no fever. This case was followed by several others — all natives, and some of them strictly abstemious. All were collapsed, all took the quinine, none had the fever, and all recovered. Among the European portion of the crew not a case occurred; notwithstanding that many of these got drunk as often as the opportunity offered, and all took their regular daily allowance of grog. In the rallying stage it is important to watch the Changes, to prevent recurrence of collapse on the one hand, and to ward off congestions of the head and viscera on the other. The first is averted by repose and external warmth, and by giving warm arrowroot in moderate quantities ; the second, when the indications are threatening, by small doses of calomel, and castor oil, with acidulated drinks. 85 TREATMENT. TREATMENT IN THE STAGE OF FEVER. The eminent Mr. John Fyfe, of Newcastle, England, who in 1831 attended 579 cases of Cholera, used to say that the duration of the consecutive fever was commensurate with the duration and severity of the collapse, and not much dependent on the kind of remedies employed. This is certainly far from being true of the Indian form of the disease, especially of those cases which have been treated with quinine ; and even in England, and in this country, a very mild case sometimes precedes a dangerous fever ; and sometimes after the severest collapse there is no fever at all. In England, under certain circumstances, the fever, unless strictly watched, proved more frequently fatal than collapse itself, though the symptoms were described as differing but little, if at all, from those of ordinary typhus — except, perhaps, in the greater rapidity with which they ran to a fatal termination. There is apt4o be much giddiness, pain in the head, and stupor. If the case is a mild one, mustard poultices applied to the neck will relieve the head, — and to the epigastrium, the stomach. Should there be constipation, it may be corrected with simple laxatives. If the cerebral oppression is very serious, the back of the neck should be blistered, and the head shaved and kept cool with wet cloths, or even with ice. Small doses of calomel and castor oil (as in a preceding paragraph) should be given ; and great care should be observed to avoid errors of diet 86 TREATMENT. The congestion which threatens the head is the chief danger, and it will often be necessary to precede the blisters (which are sometimes applied to the scalp, and sometimes also to the calf of the leg) by leeches behind the ears or on the neck. So much for a rational and successful treatment of Cholera, from first to last. Whoever may be disposed to take exception to the method, will surely not deny it the merit of simplicity, procurability, and adaptability. All the means and appliances are within the reach of the poorest man ; and in the absence of a physician, any person of fair. intelligence and common sense can use them. Children, with their fresher constitutions and their purer habits — and, above all, their minimum of susceptibility to the influence of panic — are in infinitely less danger from an invasion of Cholera than their more corrupt and conscience-stricken elders. When attacked, they suffer more from oppression of the brain than adults : and their consecutive fever almost always assumes the shape of Hydrocephalus. Relapse in Cholera — not very common — should be treated on the same principles as the original attack. 87 XI. IS CHOLERA CONTAGIOUS? Within the limits of a compact practical treatise, we cannot, with profit to the reader, and for the attainment of that handy usefulness which, from the first, has been our single aim in the preparation of these papers, indulge our zeal by engaging in the irrepressible conflict which this vexed question seems to involve — a wordy, windy warfare, which will not cease to be waged so long as straight facts can be wrenched and twisted to the needs and tricks of mere wrangling ; so long as medical Ephraims are joined to their hobby-idols ; so long as those who have the power to establish and enforce quarantine regulations find their personal advantage in the exercise of that authority. But since it is by " both houses" conceded that if Cholera is contagious, the most rigid quarantines that sagacity and experience can devise, and firmness enforce, are imperatively demanded for the protection of populations ; and that if, on the other hand, it is not contagious, such quarantines are not only useless, but infinitely pernicious, by their tendency to plunge in extreme misery the hundreds of families and thousands of individuals who are dependent upon the commerce they suddenly blockade, and the labor they sud- is cholera contagious ? denly discharge ; and so to encourage those conditions which most potently invite the disease, while, at the same time, they frighten off the humaner agencies which alone can prevent, conquer, or mitigate it ; therefore, we prefer to take this question sharply by the throat, and to declare our positive conclusion, deliberately reached through careful examination and comparison of all the evidence brought forward on both sides, as well as from unusual opportunities of observation in the very laboratories and hot-beds of this atmospheric poison, that not a single case — well attested, and clearly, completely demonstrated — of Cholera transmitted by contact alone — with the person, clothing, excretions, or effluvia of another " case " — has ever yet been cited ; and this we say in full knowledge of all the quasi "facts and proofs" elaborated by the glorious minority of contagionists, whose doctrine manifestly tends, first, to make victims, and then to leave them prostrate and unbefriended ; for Panic nurses Cholera, and the doctrine of Contagion patronizes Panic. It is safe to say that in India ninety-nine out of every hundred physicians of any professional respectability utterly flout, as a thing preposterous, this "Contagion" scarecrow, and the majority of them regard it as a nuisance sufficiently noxious to be abated by law. On this subject the present writer conferred, during two years, with numerous medical officers of the most accomplished attainments, and complete experience, in the service of the East India 89 is cholera contagious? Company, as well as with many of the Surgeons of the Royal Navy, attached to the China and India^ Squadrons; yet he cannot now remember one who did not scoff the notions of the Contagionists; and when we consider that these can, nevertheless, show upon their rolls here and there an eminent name, we