ON EPIDEMIC DIARRHCEA AND CHOLERA: THEIR PATHOLOGY AND TREATMENT. WITH A EECORD OF CASES. / ¦/ GEOEGE JOHNSON, M.D. Lond., FELLOW OF THE BOYAL COLLEGE OP PHYSICIANS ASSISTANT-PHYSICIAN TO KING'S COLLEGE HOSPITAL. LONDON: JOHN W. PAEKEE AND SON, WEST STEAND. 1855- we LONDON : SAVILL AND EDWARDS, VRINTEHS, CHANDOS STttEKT. PREFACE. The following treatise consists of three parts : first, a record of cases of cholera and choleraic diarrhoea, which came under the author's care in King's College Hospital and elsewhere, during the recent epidemic ; second, an account of the pathology of epidemic diarrhoea and cholera ; and, third, general directions for the treatment of these diseases. The first place has been given to the Cases, in order to facilitate a reference to them in subsequent parts of the volume ; but the pathological sections are those to which the reader's attention may most conveniently be directed first ; and it is upon these portions of the work that the author chiefly relies for establishing a rational system of treatment. Every medical practitioner either is, or ought to be, a pathologist; for, even those who believe themselves to be, of all men, the most practical and the most entirely free from theory, are, of necessity, guided in the treatment of nearly every disease by some theoretical opinion as to the nature of the malady, and the operation of the means by which they endeavour to remove it. Hence the great practical value of sound and scientific pathology, and the danger of an imperfect or an erroneous pathological theory. The history of cholera, of the pathological theories of 4 PREFACE. the disease, and of the various modes of treating it, affords an instructive illustration of these remarks. There is, probably, no drug in the list of the Materia Medica which has been so generally given to patients with cholera as opium; yet, there probably is not one which exerts a more pernicious influence upon such patients. In what way, then, can the frequent use of opium be explained? Simply in this way: That it appears to be better calculated than any other medicine to accomplish more than one object which pathological theory has suggested as desirable. Many of the Indian practitioners looked upon cholera as a disease chiefly of the nervous system ; they called it ' spasmodic cholera/ and they gave opium to relieve the spasms, at the same time that they often administered active purgatives to remove the morbid secretions from the bowels. The appearance of cholera in Europe gave origin to the hypothesis that the worst symptoms of the disease are occasioned by the drain of fluid from the blood through the digestive canal ; and this theory suggested the practice of giving opium, with other medicines, to arrest the vomiting and purging. No method of treatment has been attended with more unfavourable results than this; yet there is so much of apparent probability in the theory which explains the symptoms of collapse by the loss of the watery portion of the blood that the practice of giving opium to arrest the intestinal discharges will continue, more or less, in spite of failure and disappointment, until it can be clearly shown that the symptoms of collapse have an entirely different origin from that which the theory in question assumes. PREFACE. 5 I venture to express my conviction, that the interpretation which I have given of the symptoms of cholera is a nearer approach to the truth than any theory of the disease which has hitherto been published, and I believe that the principles which are to serve as guides for the treatment of this class of diseases will not long remain in dispute. Submitting my work, now, to the judgment of the profession, 'my trust is in my love of truth and the candour that inheres in cultivated minds.' I neither expect nor wish to escape criticism ; only, I desire that the criticism which I receive may be impartial and honest — such, in short, as truth and the interests of humanity alike demand. I take this opportunity to express publicly my sense of obligation to those zealous friends and fellow-labourers who assisted me in the charge of the hospital patients during the recent epidemic. My thanks are particularly due to Mr. Holberton, who was the resident medical officer at the time, as well as to Messrs. 0. N. Macnamara, Stewart, Tutin, Goodall, and Masters. These gentlemen, one or more of them, were in almost constant attendance upon the patients, by night as well as by day, and to their judicious care and watchfulness I attribute the saving of several lives which, without such aid, would probably have been lost. 3, Woburn Square, April, 1855. TABLE OF CONTENTS. PART I. PAGE Cases of Epidemic Diabehcea and Choleea . . . ii — 94 PART 11. The Pathology op Epidemic Diaeehcea and Choleea. Sec. I. The relation between the symptoms of Collapse and the loss of fluid by vomiting and purging 95 Sec. 11. Are the symptoms of Collapse such as an ex- cessive drain of fluid from the blood might be supposed to produce ? 103 Sec. 111. Does the effect of treatment upon the symptoms of Collapse afford support to the theory that a drain of fluid from the blood is the essential or the chief cause of that condition ? . . . 106 Sec. IV. The symptoms of Cholera are occasioned by a morbid poison 115 Sec. V. The poison enters the blood, and thus acts upon other parts of the body 119 Sec. VI. The symptoms of invasion indicate a morbid condition of blood 124 Sec. VII. Analogy between the effects of the cholera poison and those of some animal poisons . . 130 Sec. VIII. Condition of the blood in Cholera 133 Sec. IX. Physical and chemical characters of the intes- tinal discharges 136 Sec. X. Pathology of the stage of Collapse .... 140 Consequences of impeded flow of blood through Sec. XI the lungs 192 Sec. XII. Phenomena of reaction 202 8 TABLE OF CONTENTS. PAGE Sec. XIII. Cause of the suppression of bile and urine . . 205 Sec. XIV. Changes in the colour, coagulability, and den- sity of the blood 207 Sec. XV. Comparison of an ague fit with the Collapse of Cholera 215 Sec. XVI. The pathological significance of vomiting and purging in cases of Epidemic Diarrhoea and Cholera 217 PART 111. TBEATMENT OF EPIDEMIC DIAEBHCEA AND CHOLERA. Sec. I. Treatment of Epidemic Diarrhoea 233 Sec. 11. Treatment of Cholera with Collapse .... 253 Sec. 111. Treatment during reaction 275 Appendix . . . 279. List of authors referred to .... 292. PART I. CASES OF CHOLERA AND CHOLERAIC DIARRHCEA. MEMORANDUM. THE following record includes the history of 54 cases of cholera and choleraic diarrhoea — 3J of the former and 17 of the latter. It will he seen that 14 of the cases were fatal ; these were all suffering from cholera with collapse when they came under treatment. One man (Case 1a) had recovered from a severe attack of cholera when he was seized with a fatal inflammation of the lungs, in consequence of accidental exposure to a cold draught during his convalescence. One child (Case 11) died in collapse forty minutes after his admission, having taken only one dose of castor oil, which produced neither vomiting nor purging ; but having taken, just before his admission, a large dose of brandy, which probably caused his death. Two women (Cases 10 and 20), who were admitted late in the evening, were neglected by the nurses during the night ; they got little or no medicine after they were left by the medical officers, and they died in collapse. In the case of one woman (Case 31), who died in collapse, all attempts to evacuate the bowels were unsuccessful. This was one of the most rapidly fatal cases. In another case (No. 33), which was fatal during collapse, the purging was very scanty, and vomiting ceased soon after her admission. This child had taken brandy before she entered the hospital. B 2 CASES OF CHOLERA One man (Case 9), who had been nineteen days suffer- ing from diarrhoea before he fell into collapse, died exhausted by an escape of blood constituents from the boAvels. And one woman (Case 24), who had been previously weakened by long-continued lactation, died during collapse. This and the preceding case are the only two amongst the seven which were fatal during collapse in which purging was not either entirely absent or very scanty after the patients came under treatment. Of the six cases which were fatal during reaction, one woman (Case 35), after passing through a state of extreme collapse, died during reaction, in consequence of haemorrhage from the bowels. Two children (Cases 22 and 45) died from coma during reaction. One woman (Case 37), of intemperate habits, died from syncope, the consequence of extreme fatty degeneration of the heart. One man (Case o >^) i who had a diseased lung, died from asphyxia during reaction. And one man, aged 61 (Case s 2), died, apparently, from exhaustion. Suppression of urine did not occur in a single case after the occurrence of reaction. After the history of each fatal case, will be found remarks suggestive of the means by which it is probable that a large proportion of these patients might have been saved. These remarks are not to be considered as an excuse or an apology for the past, but rather as a warning and a guide for the future. It appears to us, that the best use which we can make of those errors and omissions which we have not been able to avoid, is to make them serve as helps for the future guidance of ourselves and others. Most of the cases of choleraic diarrhoea were of extreme severity, and had arrived at the verge of collapse before they came under treatment. Indeed, several of them, at the time, were considered to be cases of cholera with collapse ; but after a careful revision of their histories, they have been included in the other class of cases. Three or four cases of choleraic diarrhoea which entered the 3 AND CHOLERAIC DIARRHCEA. hospital were not recorded at the time, and therefore are not reckoned with the others. All the cases of choleraic diarrhoea recovered very speedily, and not one of them passed into collapse — a result which is quite inconsistent with the theory that the danger of collapse is increased by the free action of the bowels ; for all these patients took castor oil, and several of them had the medicine in larger quantities than I now believe to have been necessary or desirable. Case i.* — Cholera with collapse. — Recovery. Reported by Mr. HoLBEBTON. E.C.,set. 18. Female. Servant ofall work in Drury-lane, admitted at lialf past nine p.m., August ioth. Has always had good health, with the exception of amenorrhoea during the last four months. At seven o'clock this evening she was seized with severe pain in the stomach, followed by vomiting and purging. After these symptoms had continued about two hours, while walking up stairs she suddenly fell down senseless, and remained unconscious until she was brought to the hospital. At half-past nine, when admitted, she complained of severe pain in the stomach and bowels, and cramps of the extremities ; the surface of the body was cold ; pulse 92, scarcely perceptible ; face pale; eyes half-closed and sunken ; vomiting and purging frequent, the stools being liquid, and it was said of a dirty yellow colour. Warmth to the stomach and extremities ; cold water to drink ; to have olei ricini sij • ; brandy siij • every hour. It was found that the brandy increased the vomiting, the oil therefore was continued alone through the night. August nth, nine a.m. — Skin not so cold; pulse improved ; the oil has been continued every hour; vomiting and purging have been frequent ; the pain in the stomach is still severe ; tongue dry and furred ; much thirst. Nine p.m. — The oil has been taken during the day in half-ounce doses every two hours until four o'clock p.m. The vomiting and purging continue ; skin warmer ; pulse 80. She still complains of pain in the stomach and cramps in the legs. 12th. — Has had three half-ounce doses of oil, and a warm water * The cases are reported in the order in which they entered the hospital. B 2 4 CASES OF CHOLERA enema during the night ; bowels twice moved ; vomiting less frequent ; cramps less severe ; skin warm and moist ; pulse 90 ; countenance more natural, but the eyes are still heavy and halfclosed. 13th — Two motions during the night ; no sickness ; one dose of oil at four p.m. 14th. — Had an hysterical fit yesterday and another this morning ; bowels not open since seven a.m. yesterday ; no vomiting ; unable to pass her urine, which was drawn off with a catheter. 15th, eight p.m. — The urine was again drawn off this morning, but this evening she has passed it freely ; she appears much better ; tongue clean and moist ; bowels open at six p.m. Ifc Ether. Chloric. IT^x. quartis lioris. Milk diet. Beef tea. From this time she continued to improve. She had some hysterical symptoms, for which she was ordered to have a cold shower bath every morning. On the 19th the catamenia returned. She was discharged cured on the 26th August. Remarks. — This is the first case of cholera which we treated with castor oil. We at first thought it better to give some stimulant with the oil, but we soon discontinued the practice, for reasons which are fully explained elsewhere. The retention of urine was probably a result of hysteria. Case 2. — Cholera with great collapse. — Recovery. Reported by Mr. HoLBERTON. S. 8., set. 12. Male. Admitted from Wo. 5, Middle Serle'splace, at six a.m., August nth. He had been quite well until four o'clock the previous affcernooli, when he was seized while playing in Battersea-fields with severe pains in the stomach and a feeling of sickness. On reaching home he vomited, and was purged violently several times. These symptoms have continued throughout the night. At the time of admission he was cold and pulseless, unable to walk or even to stand. His face presented, in a very marked manner, the peculiar cholera expression ; the eyes being sunken and half closed. He was at first ordered to have a sal t-and- water emetic occasionally, and to take acid, sulph. dil. 11\x1. in water every hour. When first seen by Dr. Johnson, in the middle of the day, he was in a state of great collapse, cold, pulseless, with. 5 AND CHOLEEAIC DIARRHOEA. sunken eyes, and so torpid, that he could scarcely be roused to answer a question. He was now ordered to take olei ricini %ss., with spirit, ammoniac arom. SSS5 SS - every hour. It was found, however, that each dose of oil, when given with the ammonia, was rejected ; the oil therefore was continued alone for several hours. The precise number of doses given was not noted. The bowels continued to act freely, and he began to improve. August 1 2th. — Improved; but there is still a tendency to relapse into a cold torpor, and the choleraic expression remains. To take an occasional dose of oil, so as to keep up a moderate action of the bowels. 13th. — Improving. 14th. — Better in every respect. 17th. — Convalescent ; remained longer in the hospital only for the want of clothes. Remarks. — When I first saw this patient his condition appeared so hopeless that I went to the hospital on the following day quite prepared to hear of his death. I found, however, that although he was not out of danger, there was yet sufficient improvement to encourage us to persevere with the plan of treatment which we had commenced. Case 3. — Cholera with great collapse. — Recovery. Reported by Mr. HoLBERTON. J. C, set. 12. Male. Admitted August 13th, at half -past seven p.m. He is employed on board a sculling vessel in the Thames. Had diarrhoea yesterday. At eight o'clock this morning he was seized with pains throughout the body, followed by vomiting and purging. During the day he has been three times sick and live times purged. When admitted, at half-past seven p.m., he was in a state of considerable prostration ; eyes sunken ; voice husky ; pulse scarcely perceptible ; skin not very cold ; had great pain in the belly, but no cramps in the limbs. To have hot bottles to the stomach and' legs. Olei ricini every half-hour. After the second dose of oil, he had a copious light-coloured watery stool, the odour of which was very offensive. After this the pain in the belly was considerably relieved, and he was ordered to take the oil in the same doses every two hours. 6 CASES OF CHOLERA August 14th. — Has had nine watery flocculent stools, and has vomited frequently, the vomited matters having now a green tinge ; has passed water freely ; is very restless ; the breathing is rather quick and irregular ; he complains of pain in the epigastrium ; coolness of skin, feebleness of pulse and sinking of eyes continue. The oil has been taken every two hours, from two a.m. until six p.m. He has been allowed milk and water, but he loathes everything except cold water. 15th, morning. — Has had five doses of oil during the night, and has had five stools, in appearance like pea-soup ; had vomited frequently a green liquid mixed with oil ; has slept but little ; skin warm ; pulse 48. Evening. — Had a dose of oil at five p.m., which was followed by three motions, tinged yellow ; no cramps or vomiting ; tongue slightly coated; skin cool ; pulse 120 — stronger. 1 6th, morning. — Has had four yellow motions; no sickness. Evening. — A dose of oil at two p.m., was followed by three motions of darker colour and less liquid; is thirsty, and will drink nothing but water ; tongue coated. 1 7th. — Improving. 18th. — Still slightly feverish ; the urine deposits urate of soda copiously — no albumen. 9> Potassse Chloratis gr. x. JEther. Chloric. I7|x. M, Acacia? quartis horis. 20th. — Convalescent ; tongue clean ; no thirst ; appetite good ; pulse 80 ; one firm, natural motion to-day. Remarks. — This patient took eight ounces of castor oil. He vomited frequently, and was purged twentythree times from the time of his admission to the 16th inclusive. Case 4. — Choleraic Diarrhoea. — Recovery. Reported by Mr. HoLBEETON. L. C, set. 24. Female. Admitted at half-past eight a.m., August 13th. She had had diarrhoea for several days, and at three o'clock this morning she was seized with severe pains in the stomach, followed by violent vomiting and purging. At the time 01" her admission she Mas in a state of considerable prostration, and she was soon seized with cramps in the extremities, which were cold ; pulse 80 — very feeble. 7 AND CHOLERAIC DIARRH(EA. To take olei ricini §ss. every half-hour. August 14th, eleven a.m. — The cramps continued at short intervals all through yesterday. She has taken eight doses of the oil, which have acted seven times, the motions being very offensive, and of a dark green colour. She slept during the night, and has perspired freely ; feels much better this morning ; no return of sickness ; has passed water freely. To discontinue the oil. Evening. — She has been pretty comfortable throughout the day, but has had occasional cramps in the legs. Skin continues rather cold ; pulse feeble and slow, scarcely more than 50. 15th. — Slept but little during the night, and has had cramps in the legs. Had two pale-yellow motions this morning ; pulse 60 — rather stronger ; feet and legs still cold ; no sickness ; feels giddy, but on the whole much better. 1 6th. — No return of cramps ; no stool since the middle of yesterday ; complains of pain in the joints and back, and headache. 1 7th. — Improving. 26th. — Discharged quite well. She remained in the hospital several days longer than was necessary ; but as she was of a languid and torpid temperament, with a very slow pulse, it was thought right to give her full time to recover her strength. Remarks. — If this case had occurred at a later period of the epidemic, we should probably have given an occasional dose of oil on the second and third day, and it is likely that the cramps and other uneasy sensations would thereby have been more speedily relieved. Case g. — Cholera with great collapse. — Recovery. Reported Mr. Holbeeton. J. C, set. 29. Female. Admitted at five p.m., August 14th. A Cook : has had diarrhoea on and off for a week. Yesterday she felt pretty well, but at eleven a.m. to-day, August 14th, she was seized with violent pain in the stomach, followed by cramps in the limbs, and accompanied with sickness and purging. The vomited matters were, she says, of a very dark colour, 'as black as soot,' and had a peculiar bitter and very acid taste ; the stools had nearly the same colour. She had vomited three times, and had three stools before her admission. At about four p.m. she had a kind of fainting fit, and her sister states that her face and 8 CASES OP CHOLERA hands became purple and cold. They gave her brandy ; after which she revived a little, and they brought her in a cab to the hospital, but ' thought she would have died on the journey.' "When admitted at five p.m., the eyes were sunken, the lips blue, the skin cold, and the pulse scarcely perceptible. She complained of noises in the head and giddiness; she had occasional cramps in the legs and arms, and a constant pain in the stomach. To have a mustard poultice over the stomach, hot bottles and friction to the extremities, and olei ricini 3J. every hour. August 15th, morning. — She has taken five doses of the oil, and the bowels have acted six times, the motions being ' like pea-soup.' No vomiting. Has had occasional attacks of cramp in the legs and left arm, and there is still pain at the epigastrium. Has passed water freely, and feels much better. The skin is now warm and moist, and the pulse too. Evening. — The bowels have acted twice since the morning ; no return of cramps, but there is still pain in the region of the stomach. She has had no medicine since twelve o'clock on the night of her admission. To have a mustard poultice over the stomach. 1 6th. — Has slept well, and feels very comfortable. Had one motion this morning, of a yellow colour ; skin natural j tongue has a white coat. 17th. — Going on well. 1 8th. — Removed to the surgical ward to be treated for piles. She was finally discharged on the 9th September. Remarks. — This case affords a good illustration of the rapidity with which a patient may pass into great collapse and again come out of it. It is probable that the dark colour of the vomited matters and the first stools, was occasioned by the presence of blood. — See cases 35> 37> and 43- Case 6. — Choleraic Diarrhoea. Reported by Mr. Holbebton. A Nurse, set. 24, employed in one* of two adjoining surgical wards, in which three fatal cases of cholera had occurred. Mr. Holberton, the physician's assistant, was called to her at eight o'clock, p.m., on the 15th August. He found her sitting by the fire, breathing heavily and hurriedly. She said that about a quarter of an hour previously she had been seized with difficulty AND CHOLERAIC DIAKRH(EA. 9 of breathing, faintness, and cramps in the hands and legs. While he was speaking to her one of these attacks came on; the fingers were all drawn together, and the thumbs drawn across the palm of the hand. The cramp soon subsided under friction, and she was able, with assistance, to walk up stairs to a medical ward. She says that she has had diarrhoea for a fortnight ; the bowels have acted nine or ten times daily. Four days ago she took a dose of castor oil, and afterwards an astringent mixture. This morning, when she awoke, she felt pain in her stomach ; in the course of the day she has vomited several times, and the bowels have acted as many as fifteen or sixteen times, the motions being, she says, slimy and streaked with blood. She now complains of cramps in the stomach and legs, and a sense of tightness across the chest ; pulse ioo — feeble ; skin natural ; tongue moist, and slightly coated with a white fur. She is evidently much alarmed. Olei Bicini statim. Half-past ten p.m. — She has had one dark-coloured motion, perspires freely, and has a good pulse. 9> Olei Ricini §ss. Half-past twelve a.m. — The second dose of oil has operated four times. She feels much more comfortable, has had no return of cramp, and has only a slight pain in her stomach ; pulse ioo ; skin cool. 1 6th. — The bowels have acted twice since the last report. She has had cramp in the leg once only during the night ; pulse 90 ; skin cool ; tongue coated. After the last report she required no further treatment, and on the 19th she was sent into the country convalescent. Remarks. — This case of choleraic diarrhoea affords a good illustration of the facility and quickness with which painful and threatening symptoms may be relieved by the removal of the exciting cause. It is not possible to tell what might have been the precise effect of a full dose of opium on the night of the 15th ; but that, by checking the escape of the offending matters from the bowel, it would have hindered the cure is pretty certain, and that it might have converted the case into one of cholera with, collapse appears very probable; the more so, when it is considered that she had been inhabiting wards which had produced three cases of cholera. The 10 CASES OF CHOLERA difficulty of breathing was the symptom which perhaps was most significant of impending collapse; showing, as it did, that the pulmonary circulation was becoming embarrassed. Case 7. — Cholera with extreme collapse. — Recovery. Reported by Mb. Holberton. E. T., set. 12. Female. Admitted from No. 5, Serle's-place (the same house as case No. 2), at a quarter past eight p.m., August 17th. She was taken ill between nine and ten o'clock this morning, shortly after going to empty a pot into an open drain. When she returned she said the stench from the drain had got into her throat, and she wished she had not gone. Soon afterwards she vomited and was purged several times. She complained of thirst ; drank water and continued to vomit. At about twelve o'clock she was seen by a medical man, who gave her chalk -mixture, of which she took three doses. After this she appeared better for a time, but the vomiting and purging soon returned, and were accompanied with cramps ; she became very cold, and the skin was covered with a cold sweat. In this state she continued until the time of her admission ; she was then, at a quarter-past eight, in extreme collapse ; cold and pulseless ; the fingers were blue, and the eyes much sunken. She had some time before lost a large portion of her left cheek, from a slough after scarlatina ; and this deformity, together with the choleraic expression, made her appearance singularly painful to witness. To have olei ricini every half-hour. She took five doses without effect on the bowels, and the oil was then ordered to be given in half-ounce doses. 1 8th, eight a.m. — She has taken, up to the present time, eight ounces of castor oil ; she has vomited frequently, and has had three ' rice-water' stools ; the skin is warmer, and the cramps are less frequent than they were during the night. Evening. — Has taken, since the morning, five doses of oil, and has had six stools of the same character. Her appearance is not yet much improved. 19th, morning. — JSTo oil since the last report, but the bowels have acted four times, and the stools are now of a light yellow colour. She has passed a comfortable night, and looks wonderfully better, having quite a rosy colour on her cheeks. Evening. — Feels quite comfortable, and sleeps a great deal. 11 AND CHOLEEAIC DIAERHCEA. Skin warm ; pulse good ; three motions since the morning, flocculent and tinged with bile ; no vomiting ; the urine is albuminous, and contains some small fibrous casts, with crystals of uric acid. Has taken some beef-tea and milk, but no medicine. 20th. — Going on well ; bowels twice open ; no sickness ; tongue rather dry, and she is still thirsty. 21st. — Quite convalescent; urine copious; motions yellowishbrown ; tongue moist ; complains of hunger. 22nd. — The urine contains no albumen. Remarks. — This patient took ten ounces and a half of castor oil. She vomited frequently, but the exact number of times is not noted. During the first two days after her admission, the bowels acted fifteen times. Case 8. — Cholera with extreme collapse. — Recovery. Reported by Mr. Holbeeton. E. 8., set. 9. Female. Admitted at seven a.m., on the 19th August, from the same house as the preceding case. She was quite well until two o'clock this morning, when she was seized with vomiting and purging. She had pain in the chest, but no cramps ; the vomiting and purging have continued until within the last hour. She is now (seven a.m.) cold and pulseless ; the eyes are much sunken, and half closed ; the face is livid, and the fingers are blue ; she complains of no pain, but seems very drowsy, and can scarcely be roused to speak. She is horribly dirty. To have olei ricini 3J. every half- hour. Half-past eight a.m. — Mr. Holberton was called to her by the nurse, who thought her dying ; she was then much warmer, but looking as ill as possible. Eleven a.m. — Quite insensible and pulseless, but can be roused to take the oil. The bowels have not been moved. Half-past five, p.m. — Has taken fourteen doses of the oil. She has vomited once, and the bowels have acted four times ; the stools have the rice-water character. There is much jactitation, and the breathing is somewhat laborious ; the breath is warm ; she is very thirsty, and drinks much cold water. Muttering delirium. Half-past seven p.m. — Has just had another rice-water stool ; she is still delirious. To have a mustard emetic. Nine p.m. — She would take the emetic only by teaspoonfuls, 12 CASES OF CHOLERA and it had no effect. To have the body and limbs rubbed with camphor-liniment. 20th, one a.m. — She remains in the same torpid state ; she has had no oil since half-past five yesterday. To take now the 01. ricini, every hour. Eleven a.m. — Has taken seven doses of oil since the last report (the last dose at seven a.m.), and the bowels have acted three times ; she vomited copiously while Mr. H. was with her, the vomited matters having a green tinge ; she looks wonderfully better ; she is quite sensible, and is very thirsty. Omit the oil. Nine p.m. — Bowels not open since the morning ; has vomited twice ; she sleeps a great deal, with the eyes half-open ; tongue dry and furred ; has passed water frequently in bed. 2 ist, eleven a.m. — Has vomited five times during the night; has been restless and required watching to prevent her from getting out of bed ; she is sleeping now, and requires much rousing before she will answer a question ; tongue dry and coated ; skin warm ; pulse feeble, but perceptible. Olei ricini immediately. Ten p.m. — The oil has acted, the motion being of a brown colour ; pulse good ; she drinks a good deal of cold water, and has vomited seven times, usually soon after drinking ; she has taken beef-tea. 22nd, ten a.m. — Restless during the night ; sleepy now ; has been five times sick, but the bowels have not acted ; tongue dry and coated. Haust. effervescent., quartis horis. Ten p.m. — The bowels have acted four times, and she has vomited once ; she looks much better ; tongue moist and cleaner; urine albuminous, but contains no casts. 23rd. — Slept well ; tongue moist and cleaning ; had four motions during the night — liquid, but of natural colour. 24th. — Very comfortable ; pulse 84 ; appetite good ; tongue clean ; bowels continue relaxed ; motions frequent. Olei ricini statim. 25th. — After the immediate action of the oil, the diarrhoea ceased, and she required no more medicine of any kind. Remarks. — This patient had altogether eighteen ounces and a half of castor oil. This appears a large quantity for a girl nine years of age, hut it will he seen that at half-past five p.m., on the day of her admission, after she had taken fourteen ounces of oil, she had vomited only 13 AND CHOLERAIC DIARRHCEA. once, and had had but four stools. At a later period of the epidemic, we should have given an occasional emetic and enemata. The appearance of this patient soon after admission was quite death-like. Case 9. — Cholera with extreme collapse and hcemorrhage from the bowels. — Fatal. Reported by Mr. Holbekton. "W. X., set. 42. Male. Admitted at five p.m., August 19th. Has had diarrhot>» nineteen days, and at ten o'clock this morning he was seized with violent purging, vomiting, and cramps. His eyes are very much sunken ; face of a brownish yellow colour ; lips livid ; hands cold ; fingers blue and corrugated ; voice hoarse. Olei ricini §j\ every hour. Six p.m. — Just now, after taking the second dose of oil, he vomited a pint-and-a-half of a huff-coloured liquid, containing flocculi. Nine p.m. — Has passed a pretty copious motion, like curdled milk ; hns vomited much of the oil, and a liquid like beef tea ; has continual cramps in the legs, but no pain in the stomach; skin warm ; pulse imperceptible. He lies in a torpid state, with the eyes shut and sunken, but speaks when roused. 20th, one a.m. — Had another motion at ten o'clock, of the same character as the last ; has vomited seven times ; he frequently cries out with the cramp in his legs, and finds much relief from friction; has passed no urine. N.B. The night nurse was comfortably asleep by the fire ; she understood that nothing was to be done ! Nine a.m. — Seems a little better this morning ; the cramps are not so violent, and the face is more animated, but still of a horrible colour. He has taken, since his admission twelveand-a-half ounces of the oil ; the bowels have acted six times since one o'clock this morning, and he has vomited several times during the same period. Omit the oil for the present. Twelve noon. — Has just had a motion of a pinkish colour, apparently from containing blood, and the two previous motions, at ten and half-past eleven, had the same character. To have an ice-water injection every two hours. Argent, nit. half a grain in a pill every four hours. Seven p.m. — The bowels have acted ten times since the last report, and the stools have the same pink colour ; he has just now vomited, and the vomited matter is green ; he complains of 14 CASES OF CHOLERA severe pains in the bowels and cramps in the hands, and he entreats for an opiate ; his face is nearly black. Acid. Gallic, gr. x. Tine. Hyoscyami s ss s s- in a draught immediately. Nine p.m. — The purging and vomiting have ceased, but he is evidently weaker ; voice changed ;he mumbles his words, so that he is scarcely intelligible ; respiration 40 — laboured ; pulse imperceptible ; he is very restless, and can scarcely be kept in bed. Quarter-past eleven. — He died. Inspection sixteen hours after death. — The peritoneal surface of both large and small intestines intensely congested, and of a rose tint. The mucous membrane was everywhere congested, with here and there small patches of ecchymosis ; no appearance of ulceration. Both the large and small intestines contained a considerable quantity of a dirty-red thick liquid. On a microscopical examination of this liquid, no blood-corpuscles could be detected, but it contained numerous scales of epithelium and moulds of the intestinal villi. Liver healthy, with the exception of a few patches of fatty degeneration ; gall-bladder contained a considerable quantity of bile, but was not distended ; kidneys healthy ; bladder empty ; spleen very small — weight three-and-a-quarter ounces ; heart contained a small quantity of black blood, with some yellow fibrinous coagula in the left ventricle ; lungs pale and exsanguine. Remarks. — In this case it is to be observed that the green vomit at seven p.m. on the 20th, indicated the restoration of the biliary secretion, and there were other signs of improvement on the morning of the same day. Death evidently resulted from exhaustion, consequent on the loss of blood constituents. Perhaps it may he thought that the haemorrhage was the result of the purgative treatment. This may have been so, but I think it unlikely, for the following reasons. First, that a pink tinge of the evacuations is mentioned as an occasional symptom by authors whose patients have had no purgatives. Second, that amongst all the cases of cholera which I have treated by castor oil, the pink tinge of the evacuations has occurred in only one instance besides that at present under consideration. 15 AND CHOLERAIC DIAREH(EA. (Case 350 Third, in this case the loss of blood constituents appears to have commenced immediately after, if not before his admission. The 'buff-coloured liquid' which he vomited immediately after the second dose of oil, was probably of the same nature as the pink stools which appeared subsequently. It cannot be denied that the existence of such a complication is a serious impediment in the way of an eliminative plan of treatment, but is there any other mode of treatment which, in such apparently despernte circumstances affords the patient a better chance of recovery? Would calomel or salines be more promising remedies? The well-known influence of oil of turpentine in arresting intestinal haemorrhage in cases of typhoid fever, suggests the possibility of benefit from a combination of this medicine with moderate doses of castor oil in cases similar to this. But one reason for hoping less from the turpentine in this case than in the intestinal haemorrhage of typhoid fever is this, that, in the latter cases, the haemorrhage results chiefly, if not solely, from a local lesion of structure — from an ulcerative process involving the coats of bloodvessels ; while the pink stools of cholera appear to depend on the escape of blood constituents which have been disorganised within the vessels. Neither in this case nor in one to be noted hereafter (see Case 35), did the microscope show any entire blood-corpuscles, although it was evident that the colouring matter of the blood, as well as its albuminous constituents, was present in the liquid. There is another remedy which, if the pink stools appeared at an early stage of the disease, before the occurrence of reaction, might perhaps be had recourse to with some hope of benefit, — I mean venesection. If by this means the disease could be cut short, so as to lessen the intensity and the duration of the intestinal action, and to avoid, as much as possible, the use of 16 CASES OF CHOLERA purgatives, the patient might he saved from a fatal haemorrhage. Emetics of ipecacuanha might he given in such cases with less probability of doing harm than would be the case with castor oil, and perhaps with a better prospect of benefit. Case io. — Cholera with extreme collapse. — Fatal. — Neglected by the nurse. Reported by Mr. Holberton. M. C, set. 40. Female. Admitted at a quarter-past two a.m., August 28th ; a Basket-woman, in Covent Garden Market, of temperate habits. She has been in delicate health for some time, but, so far as could be ascertained, she has bad no premonitory diarrhoea. She was seized at six o'clock last evening with, violent vomiting and purging, wbicb have continued to the present time. She is now (quarter-past two a.m.,) quite cold and pulseless ; the fingers are cold, clammy, and corrugated ; the eyes sunken and half-closed ; the voice whispering. She is very thirsty, has occasional cramp in the legs, but no pain in the stomach. To have olei ricini §j. every half-hour, &c, &c. August 29th, nine a.m. — She is more blue than at the time of her admission, and she is breathing heavily. After a good rubbing she revived a little ; a dose of oil was given and retained. The night nurse reports that the patient has had no cramps during the night, and that she has appeared quite free from pain ; that she closed her teeth when the oil was offered to her, and that there was great difficulty in giving it to her ; that she had, therefore, taken only six doses of oil, two of which had been vomited ; and that the bowels had acted once during the night. This nurse subsequently made to another nurse employed in the same ward an acknowledgment to the following effect : — That she felt sure the patient must die, and that, as she disliked taking the oil, she (the nurse) had thrown it down the water-closet instead of troubling the patient with it. She added, that ' the doctors would never discover what had been done.' Half-past ten. — She is worse ; a large salt-and- water emetic was given, but vomiting could not be excited ; friction constantly applied. She died at eleven o'clock. Inspection. — The intestines were of a light pink colour, and contained a small quantity of a thick gruel-like matter. The other viscera were healthy. Remarks. — The post mortem record, it must be confessed, AND CHOLEEAIC DIARRH(EA. 17 is very incomplete; but the fact of the small quantity of fluid in the bowel, when taken in conjunction with the almost complete absence of vomiting and purging after the patient's admission, suffices to show that, whatever may have been the cause of death, it could not be attributed to the excessive purgative or emetic action of the oil. The most instructive lesson to be derived from the painful narrative of the case is this, — that no patient who is suffering from cholera can with safety be left for more than a very short period to the exclusive care of a nurse. Case ii. — Cholera with extreme collapse. — Fatal forty minutes after admission, probably from the effects of a large dose of brandy. Reported by Mr. Holberton. J. S., set. 6. Male. Admitted at nine p.m., August 28th, from King-street, Drury-lane. He was seized at ten o'clock this morning with sickness and frequent purging, the motions being colourless and watery ; he has been sick and purged ten or twelve times in the course of the day ; the last motion occurred while he was being brought to the hospital. He has had no cramp or pain. Just before his admission his mother had given him two-pennyworth of brandy. Ten minutes past nine. — He is horribly dirty; body quite cold ; pulse imperceptible ; face livid ; tongue cold ; eyes halfclosed ; to have hot bottles, dry rubbing, &c. Olei ricini Jss. every half-hour. He took a dose of oil very well, and then ate a lozenge which the nurse gave him after it, with much apparent satisfaction, saying it was nice. The rubbing appeared to revive him a little, and he put out his tongue when told to do so. When asked what he had been eating the day before, he made some reply which could not be distinctly heard, though he repeated it several times. When asked if he had any pain, he pointed to his mouth. Mr. Holberton then left him, the nurse meanwhile rubbing him constantly. Mr. Holberton returned in half-an-hour, and found the child dead ; he had neither been sick nor purged since his admission. Inspection, eighteen hours after death. — The body was somewhat livid, especially about the neck ; the fingers, and the nails were of a dull blue colour ; the intestines were congested, and G 18 CASES OP CHOLERA of a rosy pink colour ; they contained a small quantity, not more than an ounce or two, of gruelly fluid. There were no patches of ecchymosis in the mucous membrane. The stomach contained about half-a-pint of liquid of the same character as that in the intestine, but of thinner consistence ; this was mixed with the oil, one dose of which had been swallowed. The rugae of the stomach were well defined, and there were numerous patches of ecchymosis in the mucous membrane, about the great curvature. The other abdominal viscera were healthy : the gall-bladder was full, but not distended; the lungs were pale and exsanguine; the heart was healthy. Remarks. — In this case it is likely that the sudden death resulted from the noxious influence of the brandy which had been given to the child immediately before his admission into the hospital. It is probable that the brandy added to the difficulty of transmitting the blood through the lungs, until, at length, the circulation ceased entirely. It also appears to have checked the process of excretion into the stomach and intestines, which were found nearly empty after death. This result may have been a direct consequence of the scanty stream of blood which passed through the lungs. This is one of the cases which taught us the necessity of a practice which we invariably adopted during the latter period of the epidemic, — I mean that of commencing the treatment by an emetic. It is possible that an emetic immediately after his admission, by throwing out the brandy which remained in the stomach, might have saved this child's life, (Compare case Number 32.) No one, it is to be presumed, will attribute the child's death to the single dose of castor oil, or maintain that, in this case, the eliminative method of treatment had a fair trial. Case 12. — Cholera with great collapse — some consecutive fever — convalescence — then fatal pneumonia from accidental exposure to cold. Reported by Mr. Stewaet. M. 8., set. 31. Male. Admitted at half-past ten a.m., 19 AND CHOLERAIC DIARRH(EA. August 31st. He is by trade a painter, a strumous, delicatelooking man, with tinea-tarsi, and consequent loss of his eyelashes. He was suddenly seized this morning with vomiting, purging, and pain in the stomach ; the bowels have acted eight or ten times, and his strength is much reduced in consequence. He was ordered to be put into bed, and when seen at half-past eleven, the following was his condition : — The eyes were sunken and half closed ; he was very drowsy, and unwilling to answer questions ; voice hoarse ; pulse 84 — barely perceptible ; the temperature of the body lower than natural, though not decidedly cold. He has had several sharp attacks of cramp in the calves of the legs, and he is very thirsty. He has passed by stool about half-a-pint of liquid, looking like beef tea. Olei ricini every half-hour. Three p.m. — He is still very sleepy, and has no pain or cramps. He has vomited nine times since his admission, and has kept down only three doses of oil. The bowels have acted once since last report, the motion consists of flakes, in a colourless liquid. To have some iced water. September ist, half-past twelve a.m. — He looks better, and feels very comfortable. Has cramps occasionally. Has taken twentythree doses of oil, the last at fifty-five minutes past nine p.m., yesterday, but he has retained only about five doses for a period of more than five minutes. The bowels have acted four times since the last report ; has passed no urine since his admission. Half-past ten a.m. — Much improved in appearance ; body warmer ; pulse 84 — much improved. He is still drowsy, but not so thirsty ; he has vomited thirteen times, and had five motions during the night ; the stools are of a darker colour. Has had no medicine, but a little beef tea. Half-past four p.m. — He vomits very frequently — eighteen times since the last report, — and the bowels have acted three times. To have an effervescing draught occasionally. Half-past eight p.m. — He does not vomit so frequently since taking the effervescing draught ; no cramp or pain, but drowsy. Half-past ten. — * Called to see him and found him in a sort of hysterical fit ; breathing heavily, eighteen times in a minute ; pulse 108 — rather full; body not cold. Had great difficulty in rousing him, but in a few minutes he was sufficiently conscious to push away the water which he was requested to drink, and after a little time he was thoroughly roused by a mustard emetic. C 2 20 CASES OF CHOLERA which he did not seem to relish, and he scarcely swallowed any of it.' — Mr. Holberton. Forty-five minutes past ten. — Had a dose of oil, which he retained. 2nd, eleven a.m. — Has slept well and feels ' all right ;' he vomited seven times and had six motions during the night, — the motions are much darker and the vomited matters are greenish ; he is still drowsy, but not so thirsty ; kept down some tea this morning ; tongue covered with a brown coat. Half-past eight p.m. — He is still rather heavy and sleepy, but he looks and feels much better ; he occasionally excites vomiting by putting his finger down his throat ; he always feels relief from the vomiting, but he has been sick only four times since the morning, and the bowels have acted seven times ; he passes water with his motions, and says he has done so since yesterday evening ; tongue dry and brown ; has kept down about half-a-pint of beef tea. 3rd, half-past eleven a.m. — Has slept but little ; has no pain ; the bowels have acted nine times since the last report, and he has passed water freely ; he has vomited only once ; pulse 80 ; respiration 18. Half-past one p.m. — He frets a good deal ; has had another hysterical fit. Nine p.m. — Is very weak and drowsy, but does not sleep ; tongue brown and dry ; very thirsty ; urine copious ; seven stools since half-past eleven this morning ; has taken some beef tea. Olei ricini immediately. 4th, morning. — Has not slept ; complains of head-ache, and is drowsy ; tongue still coated ; had five motions during the night; pulse 72 ; respiration 18. To have arrow-root, with a small quantity of brandy, four ounces in twenty-four hours. Nine p.m. — Appears better, but is very restless, and grinds his teeth ; three motions since the morning. sth, morning. — Is still drowsy and obstinate ; tongue moist. To go on with the brandy, and to have beef tea. Forty-five minutes past eight. — Is very restless and delirious, attempting to bite the nurse ; when asked if he has pain, he points to his head ; he looks stupid, and mutters indistinctly ; no sickness. 6th. — Is more quiet, but rather cold and exhausted ; pulse 96 ; respiration 16; passes water freely ; bowels still relaxed, — seven motions since midnight. 21 AND CHOLERAIC DIARRHCEA. Increase brandy to six ounces. 7th, ten a.m. — Has slept a good deal, but got out of bed and was troublesome in the night ; still much exhausted, but his countenance and pulse are improved, and his skin is warmer ; tongue thickly coated ; three stools during the night. Jfc Quinse JDisulp. gr. j. Acid. Sulp. dil. I)|x. Aquse %]. — ter die. Bth, half-past nine a.m. — Says he feels better ; has slept about three hours ; takes and retains all that is given to him — namely, tea, brandy, milk, and beef tea ; tongue cleaning ; the diarrhoea has ceased ; he is comfortably warm. 9th, half-past nine a.m. — Says he feels 'all right,' and he appears much improved ; has been quiet during the night, and has slept tolerably ; tongue much coated, but cleaning. 10th. — He has a diffused redness on the nose and cheek. To wash it with lotio plumbi. nth. — The eruption, which has the character of urticaria, has now appeared on the elbows and knees ; tongue cleaning ; pulse 104 ; respiration 16. Omit the quinine mixture, and take instead — Tinct. Ferri Sesquiclil. M\xv. Aquse — quartis horis. 12th. — Eruption still present, but he is quite rational and much more cheerful. To go on as before. 13th, morning. — He feels better, and the eruption is fast dying away ; tongue a little dry, but clean. Olei ricini 335. immediately. Nine p.m. — He has been seized with difficulty of breathing, and his skin is hot. There is dulness on percussion, and crepitation, over the lower lobe of the left lung ; his tongue is dry. To have a large mustard poultice over the chest, and the following mixture: — Ether. Chloric. IT|x. Ammonias Sesquic. gr. iij. Mist. Acacise 3J. — quartis horis. N.B. ' When I was at the hospital in the middle of the day (13th), I found him going on quite well; but his bed was between two open windows and the fireplace, and a strong current of cold air was blowing over him. I had some fear that he would suffer from this exposure, and in the evening I found him in the condition before described.' — G. Johnson. 14th. — He ' feels very bad ;' pulse 112; respiration 24 — laboured; 22 CASES OF CHOLERA slept badly ; tongue clean and moist ; bowels rather loose ; urticaria almost gone. A blister over left lung. Increase the quantity of brandy. 15th. — Had a sleepless night ; breathing very laboured; pulse 118 ; respiration 24. He got rapidly worse during the morning, and died at forty-five minutes past eleven a.m. An examination of the body was not allowed. Remarks. — The remarkable points in this case are the following : — The patient was of a delicate and strunaous habit. The attack of cholera was followed by a state of exhaustion and fever, but without suppression of urine. In the course of this attack, an eruption of urticaria appeared, which was fast disappearing, together with all other unfavourable symptoms, when he rapidly sunk under an attack of pneumonia, excited by accidental exposure to a cold w T ind. The death cannot fairly be attributed to cholera, or to any direct consequence of the cholera, but to an unfortunate accident, which teaches the importance of guarding convalescents from hurtful influences which they are ill able to resist. It is interesting to observe that while he was in a state of collapse, there was, at first, very frequent vomiting, but comparatively little action of the bowels ; and after the vomiting became less frequent, the purging was more so, although the oil had been discontinued. I now believe that he had, perhaps, twice as much oil as it w T as necessary or desirable to give him, and that the frequent vomiting which it occasioned was the chief cause of the exhaustion which followed reaction. Case 13. — Cholera with great collapse. — Recovery. Reported by Mr. Tutin. T. E., set. 25. Male. Admitted at ten minutes past one, p.m., September Ist. He is a day-labourer; has lived badly, and never was very strong ; has a very narrow chest. His illness commenced on the 26th of August, with occasional purging ; on the 29th the diarrhoea became more severe, and since then he has 23 AND CHOLERAIC DIARRHCEA. had frequent vomiting, occasional cramps in the legs, and pain in the epigastrium. During this morning he has been purged six times, and vomited ten or twelve times. The surface of the body and the tongue are very cold ; pulse 96 — small ; eyes sunken, with livid areolse ; his voice is hoarse, and he has a husky cough ; he is very drowsy, and does not answer questions readily. Olei ricini every half-hour. Half-past eight, p.m. — Says he feels much better. The eyes are more sunken than they were, and the voice hoarser ; body still cold ; no pain or cramp ; feels very drowsy, but cannot sleep ; is very thirsty ; has taken fourteen doses of the oil ; has vomited twenty-one times, and has had three not very copious liquid motions. Mr. Holberton gave him five grains of calomel, which was rejected immediately. The dose was repeated in an hour with the same result. To have an effervescing draught occasionally, and to omit the oil for the present. September 2nd, eleven a.m. — Has vomited about twenty times, and had six motions during the night ; the vomited matters have an olive-green colour, and the motions are horribly offensive ; no cramp or pain ; tongue furred and warm ; pulse small and intermitting ; he is thirsty, and drinks cold water freely. Half-past eight p.m. — The vomiting has decreased ; has not been sick since fifteen minutes past five ; has had five stools since the morning ; he looks much better ; skin waim ; complains of pain under right false-ribs ; says he finds relief from vomiting, and frequently tries to excite vomiting by putting his fingers down his throat. He is taking no medicine excex^t the effervescing draughts. 3rd, eleven a.m. — Improving; has vomited three times, and had three stools since the last report ; passes water freely ; has retained half-a-pint of milk this morning ; tongue cleaner. Nine p.m. — No sickness ; two stools since the morning ; appetite returning ; tongue cleaning ; less thirst. 4th. — Better in all respects ; slept well ; tongue clean, but rather dry ; no sickness ; two motions in the night. sth. — Has had a good night, and feels ' all right.' He is sitting up, and is apparently making a hearty breakfast. Tongue quite clean and moist; no thirst, pain, sickness, or purging; is anxious to go out, and is therefore discharged rather sooner than is thought quite prudent or safe. 24 CASES OF CHOLERA Remarks. — This patient took fourteen doses of the oil and two doses of calomel. After the first day he was manifestly improving, and he took no medicine except an effervescing draught. During the first two days and nights, he vomited about seventy times and had fifteen stools. Case 14. — Severe Choleraic Diarrhoea. — Recovery. Reported by Mr. Stewaet. H. W., set. 40. Male. Admitted September 2nd, at half-past nine p.m. He is a sailor — a fine-looking man ; in great pain ; lying on the floor, and preferring to remain in that position while he is spoken to. He has just arrived in town from Bristol, having performed the whole journey on foot (120 miles) in twoand-a-half days. He was quite well until six o'clock this morning, when he was seized with violent pains in the stomach, followed by vomiting and purging, which have been very frequent ever since; he has also had occasional cramps in the thighs. He has walked with great difficulty from Reading in the course of the day, and has eaten nothing. He feels cold, and the surface of the body is cold to the touch ; tongue cool, slightly coated ; pulse 92— good ; eyes not sunken ; says his vomit is green, and the motions colourless and slimy ; has made water two or three times in the course of the day ; the pain in the stomach is very violent, and he has an idea that he shall die. Olei ricini every half-hour, hot bottles, &c, &c. 3rd, eleven a.m. — Has not vomited, but the bowels have acted six times ; complains of pains in the back and shoulders, but has had no cramp since last night ; feels warmer, and sweats freely ; tongue warm, thickly coated ; he is thirsty ; has passed water freely ; pulse 84 — good. Nine p.m. — Complains only of aching pain in the back, hips, and shoulders ; feels drowsy, but starts in his sleep ; continues thirsty ; tongue cleaner ; body warm ; no sickness ; one dark, offensive stool since the morning; he is hoarse ; head dizzy. To have an effervescing draught occasionally. 4th. — Feels better ; slept better ; pulse 70 ; has had a little cramp, and still has pain in the back and shoulder. sth. — Discharged quite well. Remarks. — A severe attack of choleraic diarrhoea with 25 AND CHOLERAIC DIARRH(EA. some symptoms of approaching collapse. The urgent symptoms were quickly relieved. There is no note of the number of doses of oil which the patient took. Case 15. — Diarrlicea and fever — the latter following an astringent mixture. — Recovery. Reported by Mr. Tutin. J. T., set. 19. Female. Admitted from Houghton-street, Clare-market, at noon, on September 2nd. Has always been in good health until four or five days ago, when she had diarrhoea, and felt sick, but did not vomit. She took no medicine until yesterday, when she had a chalk mixture to check the purging, which, however, has continued in spite of it, and since taking the mixture she has had head-ache, occasional cramps in the stomach, and vomiting of a green bilious liquid. She had been purged about twelve times, and had vomited three or four times the morning of her admission. When admitted she was drowsy, and had a severe head-ache ; she was very hot and feverish ; pulse 1 20 ; tongue thickly coated with a yellowish-white fur- she had occasional cramps in the stomach and legs ; no appetite, but great thirst. On percussing the abdomen, there appeared to be a considerable quantity of liquid in the small intestines. To take olei ricini immediately, and to repeat it in four hours. 3rd. — The bowels were freely acted on by the oil, and a large quantity of bilious liquid was discharged ; she slept for some time during the night, and has had no sickness since last evening ; the skin is much cooler, and the tongue less coated ; pulse 96 ; head- ache less severe ; no return of cramps or pain in the stomach. 4th. — Has slept well, and is very much better ; pulse 90 ; tongue cleaner ; has very little head-ache ; complains of not having enough to eat. sth. — She had another dose of castor oil at eight o'clock last evening, on account of looseness of the bowels, which had probably been induced by a too early indulgence of her craving appetite. She was much relieved by the oil, and to-day she is discharged cured. Remarks. — This case affords a good illustration of the unpleasant consequences which are frequently induced by an attempt to check with chalk, and probably 26 CASES OF CHOLERA opium, a bilious diarrhoea. The offensive and acrid matters are prevented from escaping, and the patient gets head- ache, a hot skin, a quick pulse, and a coated tongue. In the meantime the diarrhoea continues, and requires a purgative for its effectual removal. If a similar case were to come under my care now, I should give the oil only in half-ounce doses, and wait to see the effect of the first dose before ordering a second. It must, however, be remembered that, in hospital practice, the resident medical officers have a discretionary power, and a dose would not be repeated if it appeared to be undesirable. Case 16. — Cholera with great collapse. — Recovery. Reported Mr. Tutin. M. A., set. 22. — Admitted at a quarter-past eleven a.m., September 4th. She is a married woman, with a young baby, living in Queen-street, Golden-square. A delicate-looking woman, but states that she has never had any previous illness. Yesterday she did not feel quite well, and she consequently took some rhubarb and magnesia ; at eight o'clock in the evening she was seized with vomiting and purging, and at the same time she had a pain in the back of the head, a ringing in the left ear, a sense of oppression at the epigastrium, and occasional chills, followed by sweating ; the vomiting and purging have recurred nearly every ten minutes throughout the night, the liquids ejected being watery and colourless. This morning she had slight cramps in the legs. When admitted, at a quarter-past eleven, the whole body is very livid, and especially the face, which is also cold ; the tongue is cold, and covered with a yellow fur ; the eyes are much sunken, and the eyelids blue ; the voice is hoarse and whispering ; she has passed a rice-water stool since she came into the ward, but no urine since last night. She is thirsty ; has a pain in her head and a ringing noise in her ears ; pulse 98 — very small. To have olei ricini every half-hour, &c. &c. Half-past one p.m. — Complains much of pain in the stomach, and cramps in the legs ; lips more blue ; pulse 100 — small. She has vomited five times, and been twice purged. Seven p.m.— Pulse 120 — small; seems on the whole better; cramps continue. She has vomited nine times, and been twice 27 AND CHOLERAIC DIARRHOEA. purged since the last report ; the body is tolerably warm, but the tongue continues cold. Half-past eleven p.m. — Pulse ioo — stronger ; is more comfortable ; cramps less violent ; she has vomited four times, and been three times purged since seven o'clock. To continue the oil every hour. sth, nine a.m. — Pulse 100 ; respiration 24 ; expresses herself much relieved : has had some sleep and no cramps during the night ; countenance much improved ; less lividity and sinking of the eyes ; hands and arms cold, but the rest of the body is warm ; tongue warm and less coated. She has vomited eight times, and been purged five times during the night. Quarter-past one p.m. — Twice sick and once purged since last report. To continue the oil every three hours. 6th, ten a.m. — Looks and feels much better ; hands cold, the rest of the body warm ; pulse 96 ; respiration 22 ; tongue dry and coated ; has vomited thirteen times and had three stools since the middle of the day yesterday ; the stools contain bile, and she has passed water freely ; she frets about her baby, who has died of cholera since she left it at home. Fifty minutes past eleven p.m. — Is free from pain, but feels very sick ; the whole body is warm and perspiring, except the hands, which continue rather cold ; is very thirsty ; passes water freely ; has been once sick, and had one stool since the morning ; the oil has been discontinued since half-past twelve to-day. 7th, morning. — Looks much better; is drowsy, but did not sleep much during the night ; pulse 84 ; respiration 20 ; body warm ; has been purged twice or three times and vomited several times during the night, but the nurses have neglected to keep an account. Ten p.m. — Does not appear quite so well ; face and hands colder, though the rest of the body is warm ; voice still hoarse ; has had three motions and no sickness during the day ; very drowsy and free from pain ; is taking no medicine. Bth, ten a.m. — She felt very sick at about one a.m., when she was much relieved by a salt and water emetic, after which she slept for some hours ; the bowels have acted once during the night; pulse 84 — much stronger; her voice is more natural, and she has some colour in her cheeks ; tongue moist, but the centre covered with a yellow coat ; no drowsiness, pain, or sickness. 9th. — Had a good night, and felt quite well, but weak ; has 28 CASES OF CHOLEEA nearly recovered her voice ; pulse 72 ; no vomiting ; bowels once moved this morning ; tongue still coated. 10th. — Continues to improve ; body warm ; tongue clean. nth. — Another good night ; feels much refreshed. 12th. — Is quite well, except a slight eruption of urticaria about the elbows ; is sitting up, and continues to gain strength. 13th. — She looks much better and stronger ; pulse 60 — good ; tongue clean; has the eruption on the shoulders, ankles, and knees ; bowels not relieved since the 10th. Olei ricini 335. 14th. — Bowels freely moved by the oil ; the urticaria is rapidly disappearing, and she feels quite well. 1 6th. — Discharged cured. Remarks. — This patient took about seventeen ounces of oil during the first three days after her admission, and during the same period she vomited about thirty-eight times, and was purged about seventeen times. She soon began to improve, and the improvement continued very steadily. The feeling of sickness early in the morning of the Bth, and the relief afforded by an emetic, are instructive facts, the like to which we have observed in several of our cases. It appears that, during the convalescence, an occasional emetic is very beneficial, if vomiting does not occur spontaneously. It is interesting to observe that, just before she was seized with decided symptoms of cholera, she had taken a dose of rhubarb and magnesia. Are we to conclude, then, that the attack of cholera was induced by this aperient dose ? It is not improbable that the exhaustion consequent on the excessive action of a drastic purgative may, in common with any other depressing influence, predispose to an attack of cholera; but in this particular instance it appears that the patient took the medicine because ' she did not feel quite well,' and it is probable that this feeling of ill-health was, in fact, a consequence of the cholera poison having already entered her system. It is by no means unlikely that the aperient dose may have been rather beneficial 29 AND CHOLERAIC DIARRH(EA. than otherwise. If the contrary opinion were held to be the correct one, then the fact of a disease being induced by a dose of rhubarb and magnesia, and cured by repeated doses of castor oil, would be a remarkable illustration of the dogma similia similibus curantur. Case 17. — Cholera, toitk extreme collapse. — Recovery. Reported Mr. Stewakt. G. W., set. 31. Male. Admitted at half-past four p.m., September 4th.. He resides in Arundel-street, Strand, but works in a confined and bad-smelling shop in Seven Dials ; of temperate habits, and in good health until the present illness, which began at about ten, a.m., yesterday morning, when he was seized with giddiness, nausea, and vomiting ; he got up this morning intending to go to his work, but was unable to do so on account of giddiness and exhaustion ; he has been sick seven or eight times in the course of the day, and has been purged as often, the stools being like water ; cramps came on this afternoon. He has had several doses of medicine from a druggist. At the time of admission, half-past four p.m., he looks twenty years older than he states himself to be, the eyes being sunken, the skin and tongue cold, the voice a mere whisper ; pulse 92 — very weak ; respiration 18. To have olei ricini, every half hour, &c. &c. Seven p.m. — Body still cold ; has rather severe cramps in the hands and legs ; says he is very faint and sick ; pulse rather better ; has vomited five times ; of five doses of oil which have been taken, one has been retained ; has had one motion of the rice-water character. Nine p.m. — Is very cold, and covered with a cold sweat; puke more feeble; the greater depression just now is perhaps accounted for by his having recently been out of bed to stool ; has vomited four times and had one stool since seven o'clock. sth, three a.m. — Mr. Tutin and I (Mr. Stewart) were called to him. His breathing was almost stertorous, and he complained of a terrible pain across the chest ; cramps in the legs were also severe. We ordered a mustard poultice, which he would not keep on. Olei Eicini Olei Terebinth. sij> — immediately. This dose appeared to relieve him, and he breathed more tranquilly. A salt and water enema was also given. 30 CASES OF CHOLERA Nine a.m. — Has had twelve closes of castor oil during the night, all of which were vomited ; the bowels have acted three times ; the trunk and legs are warmer, but the feet and hands are cold ; pulse barely perceptible ; eyes still sunken ; respiration laboured ; he feels sick and giddy, and has a catching pain in his stomach. Eleven a.m. — Has had three stools, but no vomiting since last report. To have a mustard poultice to the epigastrium ; beef tea, and milk with water or gruel. Two p.m. — Remains very cold, and the pulse very feeble ; he is very depressed and restless ; has kept down some beef tea, which appears to oppress him ; seeing this, Dr. Johnson gave him an emetic of salt and mustard ; this quickly acted, and relieved him considerably. To have no more beef tea. He is now taking the oil every hour. Five p.m. — Much the same. Ten p.m. — Says he thinks himself a ' shade better;' not much cramp; pulse 120 — very feeble; respiration 28; the bowels have acted sixteen times since nine o'clock this morning, and he has vomited only twice, once being with the help of an emetic ; the stools have still the rice-water character. 