can only wonder at the commonness of crotchets and the uncommonness of common sense. In this connection we cannot do better than quote from the very thoughtful treatise of Dr. Brigham : " That some cities and fortresses, which established rigorous quarantine regulations, have escaped the disease, is very true ; but it is also true that other places, immediately adjoining those which were attacked, have escaped, notwithstanding that every precautionary measure had been omitted. It is further true that numerous countries, cities, and fortresses have adopted and enforced the most severe preventive regulations — that they adopted them early and enforced them with rigor — and yet the disease appeared among them. All that quarantine enactments can do towards preventing the spread of a disease from one country to another, has been done in Russia, Austria, and Prussia. "In Russia immense lines of troops were drawn, to arrest its progress ; St. Petersburg was entirely surrounded by cordons sanitmres ; but all these regulations, enforced by a powerful and despotic government, were unable to prevent the approach and the spread of Cholera throughout the Russian Empire. The efforts of Austria were equally unavailing, for in a short time the disease passed her triple cordons and invaded the country from Poland. Prussia 90 IS CHOLERA CONTAGIOUS ? employed sixty thousand of her best troops to enforce her rigorous restrictions, and travellers bear testimony to the severity with which they were enforced. And what has been the result? (turning to The American Journal of Medical Sciences for May, 1832) — ' An immense expenditure of money, the suspension of commerce, a stop put to industry, multitudes deprived of the means of acquiring subsistence, and whole families rendered favorable subjects for the disease ; but no stop to the extension of the disease — on the contrary, its progress was rendered more fatal. As an instance of this, Breslau may serve as an illustration and a warning to other cities. That city contains ninety thousand inhabitants—active, commercial, and industrious, many of them manufacturers and artisans. A quarantine of twenty days, with the difficulties almost insurmountable which it entailed, Avas established at the borders of the province, and maintained with a rigor which might serve as a model to other nations. But in the midst of this apparent security, a woman living in a damp part of the town was attacked by the Cholera, and in a few days the disease spread. The most minute researches on the part of the public authorities could not discover any communication between the woman and any stranger or goods suspected of being infected. But when the disease spread, the authorities saw too late the deep injury their sanitary measures had inflicted.' " Taught by lamentable experience, Russia and Austria and Prussia have withdrawn their cordons, and acknowledge not only their inutility, but that they are productive of immense evils. Indeed, all the nations of Europe are abandoning severe quarantine regulations, and it is to be hoped that the cities of the United States will not adopt them, but place all their reliance, for the prevention of the disease, on the removal of those causes which in all countries have appeared to produce it." 91 IS CHOLERA CONTAGIOUS ? " With such darkness as that of the St. Petersburgs, Moscows, and Breslaus of imbecility before us, is this a time to slip on the goloshes of Contagion, as Hans Christian Andersen would say, and step out into the Middle Ages of Fumigation ? To what purpose, save to set up the mare's nests of certain professional Pickwickians, is all this tedious bewilderment of wrangling, when at every turn the earnest and honest inquirer encounters such facts as these that follow ? We shall take them as we find them, plainly and sturdily arranged, in the excellent work already quoted ; and we content ourselves with asking any reader who may have previously qualified himself to answer, by learning from a school-boy's "Speller and Definer" the meaning of the word Contagion, whether any one of them could under any circumstances be true of a disease not distinctly non-contagious ? I. The great numbers attacked simultaneously, and who had previously had no intercourse with the sick — a fact which all writers on Cholera admit — cannot be accounted for without supposing the disease to be simply epidemic. 11. The general exemption from the disease of medical and other attendants on Cholera cases : 1. Dr. Jameson says that of between 250 and 300 physicians engaged in Cholera practice in Bengal, only three took the disease. 2. At Bombay none of the hospital attendants were attacked, though they were assisting the patients day and night. 92 IS CHOLERA CONTAGIOUS ? 3. The Madras report shows that, in the hospital of the Royals, only one out of 101 attendants was attacked, and at the receiving hospitals for Cholera patients at Trinchinopoly, St. Thomas dv Mount, and Madras, the attendants were numerous and sometimes shared the same bed with patients; yet not one took the disease. 4. At Berhampore none of the native attendants on the Cholera hospitals were affected. 5. A letter addressed to the Medical Council of Moscow, by eight chief physicians to the hospitals of Astrakhan, says : "We have all, without any precaution, touched and rubbed the sick; and we have daily visited the hospitals crowded with Cholera patients, where we have respired their breath ; yet we have neither contracted the disease nor conveyed it to our families. The attendants who nursed and applied frictions to the patients — who put them into baths, changed their linen, and performed other offices for the sick — remained free from Cholera. In the military, as well as in the civil hospitals, the linen and clothes of Cholera patients were transferred to other patients without being previously fumigated or ventilated ; and, nevertheless, those who wore those garments did not become affected with Cholera. Several nurses and mothers, having Cholera, suckled their children both during and after the disease ; yet the latter were not attacked." 6. Dr. Lefevre, physician to the British Embassy at St. Petersburg, reports as follows : 93 IS CHOLERA CONTAGIOUS? " In private practice, among those in easy circumstances, I have known the wife attend the husband, the husband attend the wife, parents their children, children their parents — and in fatal cases, where, from long attendance and anxiety of mind, we might expect the influence of predisposition to operate ; in no instance have I found the disease communicated to the attendants." 