6th, forty-five minutes past twelve a.m. — Pulse still weak ; he is very cold and much depressed ; the bowels have acted four times since last report ; has not vomited, but feels nausea and a desire to be sick. An emetic of salt and mustard was given by Mr. Stewart ; it acted quickly, and in half-an-hour he was much improved. Four a.m. — Very cold ; still depressed, and tries to vomit. Repeat the emetic, and give olei terebinth, . with the next dose of castor oil. Forty-five minutes past five a.m. — Says he feels better, but the pulse is not improved, and he is still very cold ; has dozed a little. Ten a.m. — He feels better; tongue warmer, but the feet and hands are still cold and the pulse feeble ; the bowels have acted eleven times since ten o'clock last night, but vomiting has occurred only twice under the influence of emetics ; just now, however, he has vomited spontaneously a green oily liquid, having the appearance of a flocculent rice-water stool, tinged with bile. He is thirsty and asks for some tea, which was given to him. The last do3e of oil was given at half-past seven a.m. To discontinue the oil. Three p.m. — Has had two motions since last report, flocculent, 31 AND CHOLERAIC DIARRH(EA. but tinged with bile, and of a thicker consistence. The pulse is improved, but he is still cold. Dr. Johnson gave him of brandy in some arrow-root ; he appeared to enjoy it, but when he was seen again half-an-hour afterwards he appeared depressed and nauseated, although his pulse had more volume. An emetic of salt and mustard was then given to get rid of the brandy, no more of which is to be given at present. 7th, ten a.m. — Says he feels much better, and he looks quite another man : eyes less sunken ; skin warm ; pulse 72 — improved ; tongue coated, but moist and warm ; he is drowsy, but does not sleep ; was sick after his breakfast of tea and dry toast ; the bowels have acted five times since last report, and he has vomited seven times. Bth, half-past nine a.m. — Is much better ; pulse 72; respiration 20 ; skin warm ; has slept comfortably for about four hours. He feels very sick ; has vomited three times during the night, but has kept down some beef tea and some milk. The bowels have acted three times ; tongue cleaning rapidly ; has passed water freely, the urine being pale, acid, albuminous ; sp. gr. 1015. 9th, half-past nine a.m. — Going on well ; pulse 84 — very good ; comfortably warm ; has slept pretty well ; tongue clean, but dry ; lie is very thirsty ; likes milk and water and arrow-root, but not beef tea; he vomited four times yesterday, but not at all during the night ; has had five stools, of greater consistence and darker colour ; passes water freely. 10th, morning. — Going on well; the bowels have acted nine times since yesterday morning. To have olei ricini nth. — Slept well; looks comfortable and happy, and complains of nothing ; tongue clean, warm and moist ; two stools since the oil ; no sickness. To have three ounces of brandy during the day. 12th. — Quite well, except a slight sore on the sacrum. 15th. — Discharged cured. Remarks. — A very useful practical lesson is to be derived from carefully noting the effect of the oil in this case. During the first day (the 4th of September) and the following night he took twenty-two doses of oil, while during the same period he vomited about as often and was purged six times. It is probable that very little oil passed into the intestines, and its purgative 32 CASES OF CHOLERA effect was comparatively slight. Then again, during the sth of September and the following night he took seventeen doses of oil, nearly the whole of which was retained, for he vomited only once, except when emetics were given, and he was purged during the same period no less than twenty-six or twenty-seven times. It is now quite evident to me that this amount of purging was excessive and hazardous. The prudent course, in case of the sickness ceasing while the collapse continues and the bowels are easily acted on, is to give the oil at longer intervals, of perhaps two or three hours, and between each dose of oil to give an emetic. No absolute rule can be given, but it is to be remembered that, in many cases, the danger of excessive purging from an incautious continuance of the oil, begins when the oil has ceased to act as an emetic. Another instructive fact in this case is the distress and sense of oppression resulting from the too early administration of beef tea, and afterwards of brandy. Case 18. — Cholera with great collapse and drowsiness. — Recovery. Reported by Mr. Ttttin. J. F., set. 20. Male. — Admitted at half-past three a.m., September 4th. He is by trade a whitesmith, and has usually had good health. On the Ist instant he drank a good deal of ale, and on the following day he was attacked with diarrhoea, but had no sickness. On the 3rd (yesterday) he ate some pears, and he was afterwards seized with vomiting and purging, and then with cramps in the legs ; at the same time he had a sensation of faintness and swimming in the head. He got some powders from a doctor, but says that he vomited them as soon as he took them. At half-past three a.m., when admitted, states that he has been purged about twelve times, and vomited as often since half-past five o'clock yesterday. The eyes are much sunken, and there is considerable blueness of the eyelids ; fingers blue and corrugated ; surface of the body below the natural temperature, though not very cold ; pulse 92 — small, but perceptible ; voice whispering ; has passed no urine for ten hours ; he is Very thirsty and drinks greedily ; tongue coated. AND CHOLERAIC DIARRHOEA. 33 To have olei ricini §ss. every half-hour, &c. &c. Forty-five minutes past seven a.m. — The bowels had not acted, and five grains of calomel were given. Twelve Noon. — Dr. Johnson saw him ; his pulse was very feeble, and he was lying with his eyes much sunk, and half closed ; he spoke in a shrill whisper, and complained of nothing but a pain in the stomach. He had taken seven doses of oil, and five grains of calomel since his admission ; he had vomited three times, but had not been once purged. To continue the oil every hour. Two p.m. — Still drowsy and torpid, as though under the influence of opium ; an emetic of salt and mustard acted quickly, and roused him ; the pulse also improved. On examination of the abdomen it was evident that the intestines contained a considerable quantity of liquid. To have an enema of salt and water. Half- past three p.m. — To have olei terebinth. sij- with olei ricini Half-past nine p.m. — The bowels have acted eight times since half-past twelve o'clock ; the motions have the rice-water character, and now they are coloured with bile, but he has passed no urine ; he continues drowsy, but there is less lividity about the eyelids and fingers, and he appears much relieved. No vomiting. sth, nine a.m. — Slept a good deal during the night, and is still very drowsy ; has taken four doses of oil since the last report ; has not vomited, and has had one flocculent motion, tinged with bile ; has passed no urine ; pulse 100 — strong ; body warm. Nine p.m. — Has taken two doses of oil, and has had three stools since the morning ; no sickness ; he sleeps a good deal ; voice still shrill and hoarse ; has passed a small quantity of urine. 6th, ten a.m. — Has slept the greater part of the night, and is still very drowsy ; pulse 90 — good ; skin warm ; tongue dry, but much cleaner ; two bilious stools, and no sickness since the last report. Half-past three p.m. — Has taken one dose of oil since the last report ; the bowels have not acted. To repeat the oil immediately. Fifty-five minutes past eleven p.m. — The bowels have acted four times since the last dose of oil; the urine is pale, sp. gr. 1010 albuminous ; tongue cleaner and moist ; voice less hoarse ; he is still drowsy. D 34 CASES OF CHOLERA 7 tli. — Much, less drowsy; tongue moist and cleaning; has passed water freely ; bowels once moved during the night ; pulse 84; skin very warm. Bth. — Improving in every respect ; tongue nearly clean ; no thirst ; appetite improved ; has passed a large quantity of urine ; bowels twice moved. 9th. — Wants to get up ; appetite good ; tongue clean, but rather dry ; bowels twice moved. 10th. — Feels quite well; is about to sit up. nth. — Looks quite well, and is sitting up in bed, reading. 13th. — Discharged cured. Remarks. — The most remarkable feature in this case was the drowsiness which occurred during the stage of collapse, this being accompanied with great sinking of the eyes and feebleness of the pulse, but with a warm skin. There was very little vomiting, and it was at first difficult to excite purging. It is probable that there was opium in the powders which he took the day before his admission, and that this increased the cerebral torpor. He took twenty-six doses of oil and five grains of calomel during the first two days, with the result of producing a moderate amount of purging and but little vomiting. There seems good reason to believe that nothing but the evacuation of the intestines could have saved this patient from fatal coma. Case 19. — Choleraic Diarrhoea, — Recovery. Reported by the patient, a Member of the Royal College of Surgeons. The following is the report of a severe attack of diarrhoea I was seized with on the 4th of September : — I was in my usual state of health up to the evening of the 4th inst., and having taken a particular interest in the cholera patients in our hospital, I had for the three or four days previous to the evening on which I was myself taken ill, almost lived in the wards allotted to those patients. On Monday night at about eleven o'clock, I awoke with violent pain and spasm in my stomach, and a most distressing sense of oppression, with an inclination to vomit. These syniptoms AND CHOLERAIC DIAERHCEA. 35 were quickly followed by cramps in my hands and feet. I at once got up and took an emetic, and as soon as the vomiting which it excited had ceased, I followed it up with an ounce dose of castor oil. In about half-an-hour's time I was violently purged, and so much relief did I experience from it, that I repeated the dose of oil during the following hour. From this time until eight o'clock in the morning, I was purged and vomited so freely that I became quite exhausted ; yet I suffered little pain, and had lost that dreadful sense of oppression to which I before alluded. I then had two hours' sleep, and awoke much refreshed. Throughout the day my bowels were opened several times, and I vomited once or twice after taking food; but in the evening I went down to Blackheath, passed a most comfortable night there, and the next day returned to town ready to resume my duties, although much pulled down by my severe though short illness. With the exception of an attack of indigestion, which was brought on by my imprudently having eaten some salmon, I have remained well up to the present time. C. N. M , M.E.C.S. King's College Hospital, Sept., 1854. Remarks. — It is obviously impossible to tell what would have been the character of this attack if it had been treated less promptly or in a different manner, but the great relief afforded by speedy elimination, renders it probable that an opposite mode of treatment would have been attended with very different results, and that a full dose of opium would have added to ' that dreadful sense of oppression,' embarrassed still more the pulmonary circulation, and induced the symptoms of cholera with collapse. This case affords a rare example of a patient being his own doctor, and yet being judiciously and successfully treated. Case 20. — Cholera, with great collapse ; neglected by nurses. — - Fatal. Reported by Mr. Tutin. M. M., set. 48. Female. Admitted September 6th, at seven p.m. She is a single woman, living in Lambeth, and was brought to the hospital by two policemen, who found her lying in Hol- D 2 36 CASES OF CHOLERA born. She is a servant, and after her breakfast this morning she went to some offices in Holborn in search of a situation; she has had no food during the day except a little bread. She was seized at one p.m., with faintness, and fell on the floor ; this was followed by vomiting, purging, and pain in the stomach. The vomiting and purging have been almost constant, but she has had no cramps in the legs. She took some brandy twice in the afternoon, but without relief. When found by the police she was on her way home, and she was hardly conscious when brought here. Fifteen minutes past seven. — She looks much older than stated ; the features are much shrunk ; there is considerable lividity about the face ; the eyes are sunken, and the eyelids blue ; she complains of intense pain in the epigastrium, and has just been seized with severe cramps in the legs ; skin very cold ; pulse g6 — scarcely perceptible ; respiration 24 ; tongue very cold ; she is very thirsty. To have olei ricini every half hour, &c. &c. Twelve, midnight. — Pulse 72 — stronger; respiration 24 ; feels very drowsy, but is much more comfortable since her admission. The cramps in the legs and the pain at the stomach are less violent ; body much warmer ; eyes more sunken ; speaks in a whisper ; has passed no urine since her attack. September 7th, eleven a.m. — Not so well ; pulse 84 — very weak and small ; respiration 30; face and hands cold ; body warm ; eyes more sunken ; tongue not so cold ; feels sick, but does not vomit so frequently. The night nurses appear to have neglected all the patients in the ward, and, so far as can be ascertained, this poor woman has had no oil since she was left by the physician's assistant at midnight. When the night nurse went off duty this morning, she told the day nurse that this patient was to have no more oil until further orders ! No account that could be relied upon was given of the vomiting and purging during the night. At one p.m., she became very livid, was pulseless and gasping, as though dying ; an emetic of salt and mustard did not act ; she was rubbed, &c, with temporary benefit, but she died at halfpast one. Inspection, twenty-six hours after death. — The points of interest in the examination are, first, that the intestines, both large and small, contained a considerable quantity of liquid, somewhat resembling beef tea. This liquid was found, as usual, to contain numerous scales of columnar epithelium. The intestines were 37 AND CHOLERAIC DIARRHCEA. pink, and the mucous membrane of the stomach and intestines congested and ecchymosed. The kidneys were small, weighing together only four ounces and six drachms. (They must evidently have been wasted from disease ; but there is no other note of their condition. I did not see them. G. J.) The bladder was empty. There was a solid tumour about the size of a small hen's egg, attached by fibrous bands to the sigmoid flexure of the colon. The other viscera were healthy. Remarks. — This patient was so much improved when left by Mr. Holberton at midnight, that he had little anxiety about her. The evidence which we obtained as to the criminal neglect of the nurses was such as to leave no doubt that the unfavourable turn which the case had taken between midnight and eleven a.m. on the following day was a consequence of that neglect. The nurses, who had been drinking brandy through the night, were of course dismissed, and since that time no patient in collapse has been left to the exclusive care of a nurse for more than an hour or two at any time, either of the day or night. Case 21. — Choleraic Diarrhoea, and fever after a chalk mixture. — Recovery. Reported by Mr. Ttxtin. E. G-., set. 14. Female. Admitted at eleven a.m., September 6th. She lives in Wyld-street, Drury-lane, and was in good health until the 4th inst., when she was seized with vomiting, purging, pain in the head, and giddiness ; but she had no cramps ; she took some chalk mixture, but received no benefit from it. She continued much the same until five o'clock this morning, since which time she has felt very stupid and drowsjr, and has had cramps in the thigh ; she has been purged about twelve times this morning, the stools being like water ; she is very thirsty, and vomits all that she takes ; she feels cold, and has occasional rigors ; pulse 88 — weak and fluttering ; she is very pallid and the eyes are rather sunken, but there is no lividity ; skin warm ; tongue hot and rather dry ; she feels giddy, and has much pain in the head. 38 CASES OF CHOLERA Olei ricini immediately, and repeat until three doses have been taken. Half-past twelve p.m. — She did not vomit the oil, but has just brought up some water taken a few minutes before ; has not been purged since her admission ; skin very hot ; pulse 1 20. Fifty-five minutes past eleven p.m. — Has vomited once since last report, and been purged about six times, but the nurse has neglected to keep an exact account ; she is now sleeping soundly, and appears quite well ; skin cooler. 7th. — Has had a good night ; has slight pain under the right ribs, but in other respects appears tolerably well. 9th. — Discharged cured. Remarks. — It seems likely that the feverish symptoms in this case were excited or increased by the chalk mixture, probably combined with opium, which the patient took before she entered the hospital. She had three doses of castor oil, and was very quickly convalescent. Case 22. — Cholera with great collapse: large doses of brandy. — Fatal coma after reaction. Keported by Mr. Stewabt. M. A. M., set. 4. Female. Admitted Sept. 7th, at ten p.m. She was quite well until the middle of the day, yesterday, and at two o'clock she is said to have been cold, stiff, and livid ; she had frequent vomiting and purging. She has been under the care of a parish surgeon, who gave every hour a teaspoonful of brandy in iced water, and three different kinds of mixtures ; she has been drowsy all clay, but has become warmer. When admitted, at ten p.m., the body was quite warm, and she appeared in no pain, but quite unconscious ; eyes half-closed ; she smells strongly of brandy ; pulse 132 — very weak and fluttering. An emetic of salt and water soon acted, and the vomited matters were strongly impregnated with brandy. To have olei ricini siij- every hour. Bth, ten a.m. — Has taken nine doses of oil, and has vomited very frequently ; the bowels have acted seven times ; the first motions had the rice-water character, but the last three are tinged with bile ; she is very thirsty, and calls incessantly for water ; body warm ; tongue dry. Two p.m. — Has had two doses of oil, two motions, and frequent vomiting since last report ; has passed water freely. Four p.m. — Seems comfortable. AND CHOLERATC DIARRH(EA. 39 9th, half-past nine a.m. — Had a restless night ; has kept down four doses of oil ; had one stool, and vomited seven times ; body and feet warm ; hands and arms cold, from exposing them ; eyes heavy and half closed ; very sleepy ; tongue clean. Eleven a.m. — The abdomen is distended by a quantity of liquid in the intestines ; Dr. Johnson ordered a salt and waver enema, which brought away a yellow liquid in small quantity. Quarter-past twelve p.m. — Bowels still full, and no stool since that produced by the enema. N.B. The vomiting is so frequent that it is difficult to obtain the purgative action of the oil. Repeat the enema. 10th, two p.m. — She has slept much, and is still very drowsy; does not recognise her mother, but lies with the eyes half-open ; comfortably warm ; tongue rather coated; pulse 100 ; respiration 24 ; the oil has been omitted since eight o'clock last night ; she has had two natural stools ; vomits occasionally, but less frequently. Ten p.m. — Still drowsy ; body warm ; pulse good. nth, ten a.m. — She has vomited twice, and had two natural motions; continues drowsy; pulse 92. Three p.m. — She lies in a semi-conscious state, uttering a low moaning noise ; grinds her teeth frequently, and bites the cup when drink is given to her. To have a blister on the nape of the neck, and to take Tinct. Ferri Sesquichl. v\y. Aquse %ss. secunda quaque hora. 12th, half-past nine a.m. — Still drowsy, moaning, and grinding her teeth ; the blister has risen ; pulse 98 ; respiration 20 ; head cool ; rhonchus over the chest ; tongue much coated. To have hydrarg. chloridi gr. iij. sextis horis. Four p.m. — Much the same. 13th. — Drowsiness continues ; two stools ;no vomiting ; head to be shaved, and a blister on scalp. Continue the calomel. 14th. — Ilemains in the same comatose condition ; has now some difficulty in swallowing. 15th. — Died at eleven a.m. No inspection of the body was allowed. Remarks. — In this case it will be seen that a fatal drowsiness came on after the choleraic symptoms had ceased, and after the secretion of bile and urine had been restored. 40 CASES OF CHOLERA It is probable that this symptom would not have occurred if the patient had not been poisoned with brandy when she was in collapse. The urine was freely secreted, and the most probable explanation of the drowsiness is, that it was occasioned by the accumulation of carbonic acid in the blood, in consequence of capillary engorgement of the lungs during reaction. If another case of this kind were to come under my care, I should apply a leech to each temple, and perhaps three or four leeches over the lower lobes of the lungs, with counterirritation over the chest. Case 23. — Cholera with extreme collapse and dyspnoea. — Fatal. Reported by Mr. Tutin. J. J., set. 7. Female. Admitted at half-past eleven p.m., September 10th. A delicate-looking girl; she is a twin child, and is reported never to have had good health ; lives in Norwichcourt, Fetter-lane ; she has had slight diarrhoea for twelve or fourteen days. At half-past six this evening she was seized, while running about, with violent purging and vomiting, and during the last five hours she has been purged as many as fourteen or fifteen times, and has vomited as often ; about ten p.m. she was seized with cramps in the legs and stomach ; the vomited matters and the stools are watery and colourless ; she has had about s"j- of brandy, and two doses of a yellow mixture; she was both sick and purged while waiting for admission. When admitted, at half-past eleven p.m., she appears very drowsy and stupid ; the eyes are sunken, with dark areolee ; the face and hands are cold ; the rest of the body tolerably warm ; tongue coldish ; she is very thirsty ; the worst symptoms are the rapid pulse and breathing ; pulse 120 — very small; respiration 40 — laboured. To have olei ricini every half-hour, &c. &c. nth, four a.m. — She has taken nine doses of the oil, and has vomited seven times, so that the greater part of the oil has been rejected ; she has passed three rice-water stools ; respiration much laboured, and pulse scarcely perceptible ; body much colder, and eyes much more sunken than when she came in ; eyes, mouth, and fingers very blue ; she is quite sensible and is constantly crying out for cold water. Seven a.m. — Respiration still hurried ; pulse not perceptible ; AND CHOLEKAIC DIARKHCEA. 41 body very cold ; the bowels have not acted since two o'clock, and she has vomited only twice since the last report, the last time being at fifteen minutes past five ; she appears very torpid. Ordered a salt and water enema, which caused a scanty evacuation ; then an emetic of salt and mustard, which excited vomiting, and seemed to rouse her, and, for a short time, the pulse became perceptible, but she soon relapsed into her former torpid condition. Forty-five minutes past seven a.m. — Much in the same condition ; respiration very rapid — about 48 in a minute ; pulse imperceptible. To have olei terebinth. 5j., with a dose of castor oil. This seemed to have little, if any, good effect. Forty- five minutes past eight a.m. — Rapidly sinking, and could not swallow an emetic which was ordered; a turpentine enema was then ordered, but she expired almost immediately afterwards. Inspection, twenty -eight hours after death. — Rigor mortis not gone off; fingers clenched, blue and corrugated ; viscera of chest healthy ; lungs not so anaemic as in some cases which have been examined ; abdomen tympanitic over stomach and colon ; the peritoneal surface of the small intestines was of a pale pink colour, and contrasted remarkably with the white surface of the stomach and colon. The stomach contained a liquid, consisting apparently of oil and curdled milk ; the mucous membrane was remarkably pale, with the exception of a very few small patches of congestion. The small intestine contained about half-a-pint of buff-coloured gruelly liquid ; the mucous membrane pale ; some of Peyer's patches had small ecchymoses on them ; the solitary glands at the lower end of the ilium were enlarged. The colon contained about of a gruelly liquid; the mucous membrane was pale ; bladder empty. Nothing remarkable in the other viscera. Remarks. — I did not see this patient alive, but it is evident from the note taken at the time of her admission that her condition was then one of great peril. The rapid pulse and breathing were signs of serious import, and she appears to have got steadily worse after she entered the hospital. She was a delicate child, and was, so far, a bad subject for a severe attack of disease. Then she had taken brandy, and a suspicious yellow 42 CASES OF CHOLERA mixture which probably contained the usual narcotic. It is a question to what extent the symptoms had been aggravated by these means ; and a question which more nearly concerns us is whether the treatment, after her admission, could have been in any way modified with advantage. She took altogether nineteen doses of oil; about half of this was vomited, and the purgative effect was very slight. From a comparison of this with other cases, it can scarcely be supposed that mischief resulted from excessive purging and vomiting, but rather that the vomiting and purging were less than was desirable ; and it is remarkable that there was only a small quantity of liquid in the bowels, and much less than the usual amount of congestion in the mucous membrane of the stomach and intestines. It is probable that the cessation of the intestinal evacuations was a consequence of the extremely small quantity of blood which passed through the lungs. In a case of this kind it now appears to me that the most hopeful remedy is venesection, — the object being to relieve the dyspnoea, to restore the freedom of the pulmonary circulation, and so to favour the elimination of the poison through the stomach and intestines. It is evident that without such aid as venesection may afford, there is no hope of relief from extreme difficulty of breathing after the vomiting and purging have ceased. Case 24. — Cholera with great collapse. — Fatal. Reported by Mr. Stewakt. F. D., set. 36. Female. Admitted at two p.m., September 10th. She is married, and has been in delicate health since a premature labour which she had two years ago. She has been suckling a child thirteen months old until the Bth inst., on which day, at about ten in the evening, she was violently purged ; the purging continued until the time of her admission ; she has been occasionally but not frequently sick, and has had cramps in the logs. When admitted, at two p.m., the countenance is anxious ; the 43 AND CHOLERAIC DIARRHCEA. eyes sunken ; pulse almost imperceptible ; respiration 16; hands cold, and rather clammy from perspiration ; body and feet warm ; tongue warm and dry ; voice whispering; very thirsty. To have olei ricini every half- hour, &c. &c. Forty-five minutes past three. — Is more comfortable since being in bed ; rather drowsy ; pulse 92 ; has taken three doses of oil, rejected two by vomiting, and had one rice-water stool. Nine p.m. — Feels sick, but has vomited only three times since last report ; the bowels have acted four times. To take the oil every hour. nth, ten a.m. — Has had some sleep, and appears better; she perspires a good deal ; the hands are cold ; body and feet warm ; tongue warm, dry, and coated; pulse 100 ; respiration 24. She has vomited only three times since last report, the last time being at forty-five minutes past two a.m. ; the bowels have acted twelve times ; the stools have still the rice-water character, and contain no bile. As, during the last few hours, so large a quantity of the oil had been retained, it was feared that the purging might become excessive, and the oil was ordered to be discontinued. Three p.m. — The bowels have been moved nine times since ten a.m ; the stools are scanty and watery ; no vomiting ; the hands and face are cold ; respiration difficult and sighing ; she perspires a good deal. To have Jss. brandy in arrow root, and to repeat it in doses of sij. every hour. Fifteen minutes past five p.m. — Pulse 80 — scarcely perceptible; respiration 20 ; the hands and face are cold and clammy ; she is very restless ; tries to get out of bed, and says she shall not be alive long ; the bowels have acted three times since three p.m. The folio vring notes are by Mr. C. Macnamara, who remained with her during the night : — Seven p.m. — Called to see her; she looks worse, and is colder; very restless ; is half unconscious, and seems delirious at times ; tried to give her an emetic of salt and mustard, but she clenched her teeth, and would swallow very little, so that no vomiting was excited. Some brandy was given her, and about an hour after some chloric ether, and she seemed rather better. At a later period a scruple of sulphate of zinc was given without effect. She went on in the same state until two a.m. on the 12th — very restless and obstinate, refusing to take or to do anything that was required ; the bowels had acted only twice since five o'clock p.m. ; I gave an enema of warm water, which had no 44 CASES OF CHOLERA effect; I then washed out the stomach with warm water by means of the pump. After this she rallied, the pulse became perceptible, and she passed a stool; but she would take no nourishment, and she gradually sunk, and died at nine a.m. on the 12th. The last stool was passed at forty minutes past five. The husband would not allow an examination of the body. Remarks. — This patient had twenty-seven doses of oil. She vomited only nine times, and was purged thirty-six times. It is true that the stools were small in quantity, but there can be little doubt that the purging was excessive. The vomiting, which had not been frequent at any period of the attack, ceased entirely at a quarter to three on the morning after her admission. From this period all the oil was retained, and the purging became very frequent. There was never any appearance of bile in the stools. It is to be observed that she was a delicate woman, and she had been exhausted by thirteen months' lactation, so that it is not improbable that, under any plan of treatment, her strength would have been insufficient for the struggle. But it appears to me that the treatment might advantageously have been modified with respect to the following points : — First, the oil at first to have been given every hour instead of every half-hour. Second, when vomiting ceased, the oil to have been given every two hours, and either combined with ammonia as a stimulant and emetic, or given alternately with an emetic of salt and water. Third, the oil to have been continued at intervals of two or three hours, until bile appeared in the stools. Fourth, no brandy to have been given. It certainly did no good, and probably did harm. The temporary benefit which resulted from pumping out the contents of the stomach, is an interesting fact which tends to show that vomiting is beneficial, not merely by giving a mechanical impulse to the circulation, but, as is only reasonable to suppose, by removing deleterious fluids from the stomach and intestines. AND CHOLERAIC DIARRHOEA. 45 Case 25. — Choleraic Diarrhoea. — Recovery. Reported by Mr. Tutin. F. W., set. 24. Male. Admitted at eleven p.m., September 15th. He lives in Weigliton-street, Waterloo-road. On the nth inst. he suffered from pain in the head and drowsiness, but he had no purging until the following day, when he was purged four or five times. The diarrhoea has continued until the present time, and this morning he became very chilly, had pain in the head and a hissing noise in the ears ; he has been purged three or four times, and has vomited as often since the morning; he has also had pain in the stomach, and cramp in the legs and arms. At present, eleven p.m., the body is warm; pulse 84 — small; tongue coated, but not cold ; voice hearse ; he is very thirsty. To have olei ricini every hour, &c. &c. 1 6th. — He has taken nine doses of the oil, has vomited three doses, and has had two stools of a flocculent character, which are now rather green with bile ; he has had some sleep ; has no pain or cramps, and is altogether much better. Omit the oil. 17th. — Has no pain, vomiting, or purging; in fact, he is quite well. 1 8th. — Discharged cured. Remarks. — This patient probably had more oil than was necessary, but his recovery was as rapid as could he desired. Case 26. — Choleraic Diarrhoea. — Recovery. Reported by Mr. Tutin. E. G-., set. 17. Male. Admitted at five p.m., September nth. He is a copper-plate printer, living in Verulam-street, Gray's Innroad. Yesterday he ate a good deal of fruit ; but he went to his work this morning, and continued well until after his dinner, when he was attacked with severe pain in the stomach, pain in the head, and a noise in his ears like thunder ; he had also slight cramps in the left arm. At half-past three his bowels became relaxed, and he has been purged about every five minutes up to the time of his admission at five p.m. He has vomited twice during the same period, and has had shivering. When admitted, he seemed in great pain, and felt rather cold ; 46 CASES OF CHOLERA his feet were moderately cold ; pulse 96 ; tongue warm and clean ; very thirsty ; voice natural. To have olei ricini §ss. every half-hour, &c. &c. September 12th, morning. — He has taken six doses of oil, the last at five minutes past eight p.m., yesterday. He has had three light yellow motions, and has vomited three times, the vomited matters containing a considerable quantity of fruit ; he had slight cramps last evening, but none since ; he has slept pretty well ; has a slight pain in the stomach ; he is still rather thirsty ; tongue clean, warm, and moist. Thirty minutes past nine p.m. — He still complains of uneasiness in the region of the stomach ; no sickness ; the bowels have not acted since the morning. To have olei ricini %ss. immediately. 13th. — The oil operated freely, and he now appears quite well. Discharged cured. Remarks. — It appears that this attack of choleraic diarrhoea is, in part at least, attributable to a free indulgence in fruit. It may reasonably be asked whether opiates and astringents, by preventing or retarding the escape of these offending matters, would have assisted or hastened the cure ? Case 27. — Cholera with slight collapse. — Recovery. Reported by Mr. Tutin. C. D., set. 40. Female. Admitted at twenty minutes past five p.m., September nth. A muscular, strong Irishwoman, living in Lincoln-court. She was quite well until two o'clock this afternoon, when she was suddenly seized with severe cramps in the legs, a hammering noise in her ears, and pain in the right side ; she then vomited several times, and was twice purged. She was brought to the hospital by a beadle, who found her lying in the street in great pain. When admitted, the whole body was very cold, and perspiration was standing like peas on her face ; the tongue was cold, but clean ; pulse 84 ; respiration 20. She shouted out with cramps in the legs and stomach ; complained of great thirst ; and appeared very drowsy ; she is suckling a child seven months old, and her breasts are full of milk. Olei ricini every half-hour, &c. &c. Ten p.m. — She has taken nine doses of oil, and has vomited four times, but the bowels have not been moved : she is much warmer, AND CHOLERAIC DIARRH(EA. 47 1 2th, ten a.m. — She has taken eighteen doses of oil since the last report ; has vomited nine times, and has had four stools, the first being floeculent, and the late ones having the rice-water character ; she has no cramps, but complains of a pain under the right ribs ; she is still very thirsty, and rather drowsy, but her voice is natural, and there is no collapse of the features ; pulse 84 — good ; skin and tongue warm ; she has passed water freely. To continue the oil every hour. Ten p.m — Expresses herself much better ; she is warm and less drowsy ; she has vomited eight times, and has had three stools since the last report ; the stools are still floeculent, but contain plenty of bile. 13th. — She has vomited four times, and had three bilious stools since the last report ; she complains only of weakness and thirst; pulse 80 — full ; tongue rather coated. She is now taking the oil every two hours. 14th. — No vomiting ; three stools since yesterday ; has taken no oil since half-past nine p.m. Discharged cured. Remarks. — This is a case about which no anxiety was felt from the first ; the symptoms at the time of her admission were certainly very threatening, but she had not passed into full collapse. She came under treatment very early, and she had a large supply of strength to bear both the disease and the treatment. She had a larger quantity of oil than we should have ventured to give to a patient with less power, or to one in whom the medicine acted with more violence. She took altogether about twenty-two ounces of castor oil ; about half of this was vomited, and the purgative effect was very moderate ; she had only thirteen stools during the three days after her admission. Case 28. — Cholera with great collapse. — Recovery. Reported by Mr. Tutin. J. C, set. 3. Female. Admitted at fifteen minutes past nine a.m., September nth. She lives in Holborn -buildings ; has been a very healthy child, and was quite well until about eleven p.m., yesterday, when she was seized with purging, and vomited 48 CASES OF CHOLERA all that she took. The first stools are reported to have been very offensive, and of a green colour. She was seen by a druggist, who gave her a mixture, which, from the description, appears to have contained sulphuric acid. She was brought to the hospital at six a.m. this morning, when I (Mr. Tutin) ordered oleiricini siij.,to be repeated if necessary, and recommended that she should be brought back to the hospital if she became worse. She was brought at fifteen minutes past nine this evening, when it was stated that she had taken two or three doses of the oil, most of which had been vomited. She had slept from three p.m. until five p.m., and got up apparently well, but soon relapsed, and became very drowsy. Now, at fifteen minutes past nine, the body is rather cold and the tongue cool ; eyes much sunken, and much blueness round the eyes and mouth; pulse 120 — small; respiration 22; complains of no pain, but is very drowsy and thirsty. To have olei ricini siij- every half- hour, &c. &c. 12th, morning. — Has continued the oil regularly ; has vomited six times, and had two rice-water stools. She appears much more cheerful ; the eyes are less sunken, and there is no blueness about the mouth or eyes ; the body is warm, and she appears to have no pain; pulse 124; respiration 24. She is said to have passed water. To continue the oil every hour. Ten p.m. — Has vomited five times, and had only two stools since the morning, the last stool being after an enema of salt and water ; they are still of the rice-water character. She has been very cheerful this afternoon, but appears drowsy to-night ; pulse very quick. Continue the oil every hour. 13th, morning. — Has vomited four times, and had two ricewater stools since the last report ; she is very drowsy, and lies with the eyes half closed; body very warm; pulse 120 — good; respiration 24. Continue the oil every two hours. Ten p.m. — Appears very comfortable, and is sleeping soundly ; surface warm ; the oil has been discontinued since half-past three p.m. ; the last stool was at forty-five minutes past nine a.m., and the last Vomit at half- past three p.m. 14th, ten a.m. — Has had a good night, and is much improved in appearance; eyes not much sunken; pulse 108; no drowsiness ; tongue coated in the centre ; has had one stool this morning. Ten p.m. — Appears much more cheerful ; has been sitting up 49 AND CHOLERAIC DIARRHffiA. in bed talking to the nurse ; no sickness or purging throughout the day. Olei ricini . statim. 15th. — Has had a good night, and eaten a hearty breakfast this morning ; the bowels have been twice moved by the oil ; tongue clean. 1 6th. — Is quite well, but cannot be discharged because she has no clothes. 1 8th. — Discharged cured. Remarks. — The drowsiness was the only symptom which afforded cause for anxiety, but this gradually disappeared, and the child had a good and rapid recovery. Case 29. — Cholera with great collapse. — Recovery. Reported by Mr. Tutin. E. J., eet. 15. Female. Admitted at fifteen minutes past one p.m., September nth (she is the sister of the girl, Case 23) ; she is a delicate, pallid girl, with sandy hair ; she was in her usual health until ten o'clock this morning, and her bowels had been confined for some days ; the attack commenced with cold shivering, followed by vomiting, purging, and cramps in the stomach. When admitted, at fifteen minutes past one, the whole body was coldish, and the eyes sunken ; tongue cold and rather coated; pulse 96 — small and compressible ; respiration 21 ; voice hoarse ; much pain in the stomach, and severe cramps in the legs ; a noise like thunder in her ears. To have olei ricini every half-hour, &c. &c. 12th, ten a.m. — Has taken the oil regularly, has vomited fortythree times, and has had ten stools ; the first stools were dark and flocculent, the subsequent ones of the rice-water character ; the skin and tongue are warmer ; pulse 108 — good ; respiration 21 ; she is less drowsy. Continue the oil every hour. Ten p.m. — She has vomited twenty-four times, and had five stools since the morning ; pulse 100 — good ; respiration 20 ; eyes more sunken; the body is warm, except the hands; tongue warmer, and dry in the centre ; she drinks large quantities of cold water ; the stools are flocculent, but tinged with bile. 13th, morning. — Feels more comfortable this morning, but she is very drowsy, and lies with the eyes half open ; the conjunctive E 50 CASES OF CHOLERA are injected ; vomiting has been frequent through the night, and from four a.m., until thirty minutes past six, it was almost incessant. She has had seven stools, and they contain a great quantity of bile ; has pain in the stomach and slight head-ache ; pulse 72; respiration 18 ; the skin is tolerably warm. Continue the oil every two hours. Ten p.m. — Has had six stools and vomited five times since the morning; stools darker; pulse g6 — good. Complains of severe head-ache ; body warm ; tongue moist, but coated ; less thirst ; very drowsy. 14th, ten a.m. — Has had some sleep during the night; feels drowsy ; complains of pain in the stomach and head, and has rather a troublesome cough ; pulse 84 ; respiration 24 ; tongue cleaning. She has had only two doses of oil since last report ; she has vomited four times, and had five stools of a much more natural character. Omit the oil, and take an effervescing draught occasionally. Ten p.m. — Pulse g6 ; respiration 24 ; is very fretful, but less drowsy ; less head-ache ; skin moist and warm ; tongue cleaning. Has vomited once and had four stools since the morning. 15th, ten a.m. — Is much less drowsy ; less head-ache and thirst ; no sickness ; the bowels have acted six times during the night ; the stools contain bile, but are still rather flocculent ; pulse 84. 1 6th, ten a.m. — Very weak and drowsy, but has not slept much ; feels rather sick, but does not vomit ; tongue moist, but coated ; pulse 96 ; the bowels have acted eleven times since yesterday morning. 17th. — Appears much better, and more cheerful; tongue cleaning ; less thirst ; appetite returning ; pulse 72 ; only two stools in the last twenty-four hours ; a slight pain in stomach. 1 8th — Has had a good night, and feels much better. 19th. — Complains of pain in the head and stomach ; tongue dry ; has vomited two or three times, and been rather purged during the night ; is very thirsty. Olei ricini 3SS. statim. 20th. — Tongue not so dry, but the skin is hot ; she slept for several hours during the night; no return of sickness ; bowels open three times in the night. To have brandy in twenty-four hours. 22d.— Feels much stronger; sleeps well; appetite good; tongue clean ; skin cool ; pulse 84. 24th. — Had pain in the stomach this afternoon, after a hearty 51 AND CHOLERAIC DIAERHGEA. dinner ; for this she took a dose of castor oil, and was relieved. The stools are natural ; tongue clean. 27th. — Discharged cured. Remarks. — This patient took about thirty ounces of castor oil, hut it is probable that not a sixth part of it was retained, and the purgative effect was very moderate. The vomiting occurred with great frequency, — more than a hundred times during the first forty-eight hours. This will serve to show that vomiting is not a very mischievous process, but I am now convinced that it occurred in this case more frequently than was desirable, and as it ceased very soon after the oil was discontinued, it is likely that this was the chief cause of the frequent sickness. If another case similar to this were to come under my care, I should give the oil at longer intervals from the time that I observed the frequent occurrence of the vomiting, and after the bowels had been two or three times acted on. I believe that one-third the quantity of oil might have been sufficient. In this case the quick rejection of the oil was a safeguard against excessive purging, and it will be observed that the bowels acted very frequently after the discontinuance of the oil and the consequent cessation of the vomiting. Case 30. — Choleraic Diarrhoea. — Recovery. Reported by Mr. Stewart. C. T., set. 19. Male. Admitted at forty minutes past five p.m., September 12th. A native of Calcutta, living at Chelsea ; was brought to the hospital by the police, who found him in the street, in great pain. He says he has not been living very well of late, but he was quite well until this afternoon, when he was suddenly seized with vomiting, purging, cramps, and pain in the stomach ; he had been purged and vomited, each about seven times before his admission. At present, forty minutes past five p.m., he complains of cramps in the legs and shoulders, and pain in the stomach ; voice hoarse ; surface rather cold ; tongue clean and dry ; pulse 72 ; respiration 20 ; he is very thirsty, and has head-ache. To have olei ricini %ss. every half-hour, &c. &c. 13th, fifty minutes past ten a.m. — Feels better, and is warm E 2 52 CASES OF CHOLEEA and comfortable ; pulse 56 ; respiration 16 ; tongue a little coated, moist and warm ; he lias taken thirteen doses of oil ; none since midnight ; has had no vomiting, but has passed six flocculent stools ; the oil was discontinued as soon as the bowels began to act ; has passed no water since his admission ; feels sleepy. Three p.m. — He is in great distress about his family and his home ; very anxious to go to them, and he was consequently discharged at his own urgent request. He was cautioned, and desired to return if he became worse. Case 31. — Cholera with extreme collapse. — Fatal, from obstruction of the bowels. Reported by Mr. Stewart. M. F., set. 30. Female. Admitted at half-past eleven p.m., September 12. A strong-looking Irishwoman, unmarried; states that she was quite well until eight o'clock this evening, when she was seized with violent purging, but without cramps or pain in the stomach. "When admitted, her hands and face were cold, but not blue ; tongue warm and moist ; eyes a little sunken ; voice natural ; a noise in her ears like the singing of a kettle. She had vomited a good deal while waiting for admission. To have olei ricini §ss. every half-hour, &c. 13th, forty minutes past twelve a.m. — Cold and perspiring; pulse 112 — small; respiration 32; tongue cold; great pain between the shoulders and over the chest ; she vomited after a salt and water emetic which the nurse gave her, and she has had one rice-water stool. Half-past one a.m. — Much the same ; very restless and thirsty; no vomiting or purging. Three a.m. — Very cold and livid ; pulse almost imperceptible ; no sickness or purging. Five a.m. — Excessively cold all over ; hands and face livid ; pulse imperceptible ; great pain in the epigastrium ; abdomen distended with liquid ; no sickness or purging ; a large dose of salt and mustard was given, but it did not excite vomiting, and after a quarter of an hour a dose of castor oil, SSS., with olei terebinth. sij. ; then an enema of salt and water, which was returned immediately, without exciting any farther action of the bowels. In the mean time there had been no vomiting, and as I was anxious to excite sickness, I (Mr. Stewart) gave her zinci sulp. with plenty of warm water ; after waiting ten minutes, finding no sign of emetic action, and fearing that the accumulation of irritants in the stomach would do harm, I washed out AND CHOLERAIC DIARRH(EA. 53 the stomach, with the pump. After this, she seemed improved, but still complained of great pain in the belly ; in half-an-hour I repeated the dose, and then sent for Dr. Johnson, who arrived soon after seven a.m. ; she was then not quite so cold ; pulse just perceptible ; perfectly conscious, and crying out with pain, which seemed to result from great distension of the bowels with liquid, the abdomen being full, and dull on percussion. Dr. Johnson ordered an enema, containing olei ricini with olei terebinth. sij., to be given with a long flexible tube; this brought away some flaky gelatinous material, and a small quantity of ricewater liquid, but no effectual relief was afforded. Four grains of calomel were then placed on the tongue, followed by a dose of castor oil; and in half-an-hour the oil was repeated with the addition of spirit, ammoniac arom. SJ-> in the hope that it would excite vomiting, but it failed to do so. Dr. Johnson was then obliged to leave (thirty minutes past eight a.m.), and before doing so he wished me to give another enema. I went out of the ward to get the instrument, and returning in a few minutes, I found her gasping for breath and dying. The nurse said that immediately after I left, the patient made an effort to vomit, and a little liquid came out of the mouth and nose, when she began to gasp as if the liquid had gone into the windpipe. She died immediately. Inspection, six hours after death. — The stomach contained some oily liquid ; the mucous membrane was not much congested ; the small intestines presented the usual pink, congested appearance, and throughout their whole course they were distended and even dilated, as in a case of ileus, with the rice-water liquid ; the mucous membrane was pink, but there were no patches of ecchymosis. The caecum and the ascending colon were full of the same liquid, and there were some large flaky masses like coagulable lymph, which, on microscopical examination, appeared to consist entirely of perfectly organized epithelium, similar to that which composes the flakes in rice-water stools. Both the serous and the mucous coats of the larger bowel were congested and pink, but there was no ecchymosis in the mucous membrane. The bladder was empty ; the heart was healthy ; the lungs were rather anaemic ; a small quantity of oily liquid was found in the trachea and larger bronchi : it appeared that this had been drawn in during the act of vomiting. Remarks. — In this case it is to be observed that when admitted, there was only a slight degree of collapse; 54 CASES OF CHOLERA that an hour afterwards the collapse was much greater ; that it continued to increase almost uninterruptedly until the time of her death ; that while she was in the hospital, she vomited only once after an emetic, and again during the last struggle; and that she had only one stool, except a scanty evacuation after an enema. It seems evident that the muscular coat of the bowel was paralysed either by over-distension or by the narcotic influence of the poison. The fact that the stomach would not eject the sharpest irritants would indicate that the paralysing influence was something besides over-distension. This case is a good illustration of the fact that two conditions are necessary for the cure of cholera. First, that the poison should be thrown from the blood into the stomach and intestines ; and, second, that it should be ejected from the gastro-intestinal canal. In this case the latter process was suspended, and the result was agonizing pain, from distension of the bowel, and probably an impeded excretion of the poison consequent on the fulness of the intestine. When I saw her at seven a.m., it was quite evident that the pain from the distended bowel was killing her, and that nothing but the evacuation of the bowels could save her life. But all our efforts were in vain, and it is probable that none of our medicines went beyond the stomach, which seems to have lost the power either to send them on or to return them. The history of this case shows the necessity of ensuring the full action of the bowels at the commencement. It is probable that larger doses of the oil, with enemata, might have been successful during the first two or three hours after her admission, but the chance of success diminished rapidly every hour. Case 32. — Choleraic Diarrhoea. — Recovery. Reported by Mr. Tutin. H. E., set. 15. Male. Admitted at thirty minutes past ten a.m., 55 AND CHOLERAIC DIARRHCEA. September 13th. A delicate-looking boy, living at Bethnalgreen, employed at a cigar manufactory in Holborn. Last evening he had head-ache, but in other respects he was well. At six a.m. to-day he first experienced pinching pain in the stomach and bowels ; he has since been two or three times purged ; he is now very drowsy and pallid ; the eyes are slightly sunken, but there is no blueness ; he is tolerably warm, with the exception of the feet, which are cold ; has very great pain in the stomach and bowels ; is very thirsty, languid, and unable to walk ; has pain in the head, but no noise in the ears ; a short cough, but the voice is natural ; feels very sick, but does not vomit ; pulse 84; respiration 24. To have olei ricini every half-hour, &c. &c. Ten p.m. — He has taken five doses of castor oil — the last at forty-five minutes past twelve ; has vomited several times, and had six stools (character of stools not noted) ; he feels much better ; has no pain, and is not drowsy. 14th. — The bowels have not acted since nine o'clock last night ; he was sick once in the night. Discharged cured. Remarks. — This case is a good illustration of the fact that more or less of general constitutional disturbance often precedes the local pains and other symptoms of choleraic diarrhoea; and that, even when the latter symptoms occur, they bear no proportion, or rather, they are often in inverse proportion to the signs of general disorder which accompany them. In this case relief was very quickly afforded by the emetic and purgative action of a few doses of castor oil ; a result very easily explained on the supposition that there were some morbific matters to be removed through the agency of the gastro -intestinal canal, and, as it appears to me, not admitting of any other interpretation. Case 33. — Cholera with extreme collapse. — Death, from congestion of the lungs and asphyxia during reaction. Reported by Mr. Stewart. W. T.,set. 27. Male. Admitted at forty minutes past eleven a.m., September 14th. A doctor's coachman, a weakly -looking man, but he says he has generally had good health, except that since 56 CASES OF CHOLERA lie lias been in London, during the last nine or ten years, he has been occasionally subject to diarrhoea, and has had an occasional pain in the chest. About nine o'clock yesterday morning he did not feel well ; had a very loose stool, but no pain ; he was out with his master's carriage from twelve o'clock until five p.m., and when he got' home he had several loose stools, like dirty water ; he then took a diarrhoea mixture. His master was out all night with a patient, and when he came home, at eight a.m., he found W. T. suffering from decided symptoms of cholera with collapse. He gave him three or four doses of castor oil, and sent him to the hospital at forty minutes past eleven. At present, forty minutes past eleven, pulse 62 — very small ; respiration 24 ; body warm ; he is very restless ; feels hot and thirsty ; voice whispering ; a ' rumbling noise in the left ear ; had cramp in the leg a short time since. To have olei ricini sss. every half-hour, &c. &c. Three p.m. — He has vomited most of the oil, and has had only two scanty stools, of the rice-water character. To take the oil in doses of every half-hour. Twenty minutes past five p.m. — Pulse exceedingly small — scarcely perceptible ; has vomited twice and had one rather scanty rice-water stool since the last report ; he is drowsy ; has much cramp in the legs, difficulty of breathing, and pain in the left side — particularly on making a deep inspiration ; hands coldish, corrugated, blue, and wet with perspiration; tongue coated, moist, and warm. Mustard poultice to side. Seven p.m. — Complains of great pain in left side, and flatulency ; his flannel shirt is wet through with perspiration ; one stool; no sickness since last report; he is desponding, and when assured he is doing well, says he is sure he shall not get over it. Ten p.m. — Body warm and perspiring profusely ; in less pain, and rather more cheerful ; three rice-water stools ; no sickness since last report. 15th, thirty minutes past twelve a.m. — Has had four rice-water stools since last report, and says he feels better since the bowels have acted freely, but he is still low-spirited ; hands and face cold ; tongue cold and moist ; pulse scarcely perceptible. Continue the oil in doses of §ss. Three a.m. — Cold ; eyes sunken ; very restless ; talking deliriously. As there had been no vomiting, an emetic of salt and mustard was given : this acted, and appeared to relieve him. Four rice-water stools. AND CHOLERAIC DIARRH(EA. 57 Five a.m. — Four stools since three a.m. ; the last coloured green, with bile. Continue the oil every hour. Half-past eight a.m. — More cheerful and less restless ; says he is better ; body warm ; hands still cold and bluish ; is delirious at times, and tells the nurse he is going to a beautiful country ; has had eight bilious stools, and has vomited twice since five o'clock. Half-past eleven a.m. — Much worse since last report ; breathing very laboured ; skin covered with a cold sweat ; eyes much sunken ; pulse scarcely perceptible ; bowels have acted four times ; no vomiting ; a turpentine stupe was put on the chest, and a mustard emetic was given, but it did not excite vomiting. The difficulty of breathing continued and increased ; he sunk rapidly, and died at half-past twelve p.m. It was evident that he had died from apncea, but it was very unexpected. When I (Gr. J.) saw him at about nine a.m., he appeared so much better that I thought him safe, and I was painfully surprised to find him dead when I went to the hospital in the middle of the day. It will be seen that the fatal result was fully explained by the post-mortem appearances. Inspection, twenty-eight hours after death. — Rigor mortis still present. Chest. — Almost universal old adhesion of the pleura on the right side ; both lungs greatly congested throughout, and forming a striking contrast to the pale and anaemic appearance of the lungs in most fatal cases of cholera. Nearly the whole upper lobe of the right lung was condensed and hardened, apparently by a deposit of lymph, about the remains of old tubercles. There was a small mass of the same kind in the upper lobe of the left lung, feeling as hard as an apple in the midst of the pulmonary tissue ; heart healthy. Abdomen. — The stomach was greatly distended, and occupied much space beneath the diaphragm ; on opening it, it was found to contain about two quarts of a brown oily liquid, apparently consisting of a mixture of beef tea with oil and peppermintwater, in which the castor oil had been given ; the mucous membrane was congested and ecchymosed ; the small intestines were congested, but less so than in the cases in which death has occurred during collapse, and the tint was more that of venous than arterial congestion; no ecchymosis of the mucous membrane ; a small quantity of greenish liquid in the bowel ; bladder empty. 58 CASES OF CHOLERA Remarks. — There is much in this case that is interesting and instructive. It is prohable that with his feeble habit and his diseased lung, he would not, under any circumstances, have struggled through the attack; but on looking back at the history of the case, and comparing it with others which have come under my observation, I find one or two useful lessons for future guidance. He had, altogether, forty-one doses of castor oil, and as he vomited only about nine times, the greater part of this must have been passed on into the intestines. It is to be observed, however, that the purgative action of the oil was, for several hours, so slight that it had to be given in doses of an ounce, and it was not until after he had been twelve hours in the hospital that the bowels began to act freely, and that he began to feel relief. The dose of oil was then reduced, and after a short time it was given at longer intervals ; but it is quite possible that from the time that the purging became frequent, he got more oil than was useful or safe. His death, however, did not arise from exhaustion, but from asphyxia, as was evident not only from the symptoms during life, but from the post-mortem appearances in the lung, which presented a striking contrast to the anaemic condition of the lung in patients who have died during the stage of collapse. We found that for some hours before his death he had been drinking considerable quantities of beef tea. He had asked for it, and the nurse had given it without orders. It is probable that this had increased the oppression, as we have seen it do in other cases when given during collapse ; and as he did not vomit, the mischief arising from the mechanical pressure of a distended stomach on the diaphragm was superadded. There cannot be a doubt that this had seriously increased the embarrassment of the breathing and the congestion of the lung, although it is probable that it would have AND CHOLERAIC DIARRH(EA. 59 been comparatively harmless if the lungs had been free from disease. It appears then, on a careful retrospect of this case, that it might have been better if less oil had been given during the latter period of the attack, after the bowels began to act freely ; that an occasional emetic might have been given with benefit, after the oil had ceased to excite vomiting ; and that no beef tea should have been given at a time when, the digestive powers being entirely suspended, the swallowing of nourishment is invariably followed by an increased sense of oppression and restlessness. Case 34. — Choleraic Diarrhoea. — Recovery. Reported by Mr. TIJTIN. J. W., set. 45. Male. Admitted at three a.m., September 14th. A few weeks since lie was an in-patient of the hospital, on account of a chronic disease of the liver, with jaundice. He was discharged unrelieved, and the jaundice still exists. He says that at seven o'clock last night he was seized with severe cramps and pain in the stomach, so that he could not lie down ; he felt very sick, but did not vomit ; during the last four hours he has been purged seven or eight times. At present he feels very giddy ; the hands are rather cold, but other parts of the body are warm, and he has been sweating profusely ; pulse very small — scarcely perceptible ; tongue warm, but coated ; he is very thirsty ; has passed no water for twelve hours ; he is deeply jaundiced, the skin being of a greenish-yellow colour. To have olei ricini every half-hour, &c. &c. Ten a.m. — He has vomited five times since his admission, and has had two white pasty motions ; he has passed water, which is loaded with bile; he feels much easier; pulse 72 — good; respiration 18. 15th. — Has vomited twice since the last report, and has been purged nine or ten times ; he has slept well ; i 3 free from pain, and feels tolerably well again. 1 6th. — Discharged cured. Remarks. — In this case there must have been complete suppression of bile for at least twelve hours, 60 CASES OP CHOLERA inasmuch as the diseased liver had lost its secretorypower, and the function of the kidneys was for a time suspended. The case, however, was not cholera, but simply one of diarrhoea. He took twenty-nine doses of oil, seven of which were vomited. This appears a large quantity for such an attack, and it probably is more than was necessary. The first fourteen doses, however, procured only two stools. He was in no way distressed by the subsequent action of the medicine, and he was quickly well of this attack, and discharged. Case 35. — Cholera toith extreme collapse. — Death during reaction, from haemorrhage. Reported by Mr. Stewaet. M. M., set. 30. Female. Admitted at eleven a.m., September 16th. She is unmarried, and gets her living by needlework. She was quite well until three p.m. yesterday, when she was seized with sickness and purging. She went to the parish surgeon, who gave her a pill with calomel, an aromatic mixture with laudanum, and half-a-pint of wine ; she also had some brandy and a glass of gin in the course of the evening, and this morning she drank some beer. The sickness and purging continued until the time of her admission. Appearances on admission, at eleven a.m. — Eyes sunken ; lips rather blue ; hands blue, cold, and corrugated, as if from soaking in water ; feet cold ; tongue coated, moist, and warm ; voice hoarse ; pulse imperceptible ; respiration 22 ; has a hammering noise in her ears ; great pain in the back, chest, and belly, and cramps in the feet ; very drowsy and thirsty ; abdomen pendulous ; very marked fulness and dulness on percussion over the small intestines, evidently from a considerable accumulation of liquid in them. To have olei ricini every half-hour. Twelve, noon. — Has had a scanty motion like coffee-grounds ; as she felt sick, but had not vomited, an emetic of mustard and salt was given ; this brought away a quantity of dark-brown acid liquid. Twenty -five minutes past twelve p.m. — Emetic repeated, with the same result. After this she expressed herself relieved. Twenty-five minutes past one. — Another stool of the same character as the first. AND CHOLERAIC DIARRHCEA. 61 Three p.m. — Much the same ; still cold ; tongue cold ; she has had two stools of the same character, and an enema of salt and water has just now brought away some more of the same liquid, looking very like porter ; she has vomited once since the action of the last emetic. Ten minutes past four p.m. — Says she is getting worse ; has had another scanty motion of the same kind ; belly still distended and tender, and there is much pain in the back; an emetic just given has acted. To have hydrarg. chlorid. gr. ij. with each of the next four doses of oil. Eight p.m. — The bowels have acted six times since the last report, and the stools have now the usual rice-water character ; the distension of the belly is relieved ; cramps continue ; pulse imperceptible ; tongue and hands cold ; an emetic just given has acted ; there is no vomiting without emetics. Forty-five minutes past nine p.m. — No stool since last report ; cramps continue. Repeat the emetic every two hours. To take with each dose of oil ammonise sesquic. gr. iij. 17th, five minutes past twelve a.m. — Pulse 90 ; much improved since taking the ammonia with the oil ; tongue warmer, and she expresses herself better ; sweating profusely, and the body is warmer ; the cramps and pain in the stomach are less severe ; two stools since last report ; an emetic just now given did not act until the fauces were tickled. Twenty minutes past two a.m. — Countenance improved; continues to sweat very much ; body warm ; four flocculent stools, which are slightly tinged with bile ; an emetic of salt and mustard acted immediately ; no vomiting without the emetics. Five a.m. — Sleeping ; four stools, which contain more bile ; no cramp ; more thirst ; repeat emetic, which acted. Half-past seven a.m. — Four bilious stools since last report. Continue the oil every hour. Ten a.m. — Looks much better ; lying composedly on her side ; eyes scarcely at all sunken ; pulse 84 ; tongue warm and coated ; complains of some pain in the belly, but none elsewhere ; four scanty stools of a reddish colour. Two p.m. — Body warm ; hands rather cold ; great pain in stomach ; has had some sleep. Nine p.m. — Stools frequent, scanty, of a blood colour, very offensive, and highly coagulable by heat and nitric acid, but no blood corpuscles could be detected by the microscope ; pulse 80 ; 62 CASES OF CHOLERA respiration 30 ; lias passed urine ; no cramp or pain ; body very cold. She was now evidently sinking, from the drain of blood. Olei terebinth. 