1. During the prevalence of the epidemic at Moscow, 587 persons, affected with Cholera, were admitmitted into a hospital where there were already 860 patients laboring under other diseases. Not a single one of the latter took the Cholera. Dr. Zudkoff, of Moscow, who had formerly been a Contagionist, declares that he saw, to his astonishment, that all the attendants and all the soldiers handled the sick, and supported their heads while they vomited, without using the least precaution, and without contracting the disease. 8. Mr. Searie, who attended a very large number of patients in Warsaw, where he had charge of a hospital for the poor, writes that not one of the attendants, not one of the nurses, not one of those who handled the dead, fell a victim to the scourge. 9. In Berlin, 409 houses were visited by the epidemic, and in 273 of these only one individual in each house was affected, while in the remaining 136 four or five suffered in each. Such is the density of the population in the quarters of Berlin so attacked, that the census assigns 4,200 families, with an average of four persons to each family, to those 409 houses, being an aggregate of 16,800 residents who 94 IS CHOLERA CONTAGIOUS ? lived in immediate contact with Cholera. Of this mass, only 803 were stricken with the disease, or about one in 18 persons. 10. In the Marine Hospital of St. Petersburg, of forty-three attendants on Cholera patients, not a single one was affected ; and in the temporary hospital in that city, of fifty-eight attendants, only one was attacked, and he after drinking kwass while very warm. 11. Those engaged in post-mortem examinations of Cholera cases have not been attacked by the diseas v Such examinations have everywhere been made without any precautions, and with perfect impunity. 12. Dr. Foy at Warsaw, and ten others, inoculated themselves with the blood of Cholera patients, tasted their dejections, and inhaled their breath, without receiving the disease. 13. As to the capability of merchandise to convey, and afterwards to communicate the infectious germ of Cholera, the Central Board of Health, in a communication to the Privy Council, remark : " There is, perhaps, no question in the whole range of sanitary police on which so many and such irrefragable facts can be brought to bear as on this — derived, too, from the most authentic sources. " Seven hundred and thirty ships, laden with hemp and flax, from infected ports of the Baltic, arrived at the different quarantine stations in this country between the Ist of June and the 31st of December, 1831. Many vessels also arrived laden with wool and hides ; yet not a single case of 95 IS CHOLERA CONTAGIOUS ? Cholera occurred among any, of these ships outside of the Cattegat sea, nor among the people employed in opening and airing their cargoes in the lazarets. At the hemp and flax wharf of St. Petersburg, where several thousand tons of these articles arrived during the spring and summer from places in the interior, where Cholera existed at the time of their shipment for the capital, the persons employed in 'bracking' or sorting, and who generally passed the night among the bales, did not suffer so early in the season, nor so severely, as other classes of the general population. The same observation holds good with respect to all the ropewalks of St. Petersburg and the Imperial manufactory of linen cloth at Alexandrofsky, where all the yarn is spun' from flax bracked and hackled on the spot " 14. Down to the 29th of February, 1832, Mr. Aspinwall, American Consul at London, reported to this Government that only one medical practitioner had died of Cholera in England, although at a moderate computation one thousand or more had been in constant attendance on Cholera patients. And, according to The Medico- Chirurgical Review, for April, 1832, not a single medical man was affected by the Cholera in Sunderland, Newcastle, or Gateshead. When the Cholera prevailed in its most virulent form among the armed vessels and transports of the East India Company's fleet, in the waters of Tennasserim and Pegu, in 1852, no case occurred among the medical officers or hospital attendants. At that time the writer, having medical charge of a war-steamer, freely handled the persons and clothes of Cholera 96 IS CHOLERA CONTAGIOUS ? patients, inhaled their effluvia, and mingled his breath with theirs, with the impunity he expected. Sodikewise did his assistants. No precautions were taken against contagion, because contagion was never thought of among men who annually renewed their acquaintance with Cholera. We believe that physicians and nurses are, cceteris paribus, less liable to the disease than other classes of persons, because, by constitution as well as habit, perhaps, they are less liable to that sort of anxiety and alarm, because in the midst of the disease their minds are actively and wholesomely employed, and because they are continually impressed with the importance of hygienic care, and necessarily inured to the practice of it. Intelligent and impartial observation has erected an iron-clad wall of proof against which the Contagionists pop their small shot in vain, and on the face of which the honest medical inquirer may read these truths, for a law to his professional life : Cholera is strictly an epidemic, existing by force of a mysterious poison diffused through the atmosphere. Whether the influences which produce this poison are " telluric," " electro-magnetic," or " animalcular," we know no better now than we did fifty years ago. Cholera moves in the form of a vast volume or field of such poisoned air. Its rate of progress is comparatively uniform, and its track not more eccentric than may be accounted for by the influence of prevailing winds. 5 97 IS CHOLERA CONTAGIOUS ? As soon as it reaches any given place, all the persons residing in, arriving at, or passing through, that place, who may be predisposed by certain conditions, hereinbefore stated, become the selected objects of its attack, however widely they may be scattered, and without regard to their possibilities of communicating with each other ; it is sufficient that they are included in the Choleraic atmosphere. Cholera is never brought; it comes. If passengers sailing from a port of France, where the epidemic prevails, arrive in an American port, whither it has not yet come, bringing with them the germs of the disease alive in their own systems, those germs will not grow and spread in the new and healthy air, but will wither and die out for want of their natural pabulum — the Choleraic atmosphere. But if that atmosphere accompanies them, then the germs will flourish and be propagated. This is why the Cholera did not extend to London in 1831, or New York in 1848, "although it had been introduced, and persons had been exposed to its infection." The cases had been brought, but the epidemic had not arrived. On the other hand, "it spread like wildfire in Paris, in 1832," because the epidemic brought its own cases along with it. But the presence of the Choleraic atmosphere is an essential condition of the spread of Cholera. Without it, a few isolated cases of aggravated Cholera Morbus, in individuals rendered peculiarly susceptible and sympathetic by their local and personal accidents, are the worst that need be feared, and we 98 IS CHOLERA CONTAGIOUS ? believe that such examples of Cholera Morbus, occurring during the prevalence of an actual epidemic, constitute a large proportion of the whole number of cases counted as true Cholera. Upon a prepared nervous system, it is most natural that the fiercer disease should beget its kind, even though the progeny may be of weaker powers. All attempts to prove that the disease was imported'into Sunderland and England, in 1831, failed ; and the opinion that it was not imported at all became very general, not only at Sunderland, but throughout England, and especially among the members of the medical profession. On the 28th of April, 1832, at the last meeting for that session of the famous Westminster Medical Society (the members of which, by their profound learning and their intimate acquaintance with the disease, were as well qualified to decide this important question as any other body of men in the world), the prolonged discussion "on the nature, character, and treatment of Cholera Morbus " was concluded by the adoption of the following resolution, Dr. Granville moving, and Dr. James Johnson seconding : " That the Westminster Medical Society, having devoted the uninterrupted space of six months to the serious and dispassionate consideration of the malady which has been prevailing in England since the latter end of September last, and especially in the Metropolis, and having heard the several arguments, depositions, doctrines, and facts, of the many members practically, as well as theoretically, engaged 99 IS CHOLERA CONTAGIOUS ? in that important inquiry, declare that, in the opinion of the majority of the Society, the evidence brought forward to prove the said malady to be a contagious disease has completely failed; and that every circumstance which has come to the knowledge of the Society shows the disease in question to have begun, progressed, and ended in the ordinary way of every other epidemic disorder : " — that is, a disorder which falls at once upon great numbers of people. Quarantines to exclude the choleraic atmosphere can, therefore, be best appreciated by such as he who complained that he had caught cold by sleeping in the Park with the gate open. Says The Medico- Ghirurgical Review : " Medical men will now see how much they will have it in their p wer, when the Cholera comes, to pronounce or withhold sentence of desolation upon a community. The word Contagion will be the word of doom ; for then the healthy will fly their houses, and the sick will be deserted ; but a countenance and bearing devoid of fear will command the aid, and inspire the hopes, that are powerful to save in the most desperate cases." 100 XII. THE INFLUENCE OF FEAR. If anything could render Cholera contagious it would be the enervating influence of Panic — as when, wanting a contagion of its own, it rides on the contagion of fear. For fear diminishes the nervous power, depresses and enfeebles the action of the heart, retracts the blood from the extreme vessels, and deranges the secretions. "Fear," says Dr. Falconer (Treatise on the Influence of the Passions on the Diseases of the Human Body) "diminishes the power of the heart, and enfeebles the pulse — sometimes to such a degree that the blood does not flow on opening a bloodvessel. Fear also arrests the natural secretions, and renders those who are frightened more liable to be attacked by contagious diseases." M. Virey (Diet, dcs Sciences Medicates) says: " Fear produces derangement of the secretions, cold perspiration, a recession of the blood from the surface to the heart, and diarrhoea, with coldness and paleness of the skin." Alibert (Phtfsiologie dcs Passions) says : " Fear is of a contagious nature, and its effect upon the body is to produce a retrocession of the blood from THE INFLUENCE OF FEAR. the exterior to the interior, and to derange or suppress all the functions of assimilation." " The tendency of Fear," says Dr. Brigham, "is to produce and spread spasmodic complaints, and to become epidemic during great public calamities. It not only disposes a person to be affected by a contagious disease, but actually produces a disease, with symptoms similar to the premonitory symptoms of Cholera." He calls attention to the fact, that an individual whose mind is constantly on the alert to detect some symptoms of disease of the stomach or bowels, who anxiously watches the effect of everything he eats or drinks upon the organs of digestion, will be very certain to create in them a morbid sensibility, which will be followed by indigestion, diarrhoea, or other derangement ; and suggests that there is great reason to apprehend that many, very many cases of Cholera, if not produced by fear alone, are aggravated by it to a dangerous degree ; and that cases of " common Cholera " are transformed, through the influence of fear, into the malignant and fatal. " At the present alarming time, no duty of medical men, and of all those who have influence over the faith of others as regards the epidemic, seems more imperative than that they should steadily endeavor to quiet public alarm, and constantly abstain from creating any fear about the prevalence of the disease, and its contagious nature. Hundreds will die of common Cholera, if they are not assured, and made to believe, that the disease which affects them is not the Cholera which their fears suggest. In such 102 THE INFLUENCE OF FEAR. cases, every look and question and action of a physician is very important. He has it in his power, not only to endanger the lives of the sufferers, but to spread around a far more dangerous contagion than that of Cholera — the contagion of fear ; to drive from the bed of sickness the anxious relatives and useful