5j- Olei ricini — secunda quaque hora. Half-past ten p.m. — Respiration sighing. To have brandy in arrow root. She continued to sink, in spite of stimulants, and died at fifteen minutes past two a.m. on the 18th. Inspection, fourteen hours after death. — The lungs were much congested ; the stomach contained a few ounces of a yellow oily liquid ; there were a few patches of ecchymosis at the greater curvature ; the small intestines had less of the pink tinge than usual ; they contained a considerable quantity of a bilious oily liquid of a bright yellow colour ; the mucous membrane in several parts was deeply stained with bile, and presented numerous patches of ecchymosis ; in the lower part of the ilium the ecchymosis covered nearly the whole surface. In the descending colon a large patch of mucous membrane presented an uneven corroded appearance, from the destruction of its epithelial surface, this portion was of a dark colour, from ecchymosed blood. It seems likely that this spot had been the chief source of the haemorrhage ; the bladder was empty. Remarks. — This case, unfortunately, did not come under our care until twenty hours after the attack commenced. In the mean time she had been freely dosed with laudanum and a variety of stimulants — beer, wine, brandy, and gin. When she entered the hospital, the intestines were so much distended, and the pain so great, that it was evident that she would live but a few hours if she were not quickly relieved, (her condition reminded us of case No. 31, p. 52-)5 2 -) She had taken eight ounces of castor oil and eight grains of calomel before the distended condition of the bowels was relieved. From this time the stools were frequent ; she got through the worst of the collapse, bile was copiously secreted, and just when we thought her nearly safe, the blood tinge appeared in the stools; this continued and increased, and she died exhausted. This pink tinge of the stools had occurred in a previous case. (See the case of W. X., 63 AND CHOLERAIC DIARRHCEA. No. 9, p. 13, and the remarks at the end.) The dark coloured stools and vomit, which occurred soon after her admission, were very remarkable. The same appearance was observed in the earlier stools of two patients admitted subsequently. (See cases 37 and 38.) It seemed probable that the dark colour depended on the presence of blood, but I regret that the chemical and microscopical characters of the liquid were not ascertained. I observed in this case one point of considerable interest ; namely, that while she was sinking, from the exhaustion consequent on the loss of blood by the bowels, her appearance was quite different from that which she had presented while in the stage of collapse. When she had recovered warmth after the collapse, the sunken appearance of the eyes went off and did not return. The pulmonary circulation had become free, and therefore the arteries of the orbit, &c, continued to be more filled with blood than they were during collapse, although the total contents of the vessels were constantly diminishing. Case 36. — Cholera with great collapse. — Recovery. Reported by Mr. Stewaet. F. R., set. 17. Male. Admitted at forty-five minutes past eight p.m., September 16th. He has had a painless diarrhoea since the 1 2th instant ; five or six stools daily, but no sickness until this morning. He got some medicine for the diarrhoea on the 14th, and again to-day ; he brought the prescription with him : — (calomel gr. iij., morphise hydrochloratis gr. ss. — in a pill.) When admitted he was very drowsy ; eyes sunken ; skin cool ; tongue cold ; pulse 96 ; pain in the stomach ; cramps in the legs ; noise in the ears. He first took zinci sulp. 3j. ; this did not act ; lie then had some salt and mustard, which, excited vomiting immediately. To have olei ricini every half-hour, &c. &c. Forty -five minutes past nine. — Cramps still bad ; has Lad one or two rice-water stools. To have calomel gr. ij. with each of the next four doses of 64 CASES OF CHOLERA 17th, twenty minutes past twelve a.m. — He lies with the eyes half closed ; body warm ; tongue cold 5 pulse 96 — good ; vomited about three pints of liquid ; pretty freely purged ; pain over the heart ; cramps continue. Mustard poultice over heart. Half-past two a.m. — Very drowsy; has vomited five times, and had four stools since last report. Forty -five minutes past four a.m. — Has slept twenty minutes ; breathes quietly ; a stool at three, of a gelatinous character (the solid portion of a rice-water stool, without the liquid) ; at halfpast three he felt sick, but did not vomit ; after an emetic of salt and water he vomited a large quantity of liquid, and felt relief: pulse 108. Half-past six a.m. — Feels sick, but does not vomit ; has pain at lower part of chest, increased by inspiration ; after an emetic he brought up a quart of liquid ; another scanty gelatinous motion. Seven a.m. — Another gelatinous stool after an enema ; passed a small quantity of urine. Ten a.m. — Body warm, except the hands ; pulse 84 ; tongue cool and coated ; is free from pain ; has had nineteen stools since his admission. Continue the oil every hour. Nine p.m. — He is very drowsy and thirsty ; pulse 98 ; respiration 16 ; is free from pain and cramps, except a slight pain in stomach ; body warm, except the hands. 1 8th, ten a.m. — Very drowsy; body warm; pulse good; tongue coated, warm and moist ; feels better, but has occasional pain in chest. Continue the oil every two hours. Two p.m. — The motions have still the rice-water character, and are very offensive ; pulse 96 — good ; continues drowsy. Fifty minutes past eleven. — Vomits large quantities, and appears relieved by it ; stools darker. Omit the oil. 19th, half-past three a.m. — Was very restless until he vomited about a pint-and-a-half of dark -brown flocculent matter ; he is now soundly asleep ; motions darker, and more copious ; body warm. Ten a.m. — Had a good night and slept comfortably ; tongue cleaning, but rather dry ; rather drowsy ; feels much better, and is in no pain ; pulse 96. Urine 10 15 — deposits uric acid, no albumen. 65 AND CHOLEEAIC DIARRHCEA. Ten p.m. — Haustus effervescens quartis horis. 20th. — Feels quite well, but is rather drowsy; pulse 84 — good; tongue rapidly cleaning ; motions liquid, but of a natural colour. 21st. — Nothing to complain of; tongue clean; no sickness. 22nd. — Feels weak — otherwise, quite well ; sitting up. 24th. — Discharged cured. Remarks. — This is one of the cases in which some of the stools had a gelatinous character, in consequence of the more solid portions of the rice-water secretion having been left in the bowel after the liquid had escaped. It is evident that this kind of adhesive stuff could not be readily removed without the action of a purgative, and it is probable that its retention in the bowel has often been attended with serious consequences. Case 37. — Cholera with slight collapse — Fatal syncope during reaction, from diseased heart. Heported by Mr. Tutin. S. C, set. 40. Female. Admitted at five p.m., September 17th. A married woman, living in Red Lion-passage, Holborn. She has been living badly for some time past ; her husband states that for a number of years she has drunk to excess, and that during the last three years she has scarcely ever been sober. About a fortnight ago she had an attack of diarrhoea ; her present attack commenced on the 12th inst., with vomiting, purging, and severe cramps in the stomach and extremities. She had. no head-ache, but was giddy, and had a noise in her ears ; she had some chalkmixture and other remedies when first attacked, but she has continued much the same until the time of her admission. She is a stout, flabby woman ; her body is below the natural temperature. Tongue cold ; eyes a little sunken, but there is no blueness about the face ; feels very weak and languid ; pulse 98 ; respiration 30 ; is very hoarse, and has a slight cough ; has been purged twelve or fourteen times to-day, and vomits everything that she takes. Olei ricini §ss. every half-hour, &c. &c. Ten p.m. — Pulse 80 — good; respiration 18 ; is very drowsy; skin and tongue warm ; no pain or cramps ; voice less hoarse ; she feels sick, but has not vomited; four stools— liquid, and nearly the colour of porter. (See Case 35 and remarks.) Continue the oil every hour. F 66 CASES OP CHOLERA 1 8th, ten a.m. — Still rather cold; pulse 72; respiration 16; very drowsy ; voice hoarse ; tongue coated ; vomited two doses of oil ; three stools — flocculent and now tinged with bile. She is now taking the oil every two hours. Ten p.m. — Very drowsy ; voice more hoarse ; pulse 84 — good ; respiration 18; body warm ; hands coldish; tongue rather dry and coated in the middle ; no pain ; not much thirst ; vomited once, and had seven bilious foetid stools. 19th, ten a.m. — Very hoarse; drowsy, and sometimes delirious ; appears confused and perplexed in answering questions ; eight or nine bilious stools since last report ; no sickness. She is taking the oil every three hours. No pain ; arms and legs rather cold ; tongue cool and coated in the centre ; pulse 96. To have occasionally brandy sij- in arrow-root. Thirty minutes past eight p.m. — Has been getting colder and lower during the day, in spite of the nourishment and stimulants she has taken ; had four bilious stools ; no sickness ; during the last hour and a half has been delirious, and kept in bed with difficulty ; an emetic of salt and mustard produced slight vomiting, after which she answered questions when spoken to, and continued to do so until about forty-five minutes past eight p.m., when she died very suddenly, from syncope. Inspection, sixteen hours after death. — Body very fat, and still warm. Lungs healthy. Heart of unusual size, much fat on its surface, and fatty growth in some parts passing quite through the substance of the walls, — this was particularly the case in the right ventricle ; the entire organ was soft and flabby, and the finger easily pushed through the wall of the ventricles. On a microscopical examination even those parts which appeared most healthy presented decided evidences of the fatty transformation of the fibres. The stomach contained a small quantity of liquid. There was a considerable amount of ecchymosis in the mucous membrane at the oesophageal end. The peritoneal surface of the small intestines presented, in a slight degree, the pink tinge. They contained a small quantity of bilious, flaky liquid ; there was no ecchymosis in the mucous membrane. Kidneys much enlarged — weighing together sixteen ounces; the surface was lobed; vascula — not examined microscopically. Bladder empty. Liver weighed six pounds, and was in a state of extreme fatty degeneration. The gall-bladder had its walls thickened, and contained a moderate quantity of bile. Remarks. — The attack of cholera in this case was 67 AND CHOLERAIC DIARRHOEA. not a severe one, and we had no anxiety about her until the morning of the 19th. When it was seen that, although the secretion of bile and urine had been restored, she was becoming colder, weaker, and delirious; the continued sinking, and at last the sudden syncope, in spite of the stimulus which she took, led to the suspicion of a fat heart. The condition of the heart, liver, and kidneys fully accounted for the fatal result. We were not aware of her long-continued habitual intemperance, until we learnt the fact from her husband after her death ; we should otherwise have given her brandy, and discontinued the oil earlier than we did. But it is doubtful whether any amount of caution could have prevented the fatal result. She would, probably, have added to the list of deaths from chloroform, if, for any purpose, she had been put under the influence of that drug. Case 38. — Cholera with slight collapse. — Recovery. Reported by Mr. Goodall. J. P., set. 35. Female. Admitted at one p.m., September 17th. She is married, and lives in Lincoln- court, St. Giles's, where there have been some cases of cholera. She was seized with diarrhoea at six o'clock this morning, and her bowels were opened four times in about ten minutes ; at the same time she had pain and cramp in the stomach ; these symptoms were followed by vomiting and cramps in the legs. When admitted, she complained of cold and heat alternately ; countenance anxious ; eyes suffused ; pulse 76 — feeble ; respiration 40 ; tongue rather furred ; of natural temperature ; she had pain in the epigastric region, and slight head-ache. To have olei ricini every half-hour, &c. &c. She continued much in the same state during the afternoon, having pain in the stomach and frequent cramps in the legs ; at six o'clock p.m. she had taken five ounces of castor oil, none of which had been vomited, yet her bowels had not been moved since her admission ; an enema of salt and water was then given, with the effect of exciting a copious discharge of dark liquid, having the colour of porter, and little or no smell (the stools F2 68 CASES OF CHOLERA were exactly similar to those in the case of S. C, ~No. 37, who was admitted on the same day) ; after this she appeared greatly relieved. Half-past nine p.m. — The bowels have now been moved ten times since her admission ; no sickness. Continue the oil every hour. 1 8th, five a.m. — Still has pain in the stomach; no cramps; has slept frequently ; pulse good ; the bowels have been twice moved since the last report ; the stools have now the rice-water flocculent character, but tinged with bile. Two p.m. — The bowels have been moved eleven times since the last report ; the stools are still flocculent and tinged with bile ; no vomiting ; skin hot and perspiring ; pulse 60 ; tongue covered with a moist white fur ; she drinks milk-and-water. Since eight o'clock this morning she has taken the oil every two hours. 19th, ten a.m. — She has slept a good deal during the night, and says she is better ; skin hot ; tongue cleaning ; pulse 60 ; considerable tenderness over the stomach ; she has been very freely purged since the last report. Four leeches to be applied over the tender part. 20th, noon. — She had a restless night ; has been several times purged since last report, but not now for some hours ; pulse 76 ; tongue coated ; still tenderness over the stomach ; no appetite ; Acid. Hydrocyan. dil. V\iv. Aquae §j- — ter die. To have a mustard poultice over the stomach. 2 1st. — Slept well ; bowels not moved since last report; still some pain in stomach. 22nd. — Better ; no pain ; bowels still unmoved. 23rd. — Pulse 60 ; tongue clean ; appetite good ; some pain in abdomen ; no action of the bowels since the 20th. Olei ricini statim. 24th. — Bowels twice moved by the oil ; going on well. 26th. — Seems quite well ; no pain ; appetite good. 29th. — Discharged cured. Remarks. — This case resembled the preceding in several particulars. The disease was about equallysevere. The first stools had the peculiar dark colour which had also been observed in Case 35. In Case 37 there was very little vomiting; in this case there was 69 AND CHOLERAIC DIARRHOEA. none after her admission. In both cases several doses of oil were taken before the bowels were moved, and in both the purging subsequently was very frequent ; more so, it must be confessed, than I now believe to have been necessary or desirable. In both cases I am of opinion that the oil should have been given at considerably longer intervals from the time that the stools became frequent and tinged with bile. Case 39.— Cholera with slight collapse. — Recovery. Reported Mr. Tutin M. L., set. 14. Female. Admitted at eight p.m., September 1 8th. During the afternoon she has been emptying some filthy slops, which a woman who lodges in the same house had allowed to accumulate. She felt quite well until an hour ago, when she was seized with shivering, a violent pain in the stomach, vomiting and purging; during the last hour she has been purged about twenty times, and vomited about twelve times. She is just on the verge of collapse, very pallid, drowsy ; tongue coldish ; pulse 84 — small. To have olei ricini every half-hour, &c. 19th, ten a.m. — She took nine doses of oil before the bowels were moved ; since then they have acted four times, and the stools are flocculent, but now tinged with bile ; she has vomited only once since her admission ; tongue clean and warm ; voice rather hoarse ; pulse 96 ; skin rather hot ; she is very thirsty, and complains of pain at the lower part of the chest ; since the bowels began to act, she has taken the oil every hour. 20th. — Looks very much better, and has a colour in her face ; pulse 78 — good; tongue clean ; voice natural. She was purged thirteen times yesterday ; discontinued the oil at fifteen minutes past nine p.m., and the bowels have acted only once since ; she has slept soundly during the night, and feels quite well. 21st. — Continues well. 23rd. — Discharged cured, Remarks. — She took twenty-six doses of oil. This was probably about twice as much as it was necessary to give her, but her recovery was, at any rate, sufficiently rapid to prove that she was not injuriously over-dosed. 70 CASES OF CHOLERA Case 40. — Cholera with great collapse. — Recovery. Reported Mr. Tutin. J. X., set. 19. Male. Admitted at fifteen minutes past twelve p.m., September 18th. He lives in Leather-lane, and is a cheesemonger. He was in good health until three o'clock this morning, when he was seized with violent cramps in the legs, occasional vomiting, and almost constant purging ; he thinks he must have been purged a hundred times, (?) the stools being like water. On admission, fifteen minutes past twelve p.m. — The eyes are a good deal sunken ; surface of body cold — feet especially so ; tongue cold and coated ; voice very hoarse ; much thirst ; drowsy ; a noise in his ears like that of a hive of bees ; has had no cramps during the last hour. He took three powders from a medical man, but says he vomited them all. To have olei ricini Jss. every half-hour, &c. &c. Ten p.m. — He has taken the oil every half-hour ; has vomited twice, and had four stools, looking like dirty-white jelly and having a very offensive odour ; he is very warm and comfortable; free from pain ; tongue warm, but coated ; pulse 84 ; he is still hoarse ; has passed some urine. Continue the oil every hour. 19th, ten a.m. — Has not slept much, but he is much better this morning; no pain or cramps; pulse 72 — good; voice less hoarse ; tongue coated ; has passed urine this morning ; had eight stools of the same gelatinous character, mixed with oil. One p.m. — Four stools since the morning. Continue the oil every two hours. 20th. — Four stools during the night, less offensive and of a more natural character; slept well; no pain ; pulse 66; tongue coated ; still rather hoarse, with a short, dry cough. To take the oil every four hours. 2 1 st. — Very much better; has regained his voice and lost his cough ; no pain ; tongue not yet clean, but the appetite is returning ; seven stools since yesterday morning, of much more healthy character. Omit the oil. 22nd. — Is sitting up, and feels quite well. 23rd. — Discharged cured. Remarks. — This patient took twenty-five ounces of castor oil in four days, yet the purgative effect was very 71 AND CHOLERAIC DIARRHCEA. moderate, and the stools were nearly solid. His own estimate of the number of stools which he had before his admission is probably exaggerated, but the purging had evidently been great and the stools watery. From a consideration of the history it seems reasonable to suppose that, although the marks of great collapse were still present when he was admitted, yet that little, if any, of the choleraic poison remained in the blood, and its powerfully purgative action had ceased. The castor oil cleared away the offensive matters which remained in the bowels, and the patient rapidly recovered. The gelatinous material in the stools of this patient, as in the case of K. R., (No. 36,) was precisely similar to the flaky masses found after death in the intestine ofM. K. (No. 31.) Case 41. — Choleraic Diarrhoea. — Recovery. Reported by Mr. Tutin. W. C, set. 28. Male. Admitted at ten p.m., September 18th. He lives in Broad-street, Golden-square ; has usually had good health. Went this afternoon to Clerkenwell, and on his way home was seized, about an hour ago, with violent cramps in the stomach and legs, and vomiting. He went to a druggist's in Holborn, who gave him a draught, and sent him in a cab to the hospital. He is a stoutly built man. Moaning with very severe pain in the stomach, and cramps ; body cold ; pulse 90 — feeble ; respiration 24 — rather laboured ; tongue rather cold ; he is very thirsty ; voice hoarse ; a short, dry cough ; no sinking of the eyes, or blueness about the face ; pain in the head, but no noises in the ears ; no drowsiness ; he has vomited three times, but the bowels have not been moved. Pulv. Ipecac. 3j. Ant. Pot. -tart. gr. j. Aquse Jiss. — statim. The emetic acted quickly, and although he had vomited three times before his admission, there was a large quantity of food in the matters ejected from the stomach. To have olei ricini every half-hour, &c. &c. 19th, thirty minutes past twelve. — Much relieved since the 72 CASES OF CHOLERA vomiting ; bowels not yet moved ; lias passed about a pint of rather dark-coloured urine — sp. gr. 1030, very acid, not albuminous. Ten a.m. — Has vomited three times during the night, and has had six copious, dark -coloured, very offensive fseculent stools ; he is quite free from head-ache and cramps ; body warm ; tongue warm and clean ; he is very thirsty ; pulse 78. To continue the oil every two hours. Ten minutes past twelve p.m. — Has just had a copious flocculent stool, containing a little bile. 20th. — Feels very much better ; slept well, and has had no return of vomiting, cramps, or head-ache ; the bowels have acted eleven times since the last report, and the • stools contain an abundance of bile ; pulse 78 — good ; tongue rather coated ; appetite good ; has passed plenty of urine. Continue the oil every four hours. 21st. — Slept well, and feels quite well ; tongue clean ; appetite good ; pulse 84 ; five natural stools. Discontinue the oil. 22nd. — Quite well, and making himself useful in the ward; three stools since last report, the last at five p.m. yesterday. 23rd. — Discharged cured. Remarks. — I was in the hospital when this patient arrived, and his appearance then indicated an attack of disease which, if not speedily arrested, would be one of great severity. Now, considering all the circumstances of the case, the rapidity with which he had been brought to the verge of collapse, the abundance of foetid matter which came from his bowels, and the great and speedy relief which he derived from the elimination of these matters by the emetic and purgative action of the medicine, what, it may be asked, would have been the effect of a method of treatment which had for its object to check vomiting and purging ? How would he have fared under the influence of a full opiate ? He would, probably, have passed rapidly into a state of collapse, from which he would have been rescued with great difficulty, if at all. He took twenty-two ounces of castor oil in four days; nine half-ounce doses of the oil were taken before he had one stool, and the purging was not AND CHOLERAIC DIAREHCEA. 73 very great at any time. He had twenty-seven stools, and vomited three times during the four days. Case 42. — Cholera with slight collapse. — Recovery. Reported by Mr. Stewart. G-. M., set. 18. Male. Admitted at five p.m., September 19th. Has usually enjoyed good health. He was first taken ill on the 16th inst., at tea-time, when he felt very giddy, and vomited, but was not purged. On the morning of the 1 7th he was quite well again, and has continued so until this afternoon, when he was employed in cutting wood, and while doing so he became so giddy that he fell down ; he was then very sick ; the last time of vomiting being about half-an-hour ago. On admission, his hands were rather cold ; body warm ; voice hoarse; pulse 84 ; respiration 14; no sinking of the eyes, or blueness. To have olei ricini every half-hour. 20th, ten a.m. — He has vomited six times, and has had nine • genuine rice-water stools ;' feels better ; no pain ; body warm ; tongue warm and moist ; pulse 84 — good. Twelve p.m. — Continue the oil every two hours. 21st, ten a.m. — Much better; slept well, and has nothing to complain of; three stools tinged with bile. Omit the oil. 23rd. — Discharged cured. Remarks. — A mild attack of cholera quickly cured. It is not clear from the notes whether there was any purging before his admission, and the condition of the urine is not mentioned. Case 43. — Choleraic Diarrhoea. — Recovery. Reported by Mr. Tutin. A. H., set. 16. Female. Admitted at eleven a.m., September 18th. She has been living in Whitefriars-street, and usually has good health. Her present illness began, on the 15th inst., with severe head-ache, cramps in the stomach, and vomiting, but no purging. She took no medicine, and she continued in much the same state until yesterday, the 1 7th, when the pain and cramps in the stomach increased, and she had violent cramps in the legs ; she has vomited four or five times since this increase of pain, and has been seven or eight times purged — the stools being, she says, of a very dark colour. 74 CASES OP CHOLERA At present she has pain in the head, and a buzzing noise in the ears ; she has felt cold, but the body is of the natural temperature ; pulse 84 — good ; respiration 24 ; no cough or hoarseness ; tongue clean and warm. To have olei ricini every half-hour, &c. &c. Ten p.m. — Has had six stools of a very dark colour ; no sickness ; complains still of head-ache, and pain in the left side of the chest ; no return of cramps ; has a short, dry cough ; voice rather hoarse ; skin and tongue warm. Continue the oil every two hours. 19th, ten a.m. — Still complains of head-ache ; has not slept much, and has slight return of cramps in the stomach ; the pain in the chest has ceased ; she is rather thirsty ; voice still rather hoarse ; body warm ; no sickness : five stools — flocculent and tinged with bile ; pulse 70 ; respiration 28 ; tongue coated. Continue the oil every three hours. 20th, ten a.m. — Slept well ; less head-ache ; no sickness ; tongue coated ; six stools. The oil has been discontinued since nine p.m., yesterday. 21st. — Much better, but has pain in the stomach; one stool since last report. To have a dose of oil. 22nd. — The oil acted twice ; she has now only a slight pain in the stomach ; tongue clean ; appetite improving. 23rd. — Going on well. 24th, ten p.m. — Has been sitting up, and eating a hearty dinner, after which she was seized with severe cramps in the stomach. She took some castor oil, and after it had operated the pain was relieved. 25th. — Still some uneasiness in the stomach ; tongue clean ; she has enjoyed her breakfast. 26th.— Nearly free from pain, and much better, 29th. — Convalescent. After the above date she had some hysterical symptoms, the record of which has no interest in connexion with the choleraic disease. Remarks. — It is to be observed that there was very decided disturbance of the general health before the commencement of diarrhoea, and the earlier stools appear to have had the same character as in Cases No. 35, 37, and 38. 75 AND CHOLEEAIC DIARRH(EA. Case 44. — Cholera with great collapse. — Recovery. Reported by Mr. Stewaet. M. P., set. 30. Female. Admitted at forty -five minutea past three p.m., 2 1st September. Married, and lives in Beecham-street, Brooks Market. Several cases of cholera have occurred in the neighbourhood. Had tolerable health, but not lived well lately. She was first taken ill on the 12th inst., with giddiness and frequent vomiting, but without purging ; she also felt drowsy and thirsty. After these symptoms had continued for several hours, she took a dose of salts, which acted as an emetic, and afforded some relief. On the following morning (the 14th) she repeated the dose. This opened her bowels, and she afterwards felt quite ¦well until yesterday, the 20th, when she felt ill all day, with giddiness, nausea, and occasional retching, but no vomiting until the afternoon, when she was sick four or five times, and purged about a dozen times. At eight p.m., she took some gruel, went to bed, and slept until four a.m. this morning, when she awoke, feeling much worse, very thirsty and cold, noise in the ears, pain in the stomach, and frequent vomiting and purging, which have continued until the time of her admission, in spite of a chalk mixture w T hich she has been taking. On her admission, at forty-five minutes past three p.m., her hands, feet, face, and tongue are cold ; eyes sunken ; voice hoarse ; pulse 84 ; respiration 28 ; pains in the chest ; cramp in the hands ; a considerable quantity of liquid in the intestines ; she is drowsy and thirsty. To have olei ricini every half-hour, &c. &c, after an emetic of salt and mustard. Ten p.m. — She is much warmer; has had cramps badly; vomits very frequently, — thirteen times since her admission, and has had only three scanty rice-water stools. 22nd, nine a.m. — Body and tongue warm; pulse good; no pain ; asks for beef tea, which was not allowed ; she has vomited twelve times during the night, and has had nine scanty ricewater stools. Continue the oil every hour. Four p.m. — Continues warm ; pulse 84 — good ; she has vomited twelve times, and had four stools since the morning ; twice in the course of the day she has had sp. am. arom. sj. in water, to relieve a sense of oppression at the stomach ; on each occasion it acted as an emetic, and relieved her. 23rd, ten a.m. — She has passed about a pint-and-a-half of floeculent 76 CASES OF CHOLERA bilious liquid, by stool, and lias vomited very frequently — as many as twenty-one times since last report ; she lias continued warm ; very thirsty, but free from pain, except once at four a.m., when she had pain in the stomach, relieved by sp. am. arom. SSS5 SS - > she is now comfortably asleep. Continue the oil every two hours. To have some iced water. 24th, half-past nine a.m. — Going on well ; she has vomited about thirty times, and had seventeen scanty bilious stools during the last twenty-four hours. Continue the oil every four hours Nine p.m. — She has vomited six times and had eight stools during the day. Omit the oil. 25th, ten a.m. — Much more comfortable ; has vomited four times, and had eight dark offensive liquid stools ; tongue warm, moist, slightly coated, but cleaning ; pulse 80 — good. An effervescing draught occasionally. 26th, eleven a.m. — Complains only of weakness ; very thirsty ; tongue clean and moist ; has a good appetite ; no vomiting ; the stools are still liquid, and of a dark -brown colour. 27th. — Going on well ; has passed a great deal of water lately — no albumen, sp. gr. 1010. 28th, half-past ten a.m. — Has had no stool since the night of the 26th ; does not feel quite so well ; is thirsty ; tongue moist and clean ; pulse 72 ; she took a dose of oil at nine a.m. ; this was vomited ; a second dose has been retained. Ten p.m. — Has had three stools, dark-brown and liquid ; she is now very comfortable. 29th. — Very comfortable Oct. Ist. — Convalescent. Remarks. — In this case the symptoms indicating a general constitutional disturbance before the occurrence of diarrhoea were very well marked. This was one of the cases in which, after admission, vomiting occurred with great frequency, so that, although she took no less than thirty-three ounces of castor oil, it is not probable that a sixth part of it passed into the intestines. It is noted that she vomited eighty-three times up to the twenty-fifth. She had, during the same time, about AND CHOLERAIC DIARRHOEA. 77 sixty stools, most of which, however, were scanty. When admitted, she was in great collapse ; she soon began to improve, and her progress was uninterrupted. It will be seen that the vomiting ceased soon after the discontinuance of the oil. Ido not doubt that it was very beneficial, but as I think that it occurred more frequently than was necessary or desirable, I should now, in a similar case, give the oil at longer intervals. Case 45. — Cholera with extreme collapse. — Fatal coma after reaction. Reported by Mr. Tutin. T. M., set. 11. Male. Admitted at eight a.m., Sept. 22nd. He lives in Shorts-gardens, St. Giles's. He was attacked with vomiting and purging on the morning of the 20th ; the symptoms continued until the middle of the day, when he applied as an out-patient, and was ordered to take olei ricini, 395., tinct. opii. V\x. He was sick and purged several times after this dose ; he then appeared much relieved. On the following day (yesterday) he appeared quite well, and his mother allowed him to go to bathe at Hungerford ; after the bath the sickness and vomiting returned, and continued until the time of his admission ; he has also had cramps in the hands, pain in the stomach, and thirst. On admission he was quite cold and pulseless ; eyes much sunken ; eyelids and mouth blue ; voice whispering ; tongue cold ; no pain ; nor has he had noise in the ears ; very thirsty. To have a salt and mustard emetic. Olei ricini ever half-hour. Half-past nine a.m. — Dr. Johnson saw him, and finding much fulness and dulness on percussion over the small intestine, the bowels not having acted since his admission, ordered a salt and water enema. Repeat the emetic every two hours if the oil does not act as an emetic. Half-past ten a.m — He is still pulseless, but warm ; the enema brought away only a small quantity of colourless liquid ; he now complains of severe pain in the stomach. Repeat the enema with the addition of olei terebinth. 3"ss. Half-past six p,m. — The bowels have acted six times since the last enema, and he has vomited three times since twelve o'clock, without the aid of the salt emetics j pulse 108— just perceptible ; 78 CASES OF CHOLERA respiration 27 ; he continues very drowsy ; eyes much sunken ; body warm ; hands and tongue cold. Ten p.m. — One stool ; no vomiting since last report. Dr. Johnson ordered the oil to be continued every hour, with sp. ammon. arom. Tl\xx., the intention being to excite vomiting. 23rd, half-past twelve a.m. — Pulse 108 — good; he is verywarm and free from pain ; eyes less sunken ; as the oil and ammonia have not excited vomiting, the emetic was repeated ; eight stools since last report. Half-past two a.m. — Rather restless and delirious ; very thirsty ; tongue dry ; two stools tinged with bile ; no vomiting. Hepeat the emetic. Half-past four a.m. — Three stools ; vomited once without an emetic ; he feels much better, is less drowsy, and more lively. Fifteen minutes past eight a.m. — Countenance much improved ; eyes less sunken ; voice still hoarse ; tongue less dry ; much thirst ; pulse 108 ; respiration 22 ; two stools and once sick ; the liquid passed by the bowel between twenty minutes past ten p.m., yesterday, and forty-five minutes past six a.m., this morning, would measure about two pints ; it is flocculent, and contains a good deal of bile. Continue the oil every two hours. Nine p.m. — He has lost the choleraic expression ; eyes natural ; body warm ; he is very drowsy, but rather restless ; pulse 100 ; respiration 24 ; three stools since the morning — they contain an abundance of bile ; vomited twice. 