attendants, palsy the hand of charity, and create in those who are obliged to attend upon the sick a disposition to a disease closely allied to, if not identical with, malignant Cholera ; for the passion of fear falls in and unites with the disease, and attacks and paralyzes the same organs." A man was once journeying in the interior of Turkey, when he met the Pestilence. " Where are you from ?" he asked. " From killing 2,000 people in Smyrna," replied the Pestilence. " That's a lie," said the man, " I know that you have killed 6,000 there." " No," said the Pestilence, " I killed 2,000, and Fear killed 4,000." Adults exhibit a much more lively susceptibility to Cholera than children, the apprehensions of the latter not being so easily excited. It has been observed that the little ones enjoy a remarkable exemption from the disease ; and its attacks are to be looked for, for the most part, among the more intelligent children of five or six years and upward, who have derived from what, they have heard or read a depressing anxiety respecting it — as of some invisible, mysterious, and fearful calamity, which is stealing upon them and those who are dear to them. In children, fear, like other passions, is soon effaced ; but 103 THE INFLUENCE OF FEAR. it is also more sudden and powerful in them, and far more likely to operate dangerously upon their delicate and susceptible nervous organizations when, by their intelligence and imagination, they are in a condition to entertain it. 104 XIII. HINTS TO THE SANITARY BOARDS. It is curious that when the attendants employed about Cholera cases in the febrile state are attacked, they are never seized with ordinary fever, but with a genuine cold blue Cholera. Nothing, therefore, is more certain than that persons may arrive in our ports apparently laboring under common feverish indisposition, who really are suffering under Cholera in the febrile stage. Dr. Lefevre observed that the epidemic Cholera, on its first invasion, baffles all attempts to conquer it ; but that it gradually loses its intensity, and " toward its decline becomes as tractable as other disorders of the alimentary canal." Many other observers have particularly noted that the deaths are everywhere most numerous, in proportion to the whole number attacked, at the commencement of an invasion. In crowded, filthy, and ill-ventilated places, where the exciting causes are actively combined against the health of all who are exposed to their influence, the disease takes an apparently infectious character, tending still further to propagate it, and aggravate the alarm. Those who have practised abstinence from the use of wine, beer, and ardent spirits, should not have 5* HINTS TO THE SANITARY BOARDS. recourse to them in the hope of " fending off" the Cholera. Nor should those who have habitually and freely indulged in the use of them, suddenly and completely abstain. In either case the experiment is a dangerous one. The following remarks of a late writer are especially worthy of attention : " Excesses and extremes of all kinds predispose to Cholera. Excessive filth does so. So does excessive bathing, with a view to extreme cleanliness ; for it reduces the heat of the body, and debilitates the system. The inordinate use of either animal or vegetable food is a predisposing cause. But so, most emphatically, is fasting or abstinence, especially as regards animal food. The fearful mortality from Cholera in Paris, in 1832, occurred during the fastings of Lent. Nothing like it occurred at any other period. In a part of Louisiana, where nearly all the people are Roman Catholic, the mortality in a Cholera epidemic was quadrupled during and after a three days' fast." In public and private, cheerfulness should be promoted by every decent device — on the streets, by gay processions — in the parks, by bands of music, and moderately exhilarating pastimes — in dwellings, by music, games, tableaux, &c. — everywhere, by the various attractions of places of rational amusement. Public journals should stand with a hopeful and encouraging face between the pestilence and the people, and children and nervous persons should not be permitted to read or talk about the Cholera at all. Food, clothing, warm water, and consolation should 106 HINTS TO THE SANITARY BOARDS. be freely distributed among the poor. Soup, soap, flannel and smiles will do as much good as temperance tracts and Cholera bulletins. " It is very doubtful whether Boards of Health, organized as they are in this country, with very limited powers, especially in small towns, are capable of doing much that is effectual towards preventing the disease ; and there is reason to fear that they often do much injury by exciting alarm, which their frequent meetings are sure to create, and by their assurances to the public that the very first case of Cholera shall be announced — as if some exceedingly contagious disease was expected. In order to do much good, Boards of Health require the power to change the habits of the sensual, the vicious, the intemperate ; and above all, to clothe and feed the poor, and to provide cleanly and comfortable dwellings for all classes in community. But they have not this power. The only power that exists in this country to stay the scourge which has ravaged Asia and Europe, and now threatens us, is in the possession of the rich. On them must fall the burden of relieving the wants of the suffering, and of thus preventing and mitigating the severity of this dreaded epidemic." — Brigham. 107 XIV. THE DEAD. It used to be believed, rather fancifully, that the bodies of those who died of Cholera underwent putrefaction sooner than those of persons dying under the ordinary circumstances of mortality. There is no evidence of any such tendency to rapid decomposition, and people should beware of the notion. In some instances the body — at least the trunk and head — has remained sensibly warm for some hours after death ; and spasmodic twitchings of the muscles have taken place and continued for a considerable time in the corpse. Dr. Lawrie observed that convulsive movements were common after mental life was quite extinct; and that it was almost impossible to say "at what moment the vital motions ceased to vibrate." A body lies apparently lifeless ; suddenly a convulsive shudder shakes it; its hands are clenched; if you insert your own within them, and force them open, they shut again with a spasmodic catch. Thus, those who cling to the notion that rapid decomposition is peculiar to death by Cholera, are apt to bury with indecent haste; while those, on the other hand, who are ignorant and superstitious in regard to the fallacious warmth and the THE DEAD. convulsive movements, are loath to inter until the remains have actually begun to putrefy. On the 24th of July, 1832, the Special Medical Council of the New York Board of Health presented a report in relation to the unnecessary haste with which the bodies of persons who had died of Cholera had, in some instances, been interred : " The Council, " they said, " are of opinion that the dead may, with perfect safety to. the living, remain unburied at least six hours [why not twelve ?], even during the present warm season, and, under proper precautions, for a much longer period. They also deem it expedient that the public should know that the neighborhood of the hospitals and burying-grounds has not been found, upon inquiry, to be peculiarly liable to the disease. At the public buryingground, called the Potter's Field, where nearly 100 bodies have been buried daily, during the past week, none of those engaged in the work have been taken ill ; and of the 100 persons living in the Asylum for the Deaf and Dumb, within 200 yards of the same not one is known to have been attacked. " MORAL. Epidemic Cholera is a main branch of the Universal Sanitary Commission of Almighty God ; and of all the nuisances it is appointed to abate, that which insults with foulest offense the nostrils of the Divine Source of all physical and moral health and healing, is fat, lazy, selfish, imbecile ignorance or indifference. Chloride of lime will not heal the sores of Lazarus, nor quarantines quiet the consternations of Dives. 109 THE DEAD. " Wealth has no power to bribe, nor Beauty to charm this oppressor ; But all perish alike beneath the scourge of his anger ; Only, alas ! the poor, who have neither friends nor at- tendants, Creep away to die in the Alms-house, home of the homeless." 110 APPENDIX. [From the New York Tribune, Jan. 20, 1866.] CHOLERA — ITS HISTORY AND LOCALIZING CAUSES. Cholera and Commerce have this much connection, that the former follows the path of the latter, and keeps most easily along water-sides. At Alexandria, it began last May in a filthy suburb occupied by a dense crowd of Arabs, Maltese, and Greeks, and there strengthened itself until it killed two hundred a day. It also travelled to Cairo and other places along the Nile. It passed around the eastern coast of the Mediterrean, reaching Beyrout, Jaffa, Alexandretta, and Smyrna, and by the middle of July was taking a thousand lives daily in filthy Constantinople. The island of Malta, the province of Palermo, the cities of Modena, Ancona, San Paulo, Valentia, Toulon, Marseilles, Gibraltar, Madrid, Odessa, Paris, and Southampton, were reached, proving that the epidemic does follow, water-lines. It travelled to Bagdad and the borders of the Persian Gulf, and to Damascus and Jerusalem. At the same time, Mecca and Medina, and the caravans of pilgrims, were most severely attacked. Out of 700,000 pilgrims visiting Mecca in May, it is estimated that 40,000 perished by Cholera. Out of a single shipload of devotees from southern India, arriving at the Arabian port of Moculla, in Midwinter, eighty died before their companions left the ship. And, generally, it may be remarked, that the relation of human agency in the transportation of APPENDIX. the epidemic was unusually marked, and that the epidemic has followed the laws previously deduced from its history; that the season was exceedingly hot and damp; that the first and chief epidemic centres were by the water-sides and in the most humid localities, and that the epidemic earliest and most fatally " afflicted the persons and classes who dwell in foul air, and who are most negligent and reckless in their diet, who indulge in excesses and abuses of their appetites, and who are generally most subject to the diseases that arise from bad diet and the neglect of self-care." This country has had four visitations of Cholera. In June of 1832, it was found in an emigrant vessel in the St. Lawrence river ; it reached Quebec a few days later, New York two weeks later than Quebec, and soon afterwards cases were found in Albany and other cities along the water-line of the Middle States. In this city, it then killed 3,513. On the 2d of December, 1848, it again reached New York in the emigrant ship "New York," having killed 14 passengers during the voyage of three weeks from Havre. About the same time it arrived at New Orleans, killing there 1,400 during January ; in a fortnight it was at Memphis; another fortnight carried it to St. Louis ; and another to Nashville and Cincinnati. On the 11th of May it reappeared in New York, finding a home awaiting it at the Five Points ; and during that year 5,071 deaths occurred in the city by it; and in the summer of 1854, it claimed 2,509 more. Dr. Snow, the Superintendent of Health of the city of Providence — than whom a more careful and efficient health officer is not to be found — in a recent report to the Providence Board of Health, declares that he " can point out the precise localities in the city where the Cholera will prevail if it visits us 112 APPENDIX. again ; can show the houses in which it will do its worst work ; can name the families and almost the individuals who will have the disease; can show what there is in those localities, houses, families, and individuals, which will cause the disease ; and can show that those causes might be removed, and the disease prevented, by the proper action of the authorities, of the owners of the houses, and of individuals." The General Board of Health of Great Britain declared that, as was anticipated, in 1849, the " Cholera returned to the same countries, and the same cities and towns, and even the same streets, and houses, and rooms, which it ravaged in 1832;" and, furthermore, it is stated that "but very few indeed who suffered then have escaped now, except in those instances in which sanitary measures have in the mean time been effected." The city of Worcester, on the Severn, which had twice been scourged, having performed a thorough cleansing, escaped the following epidemic, which swept the neighboring cities. The Cholera of 1849. with insignificant exceptions, prevailed, out of five hundred towns noted, in those previously known for their local impurities ; in sixty-eight towns, where it raged severely, the Committee of the Royal College of Surgeons found the localizing causes of pestilence prevailing ; and in fifty-one out of fiftythree quarters where it first appeared, in