24th, ten a.m. — Has been very restless through the night, and has ground his teeth ; refuses his medicine, and will not put out his tongue when desired to do so ; three stools ; no vomiting ; less thirst. Continue the oil every three hours. Half-past twelve p.m. — Very drowsy and torpid ; a salt and water emetic roused him for a time. Ten p.m. — Pulse no; respiration 22; continues drowsy, but he is more conscious, and answers questions when sharply spoken to ; quite warm ; tongue rather coated ; no vomiting ; eight stools during the day. 25th, ten a.m. — Continues very drowsy, and the eyes appear more sunken ; hands and face rather cool ; the other parts of body warm; pulse 100; respiration 18; tongue moist, but coated; three stools during the night; urine 1010 — contains a small quantity of albumen, and deposits uric acid. Haustus effervescens pro re nata. 79 AND CHOLEKAIC DIARRHCEA. Two p.m. — Still torpid ; breathing heavily and laboriously Ether. Chloric. Il\x. Sp. Am. Arom. I]|xv. M. Acaciae %]. — tertiis horis. Nine p.m. — Eyes less sunken ; breathing more tranquil ; on the whole he appears much better since taking the ether ; three stools since the morning. Continue the mixture. Omit the oil. 26th, ten a.m.— Has appeared much better during the night, but continues drowsy ; pulse 108; respiration 18; tongue dry and coated ; he has taken beef tea, and appeared to enjoy it ; has passed about a pint of urine during the night, and has had six bilious stools ; the left parotid gland is hard, swollen, and tender — to have a poultice. Thirty minutes past eleven p.m. — Pulse 104 ; respiration 20 ; much more lively and cheerful, and sleeps less ; answers questions when spoken to ; tongue moist ; has passed urine freely — it contains a very small quantity of albumen ; about the middle of the day a salt and water enema brought away a fseculent stool, and he has just now passed another. He is still taking the chloric ether mixture. 27th, ten a.m. — Pulse 120; respiration 27 ; he is more drowsy ; the swelling of the parotid appears to render swallowing difficult, but he takes a considerable quantity of nourishment ; tongue moist ; one dark stool since report. Continue the mixture. Brandy Two p.m. —An incision was made into the parotid, but no matter escaped. Ten p.m. — Pulse 124; respiration 24 ; he remains much the same; very drowsy ; stools and urine passed under him. 28th, ten a.m. — Pulse 130; respiration 32 — very laborious; body warm ; eyes not sunken ; three stools during the night ; much difficulty in swallowing. Head to be shaved and covered with a blister. Hydrarg. chloridi gr. ij. ter die. Six p.m. — Pulse 126; respiration 40 — almost stertorous ; quite unconscious ; pupils unequal, the right being much dilated ; head very hot ; no action of the bowels since last report. He died at eight p.m. Inspection, eighteen hours after death. — The swelling of the parotid had quite subsided since death ; the substance of the gland appeared to have been the seat of the inflammation. The brain and its membranes appeared to be in every respect perfectly 80 CASES OF CHOLEKA normal ; no effusion of any kind. Heart quite healthy. Lungs engorged at the back and base. The stomach contained a small quantity of liquid ; the mucous membrane was rather congested, and there were few points of ecchymosis. The intestines are slightly congested, and there was intussusception of the ileum in several parts, but without any evidence of impeded circulation consequent thereon. Liver healthy. The gall bladder contained a small quantity of watery liquid, and floating in it was about a teaspoonful of viscid green bile. Kidneys healthy. The bladder contained about two ounces of urine. Remarks. — It was very disappointing to lose this poor boy after rescuing him from a state of collapse so profound as that in which he was when he was admitted. This case resembles in the mode of death that of M. A. M. (No. 22, p. 38.) In another case of the same kind I should give no stimulants, and I should endeavour to relieve the congestion of the lungs by local bleeding and counter-irritation. It is possible, too, that a few leeches to the temples might have been of service. When this case occurred, I could not explain the return of the sinking of the eyes which occurred on the twenty-fifth. I now believe that it was a consequence of the capillary engorgement of the lung, which took place during reaction, and which impeded the flow of blood to the left side of the heart. The urine was freely secreted, and it is probable that the coma was occasioned by an accumulation of carbonic acid in the blood. Case 46. — Diarrhoea. — Recovery. Eeported by Mr. Goodaix. J. W., set. 30. Male. Admitted at forty-five minutes past twelve p.m., on the 23rd of September. He lives in Clement'slane, where there has been one case of cholera. About a fortnight ago, after attending an inquest on a case of cholera, he was seized with cramps in the stomach and extremities, and frequent vomiting and purging. For this attack he was treated as an out-patient, with castor oil, followed by an astringent. He soon recovered, and continued well until the 21st inst., when he was again seized — a few hour 3 after eating three apples — with pain in 81 AND CHOLERAIC DIARRHOEA. the stomach, and purging. These symptoms have continued, with little intermission, until he was admitted to-day. On admission, says the last evacuation was watery, had some specks of blood, and was passed with pain and tenesmus ; percussion over the stomach, tympanitic — below the umbilicus, dull ; he is thirsty ; tongue coated ; he took some brandy last night, without relief. Olei ricini immediately ; sinapism, &c. Thirty minutes past six p.m. — Three watery, bilious stools ; he is perspiring profusely, and has very little pain ; pulse 80. 24th. — Seems much better ; tongue clean ; appetite improving ; no pain, sickness, or purging. 25th. — Bowels open twice since last report ; he complains of weakness, and has some pain in the stomach ; pulse 76. Hepeat the dose of castor oil at fifty minutes past twelve p.m. 26th. — Quite well ; discharged. Case 47. — Diarrhoea. — Recovery. Reported by Mr. Stewabt. C. Gr., set. 18. Male. Admitted at half-past eight p.m., September 14th. A pale-faced, weakly fellow, by trade a tailor ; has been out of work, and lived badly. In the month of August he was an inmate of the surgical ward in which the cases of cholera had occurred ; he then had a diarrhoea which had continued for about a week in spite of opiates and astringents, when he was seen by Dr. Johnson, who gave him a tablespoonful of castor oil; after this had acted two or three times, the diarrhoea ceased. He came to the hospital this evening, and stated that he has again been very much purged ; when admitted he was shivering with cold, and his body was cold to the touch ; tongue warm ; he was a little hoarse ; pulse 80 — good ; no noises in the ears, cramps, or blueness. To have olei ricini pro re nata, &c. &c. Ten p.m. — Body now warm; he is rather delirious; has spectral visions, and says he has a dog in bed with him ; motions dark and watery. 15th. — Has had a good night ; complains of pain in the stomach, thirst, and head-ache ; when spoken to he appears bewildered, and answers, after some delay, in a stupid, incoherent manner; body warm; head hot; pulse 76; the bowels have acted, and the stools are rather flocculent. 1 6th. — Much better, quite sensible, warm and comfortable ; no head-ache. 17th. — Convalescent; discharged. G 82 CASES OF CHOLERA Remarks. — The notes of this case are somewhat imperfect. It was an attack of diarrhoea occurring in an ill-fed weakly subject, and likely to have ended in cholera if it had not been checked. The cure of the diarrhoea, when he was a surgical patient, by a single dose of castor oil after a week's unsuccessful treatment by opiates and astringents, affords a good illustration of the speedy relief which may often be obtained by the exhibition of a mild purgative in such cases. Case 48. — Extreme collapse. — Recovery. Reported by Mr. Tutin. A. R., set. 23. Female. Admitted at fifteen minutes past twelve p.m., September 30th. She has been living in Russellcourt, Drury-lane, where for three days and nights she has been in constant attendance on her uncle, who died of cholera yesterday morning. She never was very strong, and has suffered from cough and occasional spitting of blood. She was first seized yesterday morning, the 29th, with frequent vomiting and purging, and from the commencement until the time of her admission she has been purged at least sixty times, and vomited as often. Last evening cramps seized her legs and hands, and to-day she has had a buzzing noise in her ears. Yesterday she took several doses of a yellow mixture, and also of another which tasted like alum ; she also took brandy yesterday and to-day, but she has vomited everything that she has taken. On admission, at fifteen minutes past twelve p.m., she presented the usual choleraic appearance : the eyes were much sunken, half closed, and turned upwards ; she appeared very drowsy ; considerable lividity round the eyes and mouth ; lips very blue, as are also the hands ; the whole body is icy cold ; tongue very cold and coated with a yellow fur ; voice a whisper ; pulse 120 — barely perceptible; respiration 24; a short, husky cough ; very thirsty ; drinks much cold water, which is soon rejected, and the vomiting relieves her considerably ; has passed no urine since her illness commenced ; the cramps in the legs and fingers recur every four or five minutes, and she has just now been seized with pain in the precordial region ; there is considerable fulness, and dulness on percussion, over the intestines. 83 AND CHOLERAIC DIARRH(EA. A salt and mustard emetic immediately ; then olei ricini %ss. every half-hour, &c. &c. Forty minutes past twelve p.m. — The emetic was returned in three minutes ; had the first dose of oil at thirty-five minutes past twelve, and vomited immediately after. Two p.m. — Pulse and temperature improved ; no stool since her admission ; a salt and water enema. Ten minutes past two p.m. — She has just now had a colourless rice-water stool. (The flocculi, examined microscopically, found, as in other cases, to consist of epithelium.) Twenty minutes past five p.m. — She has vomited thirteen times and has passed about a pint of rice-water fluid in six stools since her admission, but there is still considerable distension of the bowels; pulse 120 — much improved; she is much warmer, and feels more comfortable ; eyes less sunken ; voice improved ; cramps still severe. Forty -five minutes past eight p.m. — Pulse 108 — stronger; voice returning ; fejAe low and tired, but cannot sleep ; she vomits frequency, and finds great relief from it ; has passed a little urine ; bowels moved twice since the last report. Continue the oil every hour. Fifteen minutes past ten p.m. — Has had an hour's comfortable sleep ; bowels not moved since last report. Repeat the enema. Oct. Ist, thirty minutes past twelve a.m. — Bowels moved twice since last report ; she continues to vomit ; countenance much improved ; less drowsy ; no cramps for two hours ; pulse 108. Thirty minutes past three a.m. — Two scanty rice-water stools ; body and tongue warm ; eyes much less sunken ; very little lividity of the face. Fifteen minutes past six a.m. — Pulse 120 ; respiration 20 ; continues warm ; tongue rather dry ; a slight return of cramps ; has passed no more urine ; no stool since last report. Repeat the enema. Fifteen minutes past eight a.m. — Two stools after the enema ; she vomits frequently, and begins to refuse the oil ; still very thirsty ; has regained her voice ; eyes very little sunken ; no lividity either of face or hands. Thirty minutes past eleven a.m. — Pulse 120; she is going on well ; cough rather troublesome ; vomiting still frequent ; one gelatinous stool at seven minutes past eleven ; she is warm, expresses herself much relieved, and has a good colour in the face. G 2 84 CASES OF CHOLERA Repeat the enema. Thirty minutes past two p.m. — Pulse 112 — good; much more cheerful ; face flushed ;no pain ; tongue moist, but furred in the centre ; has passed some urine ; bowels moved twice since the enema ; still no bile in the stools ; has not vomited for nearly an hour. Ten p.m. — Pulse 120 — much stronger; complains chiefly of weakness ; face a good deal flushed ; she has quite lost the choleraic appearance ; tongue moist ; six stools since last report, the last, as well as the vomited matters, being tinged with bile. 2nd, ten a.m. — Pulse 108; respiration 22; slept a good deal during the night and feels much better this morning ; no pain, except a little under the right ribs ; less cough ; feels very weak; she has vomited fifteen times and had five bilious stools during the night ; she has a good pink colour in her lips and cheeks. Continue the oil every second hour. Ten p.m. — Four stools since the last report — they contain much bile ; vomiting continues ; has passed water copiously. 3rd, ten a.m. — Pulse 100 ; respiration 24 ; feels much better, but very weak ; could not sleep last night, and is less drowsy today ; less thirst ; no pain ; frequent vomiting ; five stools since the last report, of a brown colour and less flocculent. Continue the oil every four hours : an effervescing draught occasionally. 4th. — Her chief complaint is weakness ; pulse 96 — good ; respiration 20 ; five stools since the last report ; she vomits occasionally, but less frequently ; not much thirst ; no pain or cough. Omit the oil. sth. — Pulse g6 ; respiration 24 ; rather a restless night ; complains of head-ache ; vomited four or five times and had five stools during the night — stools dark green ; urine cloudy, acid, 1014, slightly albuminous. 6th. — Feels much better, and more cheerful; tongue cleaning; appetite returning ; bowels moved once this morning ; stools more of natural colour ; no vomiting. 7th. — Slept well ; tongue cleaning rapidly ; complains only of weakness. Bth.— Going on well. 9th. — Vomited after her breakfast this morning ; pulse 84 ; has slight urticaria about elbows and shoulders ; tongue clean ; appetite much improved ; bowels have not acted since the 7th. $1 Acid. Hydrocyan. Dil. Il\iij. Aqua — ter die. 85 AND CHOLERAIC DIARRHCEA. nth. — Improving. To have wine %iv. 12th. — Pil. coloc. c. gr. x., pro re nata. 13th. — Is sitting up, for the third time, and feels much stronger ; appetite good ; tongue clean ; bowels regular ; urine free from albumen. 1 6th. — Feels quite well, and gains strength daily. 1 8th. — Discharged cured. Remarks. — She took thirty-five ounces of castor oil from September the 30th at twenty-five minutes to one, p.m., to eight a.m., October the 4th ; vomited 125 times from twenty-seven minutes to one p.m., September the 30th, to quarter past ten, a.m., October the sth ; and was purged sixty-eight times from ten minutes past two p.m., September the 30th, to quarter to seven a.m., October the 7th. At the time of her admission she was in extreme collapse. She soon began to improve, and her progress was uninterrupted. Yet I do not advise so frequent a repetition of the oil when the stomach and bowels are readily moved by it; and if a similar case were to come under my care now, I probably should not give more than half the quantity of oil. Case 49. — Cholera with great collapse. — Recovery. Reported by Mr. Goodall. E. S., set. 5. Male. Admitted at half-past three p.m., Oct. 10th. Was always a healthy child, a native of Ireland ; he returned with his parents from Kent on the sth inst., and went to lodge in Charles-street, Drury-lane, where there have been cases of cholera. His mother states that the water-closet in the house is in a very dirty condition, frequently running over and making the house disagreeable. At about five o'clock p.m., on the Bth, the child was seized with purging, which continued all night and through yesterday ; he was very thirsty, but had no cramps or pain. About eleven o'clock last night he began to vomit, and from that time until his admission he has vomited about twenty times ; the vomited liquids and the stools were similar in appearance, colourless, and, from her description, of the rice-water character. About noon to-day his mother noticed that his expression changed, and that on kissing him, his lips felt cold, 86 CASES OF CHOLERA afterwards his whole body became colder than natural, his fingers shrivelled and blue at the ends, his tongue cold, and his voice very weak : he also sighed very much, as if from exhaustion, and turned his eyes upwards. This was his condition when admitted at half-past three p.m. ; he was also drowsy as well as blue and cold ; eyes much sunken ; pulse very quick and weak. Salt and mustard emetic immediately. Olei ricini sij- every half-hour. Five p.m. — Pulse 120 ; respiration 20 ; he is much warmer, and less drowsy ; very thirsty ; has vomited twice, and passed one rice-water stool ; there is considerable fulness and dulness on percussion over the small intestines ; tongue coated, but warmer. Ten p.m. — He is very drowsy, rather alarmingly so ; very thirsty ; has vomited three times and had one stool since last report. nth, ten a.m. — Mr. Tutin sat up with him; he has slept a good deal, and has ground his teeth during the night ; has had several rice-water stools, but there is still a good deal of fulness about the course of the descending colon ; he has passed a little clear, very pale urine — acid, 1005, containing a small quantity of albumen ; much thirst ; pulse good. To have an enema of salt and water. Olei Ricini s\j- Sp. Am. Arom. Tl\x. — every hour. If this dose does not produce vomiting occasionally, to have a salt emetic every two hours, and besides, to take every hour the following pill, until four doses have been taken. Hydrarg. Chlorid. gr. ij. Pulv. Acacise q. s. Ten p.m. — No pain during the day ; bowels freely open, and the stools are, this evening, slightly tinged with bile ; he is still drowsy ; at four p.m. he was ordered to omit the oil until ten p.m., and then to take none until six a.m. to-morrow. 12th, ten a.m. — Has slept well; is warm and comfortable, and says he is hungry ; face rather flushed ; tongue cleaning ; pulse 90 ; respiration 22 ; two bilious stools since last report ; passes plenty of urine. 13th. — Sleeps well, and is more lively; stools still liquid, but bilious ; no pain ; tongue clean ; pulse 100 ; respiration 24 ; the eyes are still a little sunken. He takes one dose of oil a day. 14th. — Has passed a large quantity of pale, very foetid liquid from the bowels ; no pain or thirst ; appetite good. 87 AND CHOLERAIC DIARRHCEA. 15th. — Going on well ; evacuations nearly natural. 1 6th. — There seems now to be very little the matter with him, and his mother is anxious to take him out. 19th. — Discharged cured. Remarks. — This child took about ten ounces of castor oil, and eight grains of calomel. The emetic and purgative action was very moderate, and had to he assisted by salt emetics and enemata. His progress was very satisfactory, but on the second and third day after his admission the drowsiness was rather alarming. I watched him closely, remembering two former cases, Nos. %% and 45, which had ended in a fatal coma, and intending to leech the temples and the chest if stupor came on, but the threatening head-symptoms disappeared. Case 50. — Choleraic Diarrhoea. — Recovery. Reported by Dr. Johnson. A gentleman, set. about 50. Felt unwell on the morning of the 26th August, in consequence, as he supposed, of hard work on. the previous day, followed by a hearty dinner, of which damsonpudding formed a part. He left his house, in Regents-park, to go to his office at Islington, and was seized with vomiting in the street ; this was quickly followed by purging, and he soon became faint, cold, and blue. I saw him at three p.m. ; he had vomited several times, and had been five or six times purged ; he was in bed, perspiring, the skin coldish, pulse feeble ; he became occasionally, and quite suddenly, faint and pale ; and while I was speaking to him he vomited a thin, gruel-like liquid, without any tinge of bile. He was in a state of considerable alarm. I gave him immediately, in cold water, olei ricini 5 v j- 5 after a few minutes he rejected a part of the oil; I directed him to remain quiet, and in about an hour he was again sick, but the vomited matters contained no oil. As soon as the retching was over, I gave him a second dose of oil, in cold water ; he remained quiet, and when I saw him again, at half-past six, he was warmer and more comfortable ; there had been no return of sickness, nor had the oil operated. I then gave him some arrow root, with brandy sij-» and left him. I was out of town on the following day, and did not see him until the 28th, when he told me that he considered himself well. 88 CASES OF CHOLERA Shortly after I left him on the 26th he had two copious stools, the appearance of which he did not observe, and he was once sick ; since then he had had neither pain, stool, nor sickness ; his only complaint now is of weakness, but this has not prevented him from going to his office. I ordered a tonic mixture, and took my leave of him. I saw him again in September, and learnt that he had continued well. Remarks. — This case requires no comment. The cure was as speedy as could he desired. Case 51. — Cholera with slight collapse. — Recovery. Reported by Dr. Johnson. G-. 8., set. 40. Male. A gardener, was seized with vomiting, purging, and cramps, at four o'clock on the morning of September 9th ; his wife gave him some brandy, but the symptoms continued, and at six a.m. they sent for a medical man, who gave a pill containing half-a-grain of opium with five grains of calomel. After the pill was taken the sickness and purging ceased, but when he was visited again at half-past eight there was an alarming change in his appearance, and the gentleman in attendance requested me to visit his patient with him. When I saw him, at nine a.m., the features were beginning to shrink ; the voice was husky ; the skin cool ; the pulse very feeble ; much thirst ; the last stool was flocculent, with only a slight tinge of colour. It was evident that since the cessation of the vomiting and purging he had been rapidly passing towards a state of collapse. About a quarter of an hour before I saw him, he had taken half-an-ounce of castor oil, which he had not vomited, but as it seemed desirable to excite vomiting, we gave him immediately another dose, ;in a few minutes he vomited ; he was then directed to have half-ounce doses every half-hour, the number of doses to be regulated by the progress of the symptoms. To drink cold "water ad libitum. When I saw him again in the evening, I learnt that he had taken altogether about six ounces of the oil, about half of which had been vomited ; his bowels had been several times acted on, the last stool containing a good quantity of bile. At the time of my visit he was quite comfortable ; the skin was warm, and he had a good pulse; countenance much improved. To discontinue the oil. AND CHOLEKAIC DIARRH(EA. 89 10th. — Has had a good night; no return of sickness or purging ; skin and pulse natural. To take half-an-ounce of oil, and after it has acted to have some beef tea. nth. — No return of the symptoms ; quite convalescent. Remarks. — This case is a very instructive one, as showing, first, the symptoms of approaching collapse induced by the cessation of vomiting and purging, and second, the quick disappearance of symptoms of collapse after the recurrence of vomiting and purging. Those who believe that the collapse in cholera depends on loss of liquid, might perhaps suppose that there had been before the cessation of vomiting and purging, a sufficient loss of liquid to cause the collapse ; but this supposition appears quite irreconcilable with the speedy disappearance of the alarming symptoms under the influence of the emetic and purgative action of the oil. Case 52. — Cholera with great collapse. — Fatal. Reported by Dr. Johnson. Mr. S., set. 61. Of rather feeble habit. Had had diarrhoea for two or three days, for which he took carbonate of soda. On the morning of the 13th of September he became worse, and I was called to see him, with Mr. Pascall, of Charlotte-street. At eleven a.m. on the 13th, he was restlessly tossing about the bed ; the eyes were sunken, skin warm, pulse very feeble, voice husky; he was very thirsty ; he vomited while we were speaking to him, and some rice-water stools, passed just before, were shown to us ; he had no pain or cramps. To have olei ricini every half-hour, cold water, &c. Ten p.m. — Much the same. Has taken %xiv. of oil ; has vomited five times and been purged once ; skin still warm ; voice less husky. To continue the oil every hour, and to have with each dose sp. ammon. arom. SSS<»5 SS< » the object being to excite more frequent vomiting as well as purging. 14th. — Has had a much more quiet night; has been three times sick and once purged : the stool has still the rice-water character; voice and pulse improved; temperature natural; he 90 CASES OF CHOLERA feels much more comfortable ; lias taken altogether twenty -two ounces of oil. Continue the oil. 15th. — Has had a better night; appears much the same as yesterday ; has vomited nine times — a green, bilious liquid ; has had no stool. To have calomel gr. iij. with olei ricini quartis horis, until three doses have been taken. 16th. — Has had a restless night, but appears better to-day; has vomited once, and had three scanty, dark, bilious stools ; has passed a small quantity of urine ; tongue rather coated ; skin cool. An effervescing draught every hour. 18th. — Has had two restless nights ; complains of pain and discomfort in the stomach ; still tosses about the bed ; has passed rather copious bilious stools, and urine in good quantity ; tongue moist ; skin cool ; pulse quiet ; he sits up occasionally. Decoct. Aloes Comp. Tr. Cardam. Comp. 5j- — ter die. 19th. — Much the same : yesterday's mixture has no purgative action. Add to each dose mag. sulp. 21. — The mixture has brought away some dark bilious stools, of the consistence of treacle. Yesterday he began to take Quiniae Disulp. gr. j. Acid Sulp. Dil. ITJV. Syrupi Zingiberis sss. Aquse — ter die. He is better to-day, but languid ; we found him lying on the floor, where he spends much of his time ; tongue moist and clean ; urine copious. Rep. Mist, quinise. To take the aperient occasionally 22nd. — Mr. Pascall reports that 'he has passed a much more quiet night, he looks better in the countenance, and takes his beef tea well.' 23rd. — The aperient mixture acted three times yesterday ; he has had a very restless night, and they have difficulty in persuading him to take nourishment ; he is very languid ; pulse feejble ; skin coldish. Continue the quinine mixture ; to take brandy or wine, and beef tea frequently. AND CHOLERAIC DIARRHCEA. 91 24th. — Another bad night ; he takes very little nourishment ; has a pretty extensive nettle-rash over the body ; face red. $k Tinct. Ferri Sesquichl. I]\xv. Tinct. Calumb. sss.5 s s. Aquse 3,j- — ter die. Omit the quinine. 25th. — 'A restless night; the rash itches intolerably.' 26th. — ' Will take no nourishment ; almost pulseless.' 27th. — Died about the middle of the day. No examination of the body was made. Remarks. — In looking back at this case it seems to me probable that he would have had a better chance of recovery if we had assisted the purgative action of the oil by combining it with calomel at an earlier period. His age and feeble constitution were unfavourable circumstances, and after passing through the disease, he did not rally. Case 53. — Cholera with decided collapse. — Speedy recovery.— Relapse after eating pear and cake. — Final recovery. Be ported by Dr. Johnson. W. F., set. 7. Male. Was seized with diarrhoea and vomiting at six a.m., on the 16th September. The first stool was copious and feculent, the second of the same kind, the third was genuine rice-water. When his mother went to the nursery she was much shocked at his altered appearance ; she gave him some brandy, which he vomited immediately ; she then sent for a medical friend, in the immediate neighbourhood, from whom I learnt that the child appeared to be rapidly passing into collapse ; his skin being cold, and the pulse very feeble. He gave a dessertspoonful of castor oil, which was rejected by vomiting, as were two doses given afterwards ; but one dose had been retained when I saw him at two o'clock p.m. ; by that time he was much improved ; the countenance was natural ; skin warm, and the pulse good ; tongue slightly coated ; he was very thirsty ; the three stools above described were shown to me. I gave him a dessert-spoonful of oil, which he vomited immediately ; a second the same ; but he retained a third dose, which had been made into a mucilage with syrup. To have olei ricini siij- om, hora. 92 CASES OF CHOLERA Cold water for drink. Eight p.m. — Has had five doses of oil, one of which was vomited ; three rather scanty rice-water stools, with a slight tinge of colour ; a very few drachms of urine ; skin warm and perspiring ; countenance natural ; pulse good. Repeat the oil every three hours. Cold water, or milk and water. 17th, nine a.m. — Going on quite well; skin warm and moist; pulse quiet and full ; tongue has a whitish coat ; two stools, deeply coloured with hile ; about half-a-pint of urine. Continue the oil every three hours. An effervescing draught occasionally. Nine p.m. — Is sleeping quietly ; has passed urine copiously. 18th, nine a.m. — Has slept great part of the night ; two copious stools ; flocculent and bilious, mixed with urine. Hydrarg. c. Creta gr. iij. statim. Olei Eicini siij-> post horas tres. I now left him in charge of his medical attendant, convalescent. Three days afterwards I was called to him late at night, and learnt that he had gone on quite well, and had been out-of-doors that day. In the afternoon he had eaten some sweet cake and a raw pear ; the consequence was an attack of pain, vomiting and purging, with coldness of the skin. I saw first one firm, healthy stool, then one copious liquid brown one, then one pale and flocculen — a very near approach to rice-water ; in a basin there was an abundance of cake and pear which he had vomited ; his skin was still cool, and he was very languid and drowsy ; one dose of castor oil had been given and retained. Bearing in mind case No. 41, p. 71, and seeing his torpid condition, I was anxious to ensure the complete clearance of the stomach ; I therefore gave pulv. ipecac, gr. x. in warm water. He quickly vomited the oil which he had taken, and a small quantity of flocculent liquid. I then gave olei ricini siij- 5 to be repeated in three hours. 22nd, ten a.m. — Much better, but looking pale and weak ; one scanty, pale, foetid, flocculent stool ; about an ounce of urine. Hydrarg. Chloridi gr. ij., statim. Olei Eicini ? post horas tres. Milk and water. 23rd, ten a.m. — Had a good night ; was sick this morning after drinking milk and water; stools still flocculent, but deeply tinged with bile ; skin, pulse, and countenance natural. Hydrarg. c. Creta gr. iij., statim. Olei Eicini siij-> post horam. AND CHOLERAIC DIARRH(EA. 93 To have tea and dry toast for breakfast, chicken broth for dinner. I again left him convalescent, and I believe that he was soon quite well. Remarks. — There are two very instructive points in this case ; one being the beneficial effect of the repeated vomiting in bringing the child quickly out of a most decided incipient collapse (compare Case 2, p. 4) ; and the otL^r, the relapse occasioned by the double offence against common sense, sweet cake and raw pear. Does such a relapse prove that the cause of cholera acts only locally on the mucous membrane of the stomach and intestines ? It might perhaps appear so if it were certain or even probable that indigestible articles of diet do not become absorbed, and so enter the circulation. This question will be fully considered hereafter. Case 54. — Choleraic Diarrhoea ; excited by the effluvia from a hare. — Recovery. Reported by Dr. Johnson. E. G%, set. 30. Female. She is a cook, and on the 28th September she had to prepare a hare for dressing ; the animal had been killed six days before, and was 'high.' She was in good health at the time, but while occupied in this work, at about three p.m., she felt that the smell gave her a sensation of nausea, and in about a quarter of an hour she vomited twice, and soon afterwards she was purged. The sickness and diarrhoea continued, and when I saw her, at nine p.m., she had been purged about twenty times, and sick about half as many times ; she had been both sick and purged a few minutes before. She had gone to the closet, and the character of the stools had not been observed ; she was in bed, and complained of weakness, but there was not a symptom of collapse ; her countenance was natural ; skin warm; pulse not feeble. I gave her, at half-past nine, olei ricini In about a quarter of an hour she vomited a part of the oil ; the dose was repeated at half-past ten, and this was retained. 29th, half-past ten a.m. — Bowels open six times since the last report, the last stool being about a quarter of an hour ago ; no return of sickness ; no pain ; tongue clean and moist ; skin and pulse natural ; she is up and dressed. 