as many districts, the well-known and preventable causes were found. Thus the medical officers report that "in the town of Jewksbury the Cholera was first announced in an alley containing a slaughter-house, pig-styes, and a bone-deposit ; and for more than a month it lingered there, spreading thence over the town. In the city of Hull it was at first limited to the ill-drained localities. In St. Giles' Parish (London) it commenced in Church street, where the 113 APPENDIX. drainage and ventilation were bad, cleaning defective, and population dense. In Islington, malaria from bad drainage and ventilation was the general cause. In Chatham the disease was chiefly confined to the narrow lanes and alleys which are crowded, deficient in cleanliness, and where fever is more or less prevalent. In Liverpool the disease was confined for the most part to the worst ventilated, low, and ill-drained courts. Lodging-houses of this character were sometimes alone attacked." That class of lodging-houses in England that has been brought under sanitary regulations, with an aggregate population of eighty thousand, was almost totally exempt from Cholera during the last epidemics. The report of the General Board of Health for 1849 states, that in the great tenant-house, called the Metropolitan Buildings, in which health regulations were complete, with a population of five hundred, not a case occurred, although the epidemic was very fatal in that district. And the report of the same Board, in 1851, states that "in the Metropolis every efficient sanitary improvement has been followed, as directly as cause and effect, by a corresponding decrease of sickness and mortality. There is no exception to this rule. It applies to the courts, alleys, and houses occupied by the industrious classes ; it applies to public institutions of every kind — to prisons, to hospitals, to lunatic asylums, and, above all, to establishments specially erected to test the value of sanitary principle — to the model lodging-houses of the Metropolis. In a report on Epidemic Cholera, it is shown that only one out of seven hundred and ninety-five persons, inmates of these model buildings, had been attacked by the disease ; whereas, among the population of London generally, one person in seventy-five was attacked. 114 APPENDIX. CHOLERA AND COMMON SENSE. THE EMINENT DR. JACOB BIGELOW. Within the present century, Cholera, a disease indigenous in hot climates of the East, has at various intervals made its appearance in the temperate latitudes of Europe and America. It is now again exciting interest from its possible, and, perhaps, probable approach to this country. The experience of the last thirty or forty years has led a majority of medical men who had observed the disease, to believe that, as a general law, it is not contagious. In this belief I must individually remain, until evidence more satisfactory than any which has yet appeared shall justify an opposite conviction. The great epidemics of 1830 and 1847 had a remarkable coincidence in the path which they pursued, and in the order and dates of their arrival in different cities. They seem to have followed certain great routes of travel, and to have avoided others equally frequented. According to Lesegue, they both visited consecutively, and in corresponding months, Tiflis, Astrakhan, Moscow, St. Petersburg, and Berlin. In 1831, Cholera did not take the most frequented route from Berlin to Paris, but passed along the shores of the Baltic, crossed over to Sunderland, went down to London, and again crossed the channel, and arrived in Paris about six months after its appearance in Berlin. A disease propagated by contagion of any kind would hardly have avoided the most frequented thoroughfares from Berlin to Paris, while it occupied half a year in going round England. The epidemic now or lately prevailing in Europe appears to date back at least nine months, at which time it existed among the caravans of pilgrims visiting or returning from the city of Mecca. In the 115 APPENDIX. middle of May last it was at Alexandria and Cairo ; in June, at Constantinople, Ancona, and Marseilles ; and in November, at Paris, Havre, and other European cities. Thus it appears that Cholera has now existed in Europe from three to eight months, among cities having constant commercial intercourse with seaports of the United States, during which time thousands of passengers and tens of thousands of bales and packages have been landed in our maritime cities. If Cholera were as contagious or portable as many believe it to be, it ought to have begun, and perhaps finished its work, in many of our seaports before this time. Epidemics require two things for their introduction and extension. These are, first, predisposition in the inhabitants of the place visited ; and second, the arrival or presence of an existing cause. This cause in some epidemics, such as small-pox, is contagion. In others, it is an occult influence, not yet discovered nor understood, nor known to be controlled, except in some instances, by hygienic agencies. No country, I believe, has succeeded in keeping out Cholera by quarantines, and no country, as far as we know, can produce it artificially or retain it after the predisposition has disappeared. In its own time it moves on thoroughfares where men are travelling, and spreads in cities where they are stationary, for no better reason known than that mankind are its necessary food, and that where there are no people there can be no Cholera. But why, of two frequented roads or cities, it selects one and avoids the other, investigators have not yet been able to satisfy us. The credit of having introduced the present epidemic into Europe is, by a sort of popular acclamation, assigned to the hosts of squalid devotees who 116 APPENDIX. perform an annual pilgrimage to Mecca. Yet we are told that " the Cholera exists every year among the caravans of Mussulmans arriving at the holy cities," so that their supposed mission of forwarding the Cholera to Europe in most years fails to be performed. Cholera, like influenza and some other migratory diseases, has not always advanced from east to west. Of the vehicle in which it travels, or the course it is next to take, we know about as much as mankind knew of the cause of lightning before the discovery of electricity. Its conveyance and propagation have been ascribed to air, to water, to material foci, to electricity, to ozone, or to the want of it. Of late, in consequence of the vast development by the microscope of the existence everywhere