94 CASES OP CHOLERA AND CHOLERAIC DIARRHOEA. To have some beef tea and the following mixture : — Decoct. Hsematoxyli §j. Tinct. Catechu 3J. — quartis horis. Nine p.m. — Has taken two doses of the mixture ; no stool since three p.m. ; she complains of weakness and a sense of trembling, but she has been doing her work to-day. 30th. — Quite well, and at work as usual. Remarks. — In this case it seems probable that the attack of sickness and diarrhoea was occasioned bysome noxious effluvia from the putrid hare having entered the blood through the lungs, and that the offending matter was eliminated through the agency of the stomach and intestines. If the collapse of cholera depends on mere loss of liquid, why was there a total absence of collapse in this case ? Would it have been a rational or a successful mode of practice to have put a sudden check to the vomiting and purging by opiates ? Would not the' probable effect of such a practice have been to confine the patient to bed on the following day with a head-ache, a coated tongue, fever, and tenesmus, for the cure of which a purgative must have been given ? PART 11. THE PATHOLOGY OF EPIDEMIC DIARRHCEA AND CHOLERA. Sec. I. The relation betiveen the symptoms of collapse and the loss of fluid by vomiting and purging. IN commencing an inquiry into the pathology of diarrhoea and cholera, and before attempting to give what I believe to be the true interpretation of those symptoms of cholera which constitute the stage of collapse, it will, I think, be useful to ascertain w T hat amount of evidence can be adduced in support of the theory which assumes that the symptoms of collapse are chiefly and essentially due to the loss of the watery constituents of the blood. The theory in question has many advocates, and it has greatly influenced the treatment of cholera ; it is, therefore, a point of considerable importance to determine whether this theory is in accordance with the facts which it professes to explain. Now, it is evident that the essential cause of any symptom, or group of symptoms, must not only be constantly present and associated with those symptoms, but the intensity of the cause, supposing it to admit of varying degrees of intensity, should bear a direct relation to the severity of the symptoms to which it is supposed to give rise. To apply this general principle to the subject of cholera, if the symptoms of collapse are occasioned by a drain of liquid from the blood, the degree of collapse should, as a general rule, be in direct proportion to the amount of liquid which is lost. Now, 96 THE PATHOLOGY OF there are few writers of any note or authority upon the subject of cholera, who do not either assert distinctly, or record facts from which the inference plainly follows, that not only is there no direct relation between the loss of liquid by vomiting and purging and the degree of collapse, but that these conditions often bear an inverse ratio to each other. In confirmation of this important position, I purpose now to quote some of the best known authors. Dr. Parkes says, (i*. p. 79,) 'My cases bear out the observations of Scot, Jameson, Orton, Kennedy, Copland, and, in fact, almost all the English writers of reputation, that there is absolutely no ratio between these two classes of symptoms,' (i.e., between the purging and vomiting and the algide symptoms — the coldness and the other signs of collapse,) 'or that they appear even to observe an inverse ratio to each other. Thus, at a period of the case when the algide symptoms were most fully developed, viz., in the last five hours, the purging ceased ; in the cases where the algide symptoms were prominent throughout, and which cases were consequently the most malignant and the most rapidly fatal, the passage of the fluid from the intestines was oftentimes trivial in degree and shortened in the period of its occurrence. In cases in which the vomiting and purging were excessive, the algide symptoms often came on slowly, and were less marked and deadly.' Dr. Parkes then, in illustration of these remarks, cites some cases in which the frequency of the vomiting and purging was quite out of proportion to the severity of the other symptoms. He afterwards (p. 83) remarks, that 'it maybe objected to observations of this kind that the number of stools is, after all, no certain mdi * The numbers refer to the works quoted, a list of which will be found at the end of the volume. EPIDEMIC DIARRHCEA AND CHOLERA. 97 cation of the amount of fluid passed. This objection would be of weight in cases where the stools were not very different in number; but in some of those cited above, we have two or four stools attended by a more rapid death than twenty-five or twenty stools ; and yet, in the first case, it would be impossible not to suppose the quantity of the fluid passed to be much below that of the second case." 'Another objection is, that it cannot be known how many of the stools are to be included in the term of the disease, and not in its premonitory stage.' ' Perhaps here an appeal to general experience is of more weight than a reference to numbers, and it may be confidently asserted that there is no one who has seen much of cholera who does not know that, exclusive of the mildest forms of the disease, a case with little vomiting and purging is more malignant and more rapidly fatal than one in which these are prominent symptoms.' Dr. Parkes then details ' three cases of recovery during a severe epidemic in which there was as much, if not more, purging and vomiting than in the majority of the fatal cases;' and, subsequently, (p. 90,) he remarks, 'it appears to me that these cases fully bear out the inferences drawn from the amount of purging in the fatal cases, and warrant the assertion that the quantity of fluid passed from the alimentary canal was in no degree commensurate or proportioned to the malignancy of the case. May not, however, the fluid poured into the canal, but not ejected, have borne some relation to the severity of the disease? To this a partial reply only can be given. Certainly, after death, in malignant cases, there appeared to be a considerable quantity of the thick clotted fluid in the canal. It was almost impossible to measure this, but, judging by the eye, it seemed to vary, like the stools, without much reference 11 98 THE PATHOLOGY OP to the severity of the case, and to be small in quantity in some of the most rapid cases, attended with little purging.' Dr. Parkes also asks whether, if great purging and loss of watery fluid induce the peculiar symptoms of cholera, these ought not to follow certain forms of dysentery and diarrhoea in which sometimes, for days together, there is an immense number of loose stools, which, although they greatly reduce the strength, yet do not produce the distinctive choleraic symptoms; and after making some observations on the exciting cause of cramps, he infers ' that the vomiting, purging, and cramps must be considered merely as usual, but nonessential symptoms of cholera, whose absence would not in the least affect the diagnosis of the disease, and that, consequently, it is within the bounds of possibility or even probability, that cases of cholera may occur, entirely divested of these symptoms. I need scarcely remark that several cases of this kind are upon record, and, although I have never myself witnessed these extreme instances, it is satisfactory that, from reasoning on my own fatal cases, in every one of which purging was present at some period of the case, I have come to a conclusion identical with that derived from actual observation by several of the most eminent writers on this subject.' With reference to the varieties in the general features of cholera, Scot (ii. p. xxi.) makes the following statement. ' A frequent variety, the worst of all, is that which is noted for the very slight commotion in the system ; in which there is no vomiting, hardly any purging, perhaps only one or two loose stools, no perceptible spasm, no pain of any kind ; a mortal coldness, with arrest of the circulation, comes on from the beginning, and the patient dies without a struggle. This has frequently manifested itself as the prevailing type, and almost all die who are attacked by it; but, EPIDEMIC DIARRHCEA AND CHOLERA. 99 fortunately, it has not usually lasted long, the disease either disappearing, or assuming, during its further progress, a milder or less formidable character.' And again, when speaking of the prognosis, the same author says (p. liii.), 'If the case should present apparently, violent symptoms, such as great irritation of the stomach and intestines, much pain in these parts, and severe spasms of the muscles, &c the prog- nosis will be favourable. These cases are generally found to be much under the influence of curative means.' 'If, on the contrary, the case should present but few symptoms of excited or increased actions, if there be little or no pain, if vomiting and purging should either not have appeared or, having appeared, should have soon ceased, without any improvement in the condition of the patient, if there be little or no spasm, but along with these negative appearances, if there should be collapse, coldness of the surface, deafness, and great depression of the circulation, the danger is imminent indeed. This awful state of things occurs, in many instances, from the first few minutes after the invasion of the disease; in the majority, however, it takes place only after a more considerable lapse of time The danger of cholera may thus be said to be manifested, not by the violence of morbid actions, but by the diminution or cessation of natural actions.' The testimony of Bell is to the same effect. He says, (in. p. 128,) 'It has been found that the more violent the prominent symptoms are, the more likely is a cure to be effected ; and that when the disease is attended with rapid collapse, little or no vomiting and purging and no spasm, the prognosis is very unfavourable.' Orton (iv.), in several passages of his Essay, alludes to the fact that, in the worst forms of disease, vomiting and purging are slight, or quickly cease, or even do not occur at all. H2 100 THE PATHOLOGY OF Twining (v.) gives cases which illustrate the same general principle. Thus, he reports (p. 10) the case of a gentleman who died in nine hours from the commencement of urgent symptoms, in whom ' there were occasional slight efforts to vomit at intervals of half-an-hour; and he had only four stools from the commencement to the termination of the attack. And in another part of his work (p. 37) he says, ' We often see patients vomiting violently for hours, and others purged profusely for several days, without cholera coming on.' The authors hitherto cited have all ohserved the disease in India, hut the testimony of those who have witnessed it in Europe is in strict accordance with that of the Indian authorities. Thus, Magendie, describing cholera as he saw it in Paris in 1832, makes the following statement (vi. p. 66) : — ' Some patients have no evacuations, insomuch that one is obliged to excite them; for the evacuations are not one of the most serious symptoms, only they are associated with the disease; and those patients who have had copious evacuations have been more easily treated than those who have had none. This is a remark which has been made by many physicians.' Mr. French (xlix. p. 22) states, amongst other reasons for believing that the intestinal discharges are salutary, that while ' cholera, in its most intense form, produces death instantly without discharges, all those who recover from its attack experience the peculiar discharges more or less.' And again, in favour of the same view, is ' the ultimate recovery of persons who have continued in a state of collapse for a considerable length of time, often extending to a period of three days, and who, in all instances, sustained enormous discharges.' Dr. Gull, in his Report, (vii. p. 130,) cites the evidence of several practitioners to the effect that, in many cases, ' the evacuations appeared to be wholly insufficient to EPIDEMIC DIARRH(EA AND CHOLERA. 101 account for the fatal collapse.' And one case which came under his own ohservation affords a striking illustration of the same principle. 'On a post mortem examination, the large intestines contained healthy faeces, whilst in the upper two-thirds of the small intestine, the mucous membrane presented the ordinarychanges induced by the cholera process, and the ricewater effusion was abundant.' Dr. Gull adduces this case as evidence that ' cholera sicca, in a strict sense, does not occur ; for although the disease may be fatal without any evacuation, the intestines, after death, in such cases, have been found to contain the rice-water fluid.' It can scarcely be doubted, however, that when, as in the case referred to, the purging has been insufficient to remove the fseculent contents of the large intestine, the loss of fluid must have been out of all proportion less than in most cases in which recovery takes place. And Dr. Gull, in another part of his Report, (p. 211,) admits that ' the intensity of the symptoms is often, in no inconsiderable degree, greater than can be accounted for by the amount of the effusion.' With respect, then, to the question whether there is any direct relation between the amount of fluid which is separated from the blood by the gastro-intestinal canal, and the severity of the choleraic symptoms, we have a large amount of concurrent testimony to the effect that no such relationship exists. The evidence as to this point might be much increased if it were desirable. It appears to me, however, that enough for my present purpose has been already adduced ; derived, too, from authors who have witnessed the disease at different periods, under widely different circumstances, in various parts of the world, and whose theoretical views as to the pathology of cholera are very diverse. In opposition to this particular evidence we have statements of a general character to the effect, ' that in all the cases observed, 102 THE PATHOLOGY OF the severity of the symptoms was in proportion to the amount and rapidity of the discharges.' Many replies of this kind, Dr. Gull states, were received in answer to the queries issued by the cholera committee of the College of Physicians. The doctrine which these statements appear to support, has been very extensively maintained and acted upon; it is that which seems obviously to suggest itself as one sees a patient falling into collapse while he is ejecting fluid from the stomach and bowels ; nevertheless, I believe that the doctrine is erroneous, and I trust to prove that it is so. For the present, I have only to make two observations with reference to the relation between the collapse and the loss of fluid : Ist, That any amount of negative evidence may be entirely subverted by a few well-ascertained facts, such as those which I have quoted from various accurate observers; and 2nd, Even admitting that there were a constant relationship between the degree of collapse and the loss of fluid, further evidence would still be required to prove that they stand to each other in the relation of cause and effect. It might be that they were only joint effects of one common cause, which, while on the one hand it produced the signs of collapse, on the other excited vomiting and purging. How far this may be actually the case, I shall consider hereafter. In the meantime, it must, I think, be conceded, that while the proof that there is rather an inverse than a direct ratio between the degree of collapse and the loss of fluid by vomiting and purging, is fatal to the hypothesis that the collapse is a consequence of the loss of fluid, the proofs of a direct relation between these conditions, if such proofs existed, would be alone quite insufficient to establish the doctrine that the essential cause of collapse is the drain of fluid from the blood. 103 EPIDEMIC DIARRHCEA AND CHOLERA. Sec. 11. Are the symptoms of collapse such as an excessive drain of fluid from the blood might he supposed to produce ? It may fairly be asked of those pathologists who maintain that the symptoms of collapse are occasioned by a drain of fluid from the blood, whether the condition of a patient in collapse is such as the well-ascertained laws of physiology would lead us to anticipate, supposing — in accordance with the theory in question— that collapse results from a ' serous haemorrhage.' Now, what is the usual condition of a patient who has suffered a profuse drain from his blood, whether of one or of all the constituents of that liquid ? What is the effect of a copious haemorrhage, of a profuse and long-continued leucorrhoea, of prolonged lactation, of excessive purgation, whether the result of disease or of medicine ? Is not the condition of a patient who has been exhausted by such means, of the nature of syncope ? He has a small and frequent pulse, a pallid skin, dimness of sight and hearing, symptoms which are much aggravated by the erect posture ; and in extreme cases the . patient cannot raise his head from the pillow, even for a moment, without a loss of consciousness, and in fact a complete fit of syncope. For a patient in this condition to walk or stand, or even to sit up, is as impossible as for him to fly. Now there appears to be something in the collapse of cholera which is essentially different from the state of syncope ; in fact, almost the only symptom w r hich is common to the two conditions is the extreme smallness and feebleness of the pulse. The great and obvious distinction between the two pathological conditions is this — that whereas a patient verging on syncope is unable to assume the erect posture without losing at the same time 104 THE PATHOLOGY OF his pulse and his consciousness, a patient in the collapse of cholera, whose skin is as cold as ice, and whose pulse is either quite imperceptible or reduced to the smallest perceptible degree of force and volume, not only retains his consciousness when recumbent, but is often able to stand and even to walk a distance which must require a considerable amount of muscular exertion. This is a fact alluded to by several authors, and no one can have witnessed the disease without having observed the surprising amount of muscular exertion of which even a pulseless patient is capable. It is scarcely necessary to quote authorities for this statement, but I will refer to two, in illustration of what has been advanced. Scot (ii. p. xxiv.) says, — ' Instances are not wanting of patients being able to walk, and to perform many of their usual avocations, even after the circulation has been so much arrested that the pulse has not been discernible at the wrist.' The same author says, in another place, when speaking of the effects of blood-letting (p. lviii.), 'It is remarkable that in a disease like cholera syncope should be so rare a symptom.' And again (p. xxviii.), ' During the progress of this disorder, when the nervous energy seems to be almost annihilated, and the functions of the heart and arteries to be abolished, this symptom (syncope) is yet very rarely observed.' Mr. Barwell (viii. p. 95) makes the following statement. 'A very striking circumstance, connected with this particular state, is the very slight degree in which the brain and nervous power generally are debilitated. Patients will be seen actually walking with a steady gait, while their faces are perfectly blue, and who, when first seen by a medical man, are found to have scarcely any pulse # at the wrist. One of the patients walked from Horsleydown to the hospital (St. Thomas's), a distance of about a mile, and when examined, a few minutes after his arrival, was found livid and all but pulseless.' 105 EPIDEMIC DIARRHffiA AND CHOLERA. Another remarkable difference between the collapse of cholera and the exhaustion which results from the drain of fluids from the blood, consists in the rapidity with which a patient often recovers from the former condition. As an instance of this I may quote the following, from Dr. Gull's Report (vii. p. 135), ' I have seen,' says Mr- Grainger, ' a man stand at his door on Wednesday, who on Monday was in perfect collapse.' And this observation, as Dr. Gull observes, accords with the experience of others. With reference to this feature of cholera, Twining makes the following statement (v. p. 20) : 'In cases not fatal, the progress of recovery is often almost as rapid as the accession of cholera ; and if the disease be promptly treated at the very onset, it is not uncommon to see a person well on the third day after an attack of the worst symptoms, which had commenced with coldness and collapse, and who, if left without remedies, would probably have died in six or eight hours. In these instances recovery seems almost as sudden and complete as in cases of patients ivho are resuscitated after suspension of animation from submersion in water. The case of J. 0. (No. 5, P- 7) ma y be referred to as an instance of rapid recovery from the most urgent symptoms. It is scarcely necessary to state that no such instance of rapid recovery from extreme prostration by a drain of fluids from the blood was ever known to occur ; nor from the nature of things is it possible that a great loss of blood-constituents can be restored with such extreme rapidity. The natural and obvious inference from these facts appears to be that there is an essential difference between the condition of a patient who has been exhausted by a profuse drain from the blood, and that of a patient in collapse with cholera. It is therefore incumbent on those who maintain that choleraic collapse is due to the loss of fluid by the intestinal canal, to explain, if they can, 106 THE PATHOLOGY OF the remarkable difference between the symptoms of that condition and those of ordinary syncope. Sec. 111. Does the effect of treatment upon the symptoms of Collapse afford support to the theory that a drain of fluid from the blood is the essential or the chief cause of that condition ? The condition of a patient in collapse — cold and pulseless, and, apparently, exhausted as he is — is one which, at the first view, suggests the need of stimulants. Any one who has seen the speedy improvement in the pulse and other symptoms, which usually follows the exhibition of brandy to a patient who is fainting from loss of blood, or exhausted by excessive purging, would naturally expect similar results from the same means in the collapse of cholera. Accordingly, stimulants have been freely given, and the result has been a very general opinion that, in the stage of collapse they not only do no good, but positive harm. I have seen a patient grow colder, and his pulse diminish in volume and power, after a dose of brandy, and obviously as a direct result of the brandy, as I shall endeavour to prove hereafter. Dr. Gull reports (vii. p. 185) that, ' although opium and diffusible stimuli — brandy, camphor, and ammonia — were useful at an early stage of the disease, as collapse set in, they not only failed to produce any favourable result, but often aggravated the symptoms.' If brandy has failed to do good, this cannot be attributed to its having been given in insufficient doses, for one gentleman reports to Dr. Gull (p. 191) as follows: — 'In 1832 I had, in conjunction with another surgeon, charge of a cholera hospital, and found brandy, even in pint draughts, quite useless.' Dr. Paine, who has given an admirable description of 107 EPIDEMIC DIARRHOEA AND CHOLERA. cholera and its treatment in New York in 1832, writes thus (ix. p. 42) of stimulants : — 'We have seen no benefit from their liberal use, and it is even doubtful whether they contribute much, in any quantities. It requires the conviction of experience, however, to enable us to abstain from their use, and to resist the impulse to apply them to the dying spark.' It appears, therefore, to be unquestionable that the action of stimulants in the collapse of cholera is very different from their influence upon patients who have been exhausted by the loss of blood constituents. The inference is, that syncope and choleraic collapse are pathological conditions essentially different from each other; and this inference is confirmed in a most striking manner by observing the effect of another remedy, namely, blood-letting. It is quite needless to say that no sane physician would ever think of abstracting blood from the veins of a patient who had been reduced to a state bordering on syncope, by any of the ordinary sources of exhaustion to which I have before referred (p. 103). It is obvious that the loss of blood in such circumstances would be attended with perilous and even fatal results. But what has been the effect of venesection in not one or two, but in a large number of cases of cholera, and in the hands of many different practitioners ? The question is not now what are the circumstances in which bleeding is admissible and likely to be of use ? that is a question which will be considered hereafter ; but we have to inquire what has been the effect of blood-letting in cholera, as described by able and trustworthy authorities ? It is in the writings of the Indian practitioners that the largest amount of evidence is to be obtained as to the influence of blood-letting in cholera. Mr. Scot, whose Report (ii.) is one of the ablest and mosi lucid medical treatises with which I am acquainted, makes the 108 THE PATHOLOGY OF following interesting remarks on the subject of bloodletting in cholera (p. lviii.) :—: — ' The abstraction of blood, unless as an anti-spasmodic, is a remedy so little indicated by the usual symptoms of cholera, that its employment in the cure of this fatal disease has afforded a signal triumph to the medical art. It requires no common effort of reasoning or reflection to arrive at the conclusion that when the powers of life appear to be depressed to the lowest degree, the pulsation of the heart all but extinct, the natural heat of the body gone, and the functions of the system suspended, and incapable of being revived by the strongest stimulants, the abstraction of blood might yet prove a remedy against a train of symptoms so desperate. Bleeding was no doubt first employed in cases where there was much spasm, and where the powers of the system had not much declined : the relief was generally obvious and immediate, and the practice in such instances was thus established. Dissections having frequently shown a loaded state of the vessels of the viscera, and apparent inflammation of their mucous membranes, venesection was also adopted to obviate these conditions, and naturally enough ; but the employment of blood-letting without reference to either of these states, and as a remedy for collapse in cholera, must have been the result of reasoning and reflection, founded on the general principles of the science ; a result highly honourable to the profession ; and, as we shall endeavour to show, of the utmost practical importance in the cure of the disease.' ' Few remedies,' he says, l on a fair trial, have been more generally and unequivocally advocated than free blood-letting ; and the most that has been urged against it is, that it is not always successful.' He then quotes reports from various medical officers, furnishing very striking testimony as to the benefit of blood -letting in cases of extreme collapse. A few of EPIDEMIC DIARRH(EA AND CHOLERA. 109 these may be referred to in illustration of his general remarks. ' Mr. John Wilson, in the case of Mootien, where the pulse had long ceased to be distinguishable at the wrist, abstracted twenty ounces of blood, on the supervention of oppressed respiration. The blood was of the darkest colour, very thick, and was obtained with the greatest difficulty. The patient had been ill about twenty hours ; for at least twelve of these he had remained without pulse at the wrist — that is, from the time he had entered the hospital ; yet, within ten minutes after the bleeding, the pulse was distinguishable : it soon began to rise, and the patient recovered.' ' In the case of Vencanah the pulse had likewise disappeared ; there was deafness, laborious respiration, and every bad symptom ; he was bled to twenty ounces with great difficulty ; the blood was of the darkest colour, and extremely thick. Immediately after the bleeding he breathed much easier, and the pulse, at the wrist, could be faintly felt. The patient recovered.' ' Mr. McCabe, Poonamalee, in the case of Greenfield. This case appeared to be going on well for about twelve hours, when a violent return of symptoms led to the abstraction of twenty ounces of blood, with immediate relief, and the skin became warm, and the pulse stronger.' ' In the case of Howard, — while the pulse was extremely feeble, he was bled to thirty ounces on the occurrence of urgent symptoms, and with immediate relief: three hours after, the pulse was full, and heat of skin nearly natural.' Scot refers to a return made by Annesley, who says — ' In place of syncope being produced by bleeding, in the cases which I have treated the pulse has invariably improved, and the feelings of faintness and debility disappeared' (p. lx.) Abundant evidence of the same kind is contained in 110 THE PATHOLOGY OF Scot's Report ; but it may be well to refer to the reports of some other Indian authors. Bell's testimony is to the following effect (iii. p. 1 1 8) : — 'All who restrict their attention in the treatment of cholera to the discharges and spasms, are in danger of losing sight of the true nature of the disease. They are prescribing for symptoms, which, it will generally be found, at once disappear when the power of circulation is recovered. In fact, the removal of blood to the necessary extent has invariably, so far as the author's experience goes, put an immediate stop not only to spasms and oppression, but to vomiting and purging, and has relieved the prostration of strength. And in no situation has the physician more reason to be proud of his art than when, in the course of a few minutes, a patient, from the agonies of cholera and from the jaws of death, is placed in safety, and not only restored to a sensation of health, but to one of positive bliss.* The effect of bloodletting would indeed sometimes appear almost miraculous. A patient will be brought in on a cot, unable to move a limb, and but that he can speak and breathe, having the character (both to touch and sight) of a corpse, yet will he, by free venesection alone, be rendered, in the course of half-an-hour, able to walk home with his friends.' The following case is briefly reported by Annesley (x. p. 1 60) : — ' Captain M was seized with cholera, and had taken the cholera dose of opium and calomel. When I was called in he complained of severe pain in the bowels, difficulty of respiration, great irritation, and a hurried, feverish pulse. I raised him up in bed, and bled him profusely, till his pulse became regular, low, and tranquil. During the operation he continued to repeat, ' Oh, this is delightful, this is delightful ! — you have saved my life.' In two days he was quite well.' * 'A very common expression on such, an occasion is, ' Oh, Sir, I am in heaven ! ' 111 EPIDEMIC DIARRHCEA AND CHOLERA. One more case of this kind must suffice ; it is a very striking one, reported by Mr. Martin (xi. p. 349) : — 'On visiting my hospital in the morning, the European farriermajor was reported to be dying of cholera. I found that during the night he had been drained of all the fluid portion of his blood ; his appearance was surprisingly altered, — his respiration was oppressed, the countenance sunk and livid, the circulation flagging in the extremities. I opened a vein in each arm, but it was long ere I could obtain anything but a trickling of a dark treacly matter. At length the blood flowed, and by degrees its darkness was exchanged for more of the hue of nature. The farrier was not of robust habit, but I bled him largely, when he whom, but a moment before, I thought a dying man, stood up and exclaimed, ' Sir, you have made a new man of me.' He is still alive and well.' Again I have to ask, is it possible to reconcile the well-authenticated facts — and these are only a few selected from a great number equally decisive — to which I have referred, with the theory that the collapse of cholera results from a loss of the liquid constituents of the blood ? If Mr. Martin's hypothetical statement, that his patient ' had been drained of all the fluid portion of his blood,' were an accurate expression of facts, can we conceive it possible that he could have 'made a new man ' of him by abstracting largely the blood which remained in the vessels ? I put these questions now to those who still believe that a drain of liquid from the blood is the essential cause of choleraic collapse ; I will attempt a solution of the difficulty hereafter. There is yet another mode of treatment, the results of which, as I have observed them, appear to be entirely opposed to the notion that the collapse in cholera is chiefly due to loss of liquid, — I allude to the treatment by purgatives. The earlier Indian practitioners had no such theory as that in question ; they gave purgatives 112 THE PATHOLOGY OF in large doses, and they were satisfied (with good reason, as I think,) that the result was beneficial. At the commencement of the last epidemic I had arrived at the conclusion that the commonly received theory of collapse was not well founded, and I gave purgatives to all the patients who came under my care. The result appears in the reports of the cases. It will be seen that a considerable number of patients who were in a state of collapse when they came under treatment, took repeated doses of castor oil ; they continued to vomit, and had frequent liquid stools ; yet while this drain of liquid was going on, the symptoms of collapse were disappearing. The facts and the hypothesis appear again to be at variance, and it devolves upon those who maintain the theory to reconcile it with the facts. I once heard this particular difficulty explained somewhat in the following manner : — It is quite certain that collapse results from the loss of liquid blood-constituents, therefore the disappearance of the symptoms of collapse is conclusive evidence that the liquid has been restored to the blood. A mode of reasoning which I believe may be designated apctitio principii, or begging the question. A method of treatment which has usually been considered to afford almost conclusive evidence that the symptoms of collapse are due to the deficiency of fluid in the blood consists in the injection of a saline solution into the veins. The idea of restoring to the blood the fluid which it was supposed to have lost first suggested itself to the late Dr. Latta, of Leith. He adopted the practice in a few cases ; and the late Dr. Mackintosh, of Edinburgh (xii. p. 363), during the summer of 1832, injected the veins of no less than 156 patients, of whom only 25 recovered — a result which can scarcely be considered satisfactory. The experiment has since been repeated by different practitioners in various parts of the world — on the continent of Europe, in India, and in 113 EPIDEMIC DIARRH(EA AND CHOLERA. America. A very small proportion of the patients who have been subjected to the operation have recovered, but in most cases the temporary relief has been surprisingly great. The substances injected by Dr. Mackintosh were in the following proportion : — Muriate of soda, Jss., bicarbonate of soda 3iv., water lb. x. This was the proportion of salts used at the commencement of the treatment ; at a subsequent period the quantity of each salt was doubled. The temperature of the solution was from 106 0 to 12O°. The following description of the effects is slightly condensed from the account given by Dr. Mackintosh : — It is remarkable how speedily the injection affects the pulse, making it perceptible, after it had ceased to be felt at the wrist. By the time four ounces were introduced, the pulse could generally be distinctly counted; and when about three pounds were injected, it became a tolerably good one, although it might be still feeble, and perhaps rapid. The effect on the cramps was quite remarkable ; they generally ceased as soon as the pulse became good, and seldom troubled the patient again. The effect on the temperature of the body was also almost instantaneous ; the body, which could not previously be heated, now became warm, and, instead of a cold, damp exudation on the surface, there was a gentle and genial moisture. The respiration, however weak previously, soon became stronger ; it sometimes happened, when about four pounds of the injection were introduced, that the respiration became rather laborious, which generally gave way after more fluid was thrown into the system. The voice, which had been whispering, now became quite natural. In proportion as the pulse and the temperature were restored, so did the countenance improve. The eye, from being sunk, became prominent ; the shrinking of the features, and the dark colour of the face and of the body, generally disappeared ; the expression, in fact, became animated, and the mind lively. The restlessness I 114 THE PATHOLOGY OP and uneasy feelings vanished, and not unfrequently patients sat up in bed immediately after the operation, in perfect possession of themselves, and spoke with joy on the sudden transition from agony and death to happiness and life. The secretion of urine in general soon returned after the injection ; but disappointment was more frequent with regard to this than to any of the other favourable symptoms. Unhappily, in an immense majority of cases, the great relief was of very short duration. It is remarkable that severe rigors almost invariably followed the saline injection ; they generally commenced a few minutes after the completion of the operation, sometimes during its performance. The rapid improvement and the almost equally sudden relapse are graphically described by Dr. Paine (ix. p. 50), as they occurred in the case of a very robust man, ' who was suffering the whole array of symptoms that distinguish the collapsed cholera. The operation was performed by Dr. Depeyre, and the solution injected stood at the temperature of 114 degrees. A thermometer was introduced within his mouth, and the temperature marked at 93 degrees. Three pounds were slowly transfused, and the thermometer had risen to 101^ degrees. All the evident improvement I have noticed above immediately ensued, and the man laughed aloud, from the ecstacy of relief. This man was a corpse an hour after.' There are probably few practitioners who now expect any practical benefit from saline injections in cholera, but there are many pathologists who refer to the results of the experiment as proving conclusively that, since all the symptoms of collapse speedily disappear after the injection of a certain quantity of liquid into the veins, the symptoms which previously existed must have resulted from the loss of a liquid similar in character to EPIDEMIC DIARRHCEA AND CHOLERA. 