of minute living organisms, it has become more common to ascribe the arrival of this and other like epidemics to certain unseen " germs," which are called seeds, or ova, cryptogamic, or animalcular, according as the fancy of the theorist inclines him to adopt a vegetable or an animal nomenclature. But in this, as in many other cases, it is easier to trace an analogy, or to assume a cause, than it is to prevent an effect. Although inquirers have been indefatigable in their attempts to enlighten the world on the means of ridding ourselves of the presence of the various co-tenants of our globe, yet no crusade has succeeded in banishing from our fields and houses the unwelcome swarm of mosquitoes, worms, grubs, and flies, which molest us with their annual presence, nor in suppressing the blight of grain, the potato-rot, or the peach-tree disease. Happily, some, if not most of these, have their periods of abatement or disappearance ; and this rather through the order of Providence than the agency of man. Cholera seems to abide in the same 117 APPENDIX. category. We know little of its exciting cause, and not much of its prevention, except that by following in our personal habits the dictates of reason and experience we diminish both the frequency and danger of its occurrence. Whatever may be the cause or vehicle of Cholera, credulous and excitable persons are impatient of suspense, and are prone to cut a knot which they fail to untie. When an epidemic disease first appears, some coincidence is always brought to light which is supposed capable of accounting for it. The arrival of a ship, the opening of a trunk, or the washing of a garment, are among the most frequently accepted causes. But as these have happened a thousand times before, and apparently under like circumstances, without any known results, it had been thought necessary by some of our late writers to narrow the compass of actual exposure down to the reception of the morbid excretions of one individual into the digestive canal of another. The first impression made by this announcement must, if true, be one of relief, the clanger not seeming likely to happen very often. But to the possibility of such danger we can never oppose an absolute negative, so long as we persist in eating smelts and flounders caught about the mouth of our drains, or even turnips, salads, and strawberries raised at Brighton. The risk, however, is so small, that most persons will prefer to take it, rather than to deprive themselves of food or luxury. Of the many sensation tales printed and reprinted about Cholera, and the supposed instances of remarkable communication or arrestation, it is sufficient to say that they are frequently interesting, being fully as dramatic as they are probable. In the same regard we cannot help noticing that credulity, and perhaps private cupidity, have caused 118 APPENDIX. much stress to be laid on the supposed preventive efficacy of what are called " disinfectants ;" a mysterious word, which implies a thing assumed but not proved to exist. We have deodorizers, such as chlorine, charcoal, etc., which by their combination render certain effluvia imperceptible to our noses. The narrative, then, of the physician of Malta, who covered certain surfaces in vessels with oil, and had them " disinfected by chlorine gas," " after which no new cases occurred," is to be classed with other like results with which the medical press always abounds at the close of epidemics. In clean and well-regulated cities of temperate climate, Cholera is far from being the most formidable of epidemics. A greater part of its victims are the miserably poor, the worn-out, the ill-provided, and the intemperate, in whom this disease only anticipates the date, but does not greatly increase the annual and biennial number of deaths. Its mortality in our Northern Atlantic cities rarely amounts to one per cent, of the population in a given place or year, so that a man may reside through an epidemic in one of these cities with less risk than he can take a pleasure voyage to Europe. After having witnessed many cases of Cholera in this and other cities, I am further satisfied that it affords one of the easiest modes of exit from the world. People who would avoid or prevent Cholera, should cultivate equanimity, regularity of life and habits, cleanliness, salubrious exercise, temperance, and avoidance of all excesses. When they have done their duty in providing for the care of the sick, allaying public panics, and abating public nuisances, they may safely dismiss their apprehensions. Little good and some harm is always done by the indiscreet agitation of a subject which is to a great extent beyond our control. A single or sporadic case 119 APPENDIX. of Cholera occurring in a village of a thousand inhabitants may attract little notice, and pass without record ; but a hundred cases in a city of a hundred thousand inhabitants, make an aggregate which generally causes some panic, though the proportion is exactly the same, and the panic equally unnecessary. It is possible that the supposed immunity of country districts in comparison with cities, may be accounted for by the fact, that in the sparse population of country towns, cases are less liable to be detected and published. I may be excused for repeating the following remark from among some " Aphorisms" published by me about thirty years ago, when the disease was new and little known to us : " Should the Cholera continue to prevail for three years throughout this continent, it would cease to interrupt either business or recreation. Mankind cannot always stand aghast, and the wheels of society at length would be no more impeded by its presence than they are now by the existence of consumption, of old age, or of drunkenness."-— Boston Medical and Surgical Journal. 120 Former Surgeon of East India Co., Epidemic cholera..., WC 262 E64 1866 Condition when received: Page 52 bore a large section of missing paper at the bottom corner. Two fly pages in the back of the book were attached at the bottom edge using an unknown adhesive. Conservation treatment: The missing comer was repaired using kizukishi paper (Japanese Paper Place) and secured with wheat starch paste (zin shorn. Bookmakers). Areas of adhesive were humidified using a methylcellulose poultice (A4M, Talas). The adhesive was reduced using a Teflon spatula and the aforementioned poultice. The pages were brought into plane between blotters using mild pressure. Conservation carried out by Rachel-Ray Cleveland NLM Paper Conservator, 08 / 2007