115 that which the operation restores to the hlood. I believe, however, that the true explanation of the manner in which the saline injections have produced the surprising temporary relief which they are acknowledged to have done, has hitherto been missed ; and that, rightly interpreted, the results of this experiment afford as little support to the hypothesis that collapse depends on loss of fluid, as do the effects of the other modes of treatment to which reference has before been made. After describing the pathology of collapse I shall return to this subject, and I shall then give what I conceive to be the true interpretation of the results of the saline injection into the veins. Sec. IV. The symptoms of Cholera are occasioned by a morbid poison. In the preceding sections allusion has been made to some important facts, in the history of cholera, which appear to be at variance with the hypothesis which assumes that the chief symptoms of the disease are due to the loss of the watery constituents of the blood. It is to be hoped that a consideration of those facts will prepare the reader to give his attention to a theory of cholera which is more in accordance with the phenomena of the disease. To begin, ab ovo, it appears impossible to give any rational interpretation of the phenomena of cholera without assuming the existence of some morbific agent or poison, to whose influence upon the human body the symptoms of the disease owe their origin. The necessity for this assumption is so obvious that almost every author who has written upon the subject has habitually used expressions which imply the adoption of the hypothesis, although it has not always been distinctly enunciated; so that whether the term 'cholera poison,' or 12 116 THE PATHOLOGY OF 1 morbific ' or ' toxic agent,' or ' atmospheric influence/ is used, the same idea is implied, namely, a noxious something which exerts an influence upon the human body. Now, the proofs of the existence of morbid poisons are to be found mainly, if not entirely, in the history of the diseases to which they give rise, and in the impossibility of giving a rational explanation of the morbid phenomena without assuming the existence of some morbific agent. Dr. Carpenter, in his Principles of Human Physiology (p. 201) has so well described the nature of the evidence which we possess, with regard to the existence of morbid poisons, that I venture to borrow his remarks on the subject. He says, 'It maybe admitted that our belief in a specific material cause, for a great many of the effects set down to the influence of morbid poisons, is merely inferential; and there are many persons to whom their exhibition, in a tangible form, seems to afford the only convincing evidence of their existence. But it must be remembered that the evidence of chemistry itself is often purely inferential ; for we recognise the existence of a chemical substance, not merely by obtaining it in a separate form, but by witnessing the reactions which it displays with various tests; and there is one substance, fluorine, which has never yet been isolated, but of whose existence, however, no chemist would hint a doubt. Now, it is the human body which forms the appropriate testing apparatus for morbid poisons ; and even if we could always obtain them in a separate state, and could subject them to chemical analysis, we should know much less of their most important properties than we can ascertain by observation of their actions in the system ; this alone, affording the means of judging of their dynamical character, which is of far more importance than a knowledge of their chemical composition. In the case of those poisons which are capable of being introduced by EPIDEMIC DIARRH(EA AND CHOLERA. 117 inoculation, we have indeed the required proof of their material existence ; and this proof is capable of being extended, by a safe analogy, to infectious diseases generally. For if small-pox can be communicated by the inhalation of an atmosphere tainted with the exhalations of a person already affected with it, as well as by the introduction of the fluid of a cutaneous pustule into the blood of another, it can scarcely admit of a question that the same poisonous agent is transmitted in both cases, although through different media, and that it has as real an existence in the transferred air as in the transferred pus. Diseases, then, which are capable of being transmitted in both these methods, form the connecting link between those resulting from ordinary toxic agents and those which must be assumed to depend upon a subtle poison, of which the air alone is the vehicle, — such, for example, as malarious fevers ; this assumption being required by all the rules of logic, as the only one which will account for the phenomena to be explained, and therefore, possessing a claim to be considered an almost certain truth.' With respect to the poison of cholera, while there are some persons whose scepticism will apparently yield to nothing short of a complete demonstration of its atomic constitution and its equivalent proportions, there are others sanguine enough to hope that a diligent microscopic search may detect it as it floats through the atmosphere. It seems probable, however, that morbid poisons are far too subtle to be detected by such a mode of investigation. I believe that the most careful microscopical examination will discover nothing in the liquid of a small-pox pustule different from the pus of an ordinary abscess ; and it is not probable that the poison of scarlatina will ever be detected in the magnified particles of the scaling cuticle. Yet we may be sure that the poison of small-pox is in some way combined with 118 THE PATHOLOGY OP the pus, and that of scarlatina with the epidermic scales. How, then, can we hope to detect, by similar means, the poison of cholera or of marsh malaria, which cannot be thus circumscribed ? And, moreover, it appears to me, that the anticipation of practical benefit from such a discovery has no foundation in fact or in analogy. We are acquainted with the ultimate constitution of many of the vegetable alkaloids, such as, morphia, quinia, and strychnia ; but this knowledge in no degree assists us to comprehend the physiological or therapeutical action of these agents, or to counteract the poisonous effects of an over-dose. There appears, therefore, no reason to suppose that, even if we were able to isolate and analyse the cholera-poison, we should thereby be better enabled to control its influence on the human body. The evidence as to the contagious nature of cholera is of the most conflicting kind. That, if contagious at all, it is so in a manner and degree very different from such diseases as small-pox and scarlatina must be evident to the most superficial observer ; yet there are many striking facts which appear to show that the disease may be conveyed by means of human intercourse from an infected district to one previously healthy. (See the evidence upon this point in Dr. Baly's Report on the Cause and Mode of Diffusion of Epidemic Cholera.) Now all the evidence which tends to prove such a mode of diffusion is pro-tanto in favour of the existence of a material poison ; yet a complete proof, if such were possible, of the non-contagiousness of cholera would scarcely affect the question of a materies morbi. Ague is, so far as we know, a non-contagious disease, but it would be unreasonable to doubt the existence of the ' marsh-poison.' Henceforth, in describing the phenomena of cholera, the existence of a poison will be assumed, and the 119 EPIDEMIC DIARRHOEA AND CHOLERA. reasonableness of the hypothesis will become more and more apparent as we proceed. Sec. V. — The poison enters the blood, and thus acts upon other parts of the body. There are many facts which tend to prove that the poison of cholera enters the blood, changing the characters of that liquid, and thus acting upon various other parts of the frame. There is reason to believe that cholera and choleraic diarrhoea* may be excited by the inhalation of noxious gases through the respiratory organs. In many cases the symptoms are reported to hare commenced soon after exposure to the foetid effluvia from an open drain or cesspool, or from some other decomposing animal matter. In three of the cases reported in a previous part of this work such appears to have been the origin of the symptoms. In Case 7 (p. 10) the stench of an open drain, in Case 39 (p. 69) the emptying of filthy slops, and in Case 54 (p. 93) the stinking entrails of a hare, seem to have been the exciting cause of the attack. Cases of this kind are of so common occurrence, and are so well known, that it is needless to multiply instances, but the following extract from Dr. Christison (xxxiii. p. 636) may be put in as evidence : — ' Another affection sometimes brought on by putrid exhalations is violent diarrhcea, or dysentery, of which a remarkable instance lately occurred in the person of a well-known French physician, M. Ollivier. While visiting a cellar, where old bones were stored, he was seized with giddiness, nausea, tendency to vomit, and general uneasiness ; and, * It is probable, as we shall see hereafter, that cholera and choleraic diarrhoea are different degrees or stages of the same disease, and that the cause of each condition is identical. 120 THE PATHOLOGY OF subsequently, he suffered from violent colic, with profuse diarrhoea, which put on the dysenteric character, and lasted for three days. Chevallier, in noticing this accident, mentions his having been affected somewhat in the same way when exposed to the emanations of dead bodies; and it is a familiar fact that medical men, who engage in anatomical researches after long disuse, are apt to suffer at first from smart diarrhoea.' Mr. Simon has carried the evidence as to the cause of this diarrhoea a step farther, by stating that when a diarrhoea has been excited by dissecting animals whose flesh has a peculiar odour, this odour may sometimes be detected in the evacuations of the patient (xxxvii. p. 231). Now, if a poison which enters the body with the inspired air through the lungs is eliminated through the digestive canal, it is impossible to conceive for it any other channel of transmission than the blood. Moreover, it has been proved by experiments on the lower animals that many of the symptoms of cholera may be produced by the direct introduction of decomposing substances into the blood. Mr. Lee refers to some observations of this kind (xxxiii.) One experiment is thus described (p. 22) :—: — 'An ounce of fluid, resulting from the fermentation of the leaves of beet-root in about an equal quantity of water, was injected into the jugular vein of a very little dog. At the expiration of an hour the animal vomited ; this was followed by evacuations of the bowels — at first of moderate consistence, but subsequently liquid, and consisting chiefly of mucus. Symptoms of dysentery now made their appearance : there was pain in the stomach upon pressure, difficulty of breathing, and expression of much uneasiness. Three hours after the injection, there were complete prostration of strength, inability to walk or even to stand, and fresh evacuations 121 EPIDEMIC DIARRHOEA AND CHOLERA. of gelatinous mucus, tinged with blood. These symptoms were followed by renewed vomiting of glairy, bilious fluid, and discharge of urine. The fluid evacuations from the bowels were now repeated upwards of five times, and were very foetid, tinged with blood, and black, as if mixed with soot. Under the persistence of these symptoms the strength became greatly impaired : the animal was affected with convulsive twitchings of the muscles, and died eleven hours after the injection.' ' On a post mortem examination, the whole of the intestinal canal was covered with a muco-sanguineous fluid, like the lees of red wine. The mucous membrane was healthy, except in the duodenum, the commencement of the jejunum, and the rectum, where it was of a violet-red colour, and bore marks of having been inflamed in longitudinal ridges.' Similar results followed the introduction of putrid animal matter into the peritoneal cavity of another dog ; and Mr. Lee states (p. 25) that, ' after a putrid element has been introduced into the system, the blood is evidently altered in composition ; — it becomes black, viscid, and in a great measure deprived of its fibrine. After death it is found fluid, of a very dark colour, and not unfrequently mixed with gas.' It is scarcely necessary to remark that this description of the blood is, in almost every particular, applicable to the condition of the blood in cholera. In some cases the symptoms of cholera commence quickly after a meal of indigestible or unwholesome food. During the late epidemic, for instance, two cases were reported as occurring simultaneously in one house, after a supper of crab and cucumber. Cases of this kind have been thought by some pathologists to favour the opinion that the essential cause of cholera is a local irritation of the mucous membrane of the stomach and intestines. But surely such an assumption is not only improbable, 122 THE PATHOLOGY OF but contrary to some well ascertained facts ; for it is in the highest degree likely that some portions of an unwholesome meal quickly find their way into the blood ; and in many instances we have the most conclusive evidence that they do so. For instance, when crab or lobster act as poisons, it frequently happens that, simultaneously with the vomiting and purging to which they give rise, there occurs the most violent eruption of nettlerash on the skin, — the only reasonable explanation of the cutaneous rash being, that it is excited by the irritating particles of the food, which have been conveyed to the skin by the blood. I saw a gentleman last summer, who had vomiting, purging, and nettle-rash after eating salmon. Now, it has sometimes been supposed that the rash in these cases may be the result of a 'sympathy' between the skin and mucous membrane ; but there is nothing to prove that nervous sympathy would be attended with such results ; and certain articles of diet excite nettle-rash in some individuals without any apparent irritation of the mucous membrane. I once had a dispensary patient — a robust stone-mason — who could never eat even the smallest quantity of any of the ordinary kinds of fresh fruit without suffering from a most violent nettle-rash, which produced so much swelling of the face as to close his eyes. Again, when head-ache and other constitutional symptoms are associated with gastric disturbance, as a consequence of errors in diet, it will often be found that the urine contains an excess of urea, and deposits a copious sediment of urates, &c, — the product, as may with reason be supposed, of the illdigested meal, which has thus been eliminated from the blood. It is well known that arsenic produces inflammation of the stomach, even when introduced into the system through the skin ; and it is the general opinion of toxicologists, that arsenic, even when taken into the stomach, EPIDEMIC DIARRH(EA AND CHOLERA. 123 occasions death more frequently through means of its remote effects than in consequence of the local inflammation which it excites in the mucous membrane. Now, formerly there appeared some reason to suppose that the connection between the local and the remote effects of arsenic might be explained by the theory of a nervous sympathy between the tissues primarily and secondarily affected. This theory, however, was superseded by the important discovery of the late Professor Orfila, ' That arsenic is absorbed in such quantity, in cases of poisoning, as to admit of being discovered by an improved process of analysis, in various organs and fluids of the body, such as the liver, spleen, kidneys, muscles, blood, and urine' ( Christison, xxxiii. p. 289). It now became evident that the cramps, and the other nervous symptoms, may be, and probably are, due to the introduction of arsenic into the blood, the physical properties of which are obviously much changed by the action of the poison. The application of these facts to the subject of our inquiry is sufficiently clear. We have seen that many of the symptoms of cholera may be induced by the introduction of putrid matters, either directly into the blood or through the lungs or the digestive canal ; and that in the latter case the symptoms of local irritation are often accompanied by others which indicate that some of the offending matters have entered the circulation. There appears, therefore, good reason to believe — and the analogy of poisoning by arsenic affords strong confirmation of the opinion — that whether an attack of cholera has been excited by the inhalation of foetid effluvia through the lungs, by the imbibition of impure water,* or by a * Dr. Snow has contributed important evidence as to the connection between epidemic cholera and impure water, by showing that in a district on the south side of the Thames, which is supplied by two companies, whose water is of very unequal 124 THE PATHOLOGY OP meal of unwholesome food, in every case the noxious matters enter the blood and change the composition of that fluid. The proofs of this position will be found to accumulate when we come to examine the changes in the blood itself, which are of such a nature as cannot be satisfactorily explained by any merely local irritation of the mucous membrane of the stomach and intestines. » Sec. VI. The symptoms of Invasion indicate a Morbid Condition of the Blood. Evidence as to the introduction of the cholera poison into the blood may be derived from a consideration of the symptoms of invasion. The pathological theories prevalent in this country have resulted in an undue regard being paid to diarrhoea as a premonitory symptom of cholera, and to an almost entire disregard of other symptoms, to which the Indian authorities attach great importance. The symptoms in question are those indicative of general discomfort and derangement of function, particularly affecting the nervous system. The description of these symptoms will best be given in the words of the authors who have most fully described them. Twining says, (v. p. 9,) ' Prior to the more distinct and alarming attack, there are sometimes, for a few hours, and, in some cases, for two or three days, symptoms of indisposition, evident not only to the patient himself, but to his friends. When cholera is raging severely, the disease is often ushered in by diarrhoea ; at other times it begins with catarrh, nausea, degrees of purity, the inmates of the houses which receive the less pure water suffered during the recent epidemic in a much greater degree than the inhabitants of other houses, in the same streets and courts, which are supplied with cleaner water from another company. — On the Mode of Communication of Cholera. By John Snow, M.D. Second Edition. 1855. EPIDEMIC DIARRHCEA AND CHOLERA. 125 and oppression at the scrobiculus cordis, which are not, in an early stage, to be distinguished from the slight indisposition which often precedes fever. The approach of cholera in this manner makes the patient suppose he is feverish or bilious, and if recourse be had to some of the medicines commonly used in slight ailments of that sort, the disease is said to be caused by the dose of medicine taken, when, in fact, it had been insidiously making considerable progress for some hours.' It will be seen, from the following extract, that Annesley attaches great importance to the recognition of the symptoms of invasion (x. p. 20). 'It is a matter of the most serious importance, both as respects the reputation of the practitioner, and the lives of those who come under his care, that the symptoms denoting the invasion of the epidemic cholera be familiarly known to him. From these symptoms lam fully convinced that an experienced and an attentive observer may discover the approaching invasion of the disease, and by having recourse to suitable treatment may prevent it from assuming that degree of severity which it inevitably would assume if it were left uninterfered with, even for a few hours.' 'A practitioner possessed of true professional tact will discover in the countenance of the patient the earliest changes which mark the approaching invasion of cholera. The features are expressive of something approaching a state of anxiety, although the patient himself may not be aware of his state, or even that he is at all ailing. If the medical attendant inquire how he feels at this time, he generally answers ' Very well ;' but if pressed upon the subject, he acknowledges that he experiences feelings which he cannot distinctly describe, though he feels neither pain nor sickness. His spirits are, however, low, and there is sometimes a clammy moisture on the 126 THE PATHOLOGY OF skin; and the pulse, though occasionally full and strong, is sometimes oppressed and labouring. ' I could adduce many instances wherein a close attention, paid with the express purpose of discovering and observing this stage of the disease, has led to the adoption of measures which have had the best effects, as respects both its subsequent severity and the recovery of the patient ; but this is unnecessary, the necessity of closely watching for and of paying unremitting attention to this stage of the malady being sufficiently obvious.' Annesley gives an extract from the letter of ' a zealous and intelligent medical officer,' who insists on the great practical importance of this subject. Referring to the purging, vomiting, and spasms, his correspondent says, (p. 24), ' I am so thoroughly convinced that these symptoms are only secondary, that were the following marks present, I should not hesitate to pronounce the case one of epidemic cholera. 1 As the patient is approached, an appearance of overpowering lassitude is at once perceived, with a pallid, anxious, and sorrowful cast of countenance; and in more advanced stages the countenance is dejected and sunk. Here allow me to remark that this peculiarity of countenance was so very obvious to every intelligent person, that many of the officers deserve my best thanks for bringing to my notice those who assumed this oppressed appearance. ' My object being merely to point out early symptoms, you will grant me the use of the patient's own words : — ' I must knock off work ; I feel unable to do more, but don't know what is the matter. I have only a little pain in the stomach and rumbling in the guts.' These are the patient's own words ; sighing, peevishness, and uneasiness accompanied these complaints.' He then reports a case in the following terms : — 'July 4th, 1831, ten o'clock, a.m. Robert Smy came 127 EPIDEMIC DIARRHCEA AND CHOLERA. in the manner above described : I purposely neglected him, but I kept an attentive eye upon him, often passing his berth and asking him how he was, feeling confident that cholera would be the result. One experiment of this kind was quite enough, and it was a sufficient warning to my assistant and myself to attend to the early symptoms. The patient was saved, but with much difficulty. At eight o'clock, p.m., I was sent for, and found him vomiting, and affected with spasms. His pulse was feeble and his spirits low. He considered himself as having been neglected, and refused to take medicines. Nine hours had elapsed from the appearance of the premonitory symptoms until purging, vomiting, and spasm appeared.' Bell's description of the symptoms which indicate the invasion of cholera is essentially the same as Annesley's; and Dr. Paine, whose experience was obtained in New York, says (ix. p. 20), 'Diarrhoea and vomiting do not always distinguish the premonitory stage ; but it is sometimes denoted only by head-ache, loss of appetite, oppression at the chest, &c. ; and again, spasms are known to have been the earliest symptom, and, at first, the only prominent one.' Orton mentions vertigo, tinnitus aurium, and headache as being, in many cases, the first symptoms (iv. p. 89); and he considers that 'these facts are in support of the opinion that the brain is the principal seat of the disease.' It appears, however, more probable that the nervous symptoms result from the entrance of the poison into the blood, and the consequent changes in that fluid. Mr. Grainger, in his Report (xxxii. p. 103), states that 'it was the result of a cautious investigation instituted at the General Hospital at Hamburgh into the history of between three and four hundred cases of developed cholera, that the attack was, in many cases, 128 THE PATHOLOGY OP preceded by depression of spirits, loss of appetite, uneasiness about the bowels, and an inclination to go to stool, but without effect ; dizziness, noises in the ears, and other disturbance of the sensorium ; oppression at the prsecordia, the person often waking up with the feeling of want of breath ; nightmare and frightful dreams were often experienced ; one premonitory sign was an uneasiness in the legs, with slight twitching or spasms, which, for the most part, closely preceded the profuse evacuations, and evidently indicated the approaching cramps. This peculiar twitching was often observed in London during the late and previous epidemic, especially in those districts where the disease was severe.' Mr. Grainger adds, 'Itis an interesting point, pathologically, that these slight cramps which, like the other symptoms were not, of course, always followed by collapse, often occurred without being preceded or accompanied by diarrhoea ; a circumstance which tends to show that the violent cramps and spasms accompanying the profuse discharges in collapse do not depend on these, but rather on the morbid quality of the blood deranging the force of the spinal cord.'* * It may be a question whether the morbid quality of blood which excites the cramps and spasms during life, is also the cause of those muscular contractions which sometimes occur after death to such a degree as to excite movements in the limbs of the corpse. But that these movements after death from cholera are occasioned by the altered qualities of the blood acting either through the nerves or directly upon the muscular tissue, is rendered probable by Blake's observation (xxxi. vol. lvi., p. 113) that when a dog has been killed by the injection of a salt of lead, baryta, or strontia into the veins, muscular contractions always occur for a considerable period after death. Sometimes the contractions occur simultaneously in different sets of muscles, while at other times they are confined to one set. The force of contraction is sometimes so considerable that the posterior part ot" the trunk has been moved by the contractions of the hinder muscles, and on two occasions the body was pushed away when a point d'appui was furnished for the sole of the foot. Blake's observations were made without any thought of the post-mortem EPIDEMIC DIARRHffiA AND CHOLERA. 129 These nervous symptoms, which often attend the invasion of cholera, appear to he strictly analogous to those which mark the commencement of other zymotic diseases, — as, for example, the eruptive fevers. The formidable nervous symptoms which occasionally precede the eruption of small-pox afford a good illustration of the degree in which the functions of the nervous system may be disturbed by a morbid poison in the blood, as well as of the speedy removal of those symptoms by the elimination of the poison. The symptoms of general disturbance which mark the invasion of cholera did not escape the observation of my clinical clerks, whose reports show that some of these symptoms were present in a considerable number of cases. I may refer particularly to Case 19 (p. 34), in which the patient describes ' the dreadful sense of oppression' which he experienced at the commencement of the attack. In Case 16 (p. 26), the patient 'did not feel quite well' during the day on the evening of which the vomiting and purging began. In Case 17 (p. 29), giddiness, nausea, and vomiting occurred several hours before the commencement of purging. Tinnitus aurium was present in nearly every case. In most cases it probably happens that the patient is not seen by the medical attendant until the symptoms of invasion have been succeeded by vomiting and purging ; and this is the more likely to occur when the attack takes place, as it so frequently does, during the night. Yet it is probable that if these symptoms had been as constantly and perseveringly inquired for as the, socalled, premonitory diarrhoea, they would be found to be rarely absent. The recognition and the right appreciation of these symptoms is obviously of much import- movements in cholera, but I have referred to them in this place as they afford some confirmation of the hypothesis of a morbid poison being the essential cause of the disease. X 130 THE PATHOLOGY OP ance, not merely with reference to the pathology of cholera, hut also on account of the timely warning which they may afford of the approaching mischief. Sec. VII. Analogy hetiveen the effects of the cholerapoison and those of some animal-poisons. In some of the worst forms of cholera the period of invasion is one of short duration, and the most urgent symptoms come on with terrible celerity, but even in these cases the action of the morbid poison is less rapid than in the case of some animal poisons, which obviously enter the blood, and sometimes destroy life by changing the composition of that fluid. Several of the Indian practitioners appear to have been struck by the analogy between the effects of the cholera-poison and the symptoms produced by snakebites. Orton has the following observations on this subject (iv. p. 142) : — ' The poison of snakes and other venomous animals, introduced into the system by a wound, produces effects very similar to cholera, although some of the more prominent symptoms of the disease, particularly the purging, are not usually mentioned in the accounts which are given of them. But two cases are related at p. 107 of the eighth volume of the Philosophical Transactions, which were characterised by vomiting, purging, and excessive debility, arising from bites of the viper.' He gives a case in which the sting of a scorpion was attended with fatal results (p. 144) : — 'A sepoy under my charge, several years ago, was stung in the foot, and shortly afterwards attacked with vomiting, purging, coldness, extreme debility, and all the principal symptoms of the present epidemic. He died in less than twenty-four hours from the accident ; and the case was reported under the head of cholera.' EPIDEMIC DIAKRH(EA AND CHOLERA. 131 In the year 1843, when I was house-surgeon of King's College Hospital, I admitted a man thirty-three years of age, who, two days previously, had heen bitten in the hand by a viper. It will be seen from the history of the case, which I extract from my notes made at the time, that the symptoms bore a more striking resemblance to those of cholera than even in the cases referred to by Orton. He was admitted at four p.m., on Sunday, May 14th. On the previous Friday afternoon he was in the country, and caught an adder, which in its turn, bit his right thumb. The thumb and back of the hand began to sweli immediately, and were very painful, and in the course of an hour he ' felt as if he should die ;' he could not stand, he vomited, and was purged many times ; he shivered very much, felt pains all over him, his breathing was very rapid, and attended with so much pain as to make him cry out, and his tongue was so much swollen that he could not speak intelligibly. In about two hours after the bite, a doctor gave him some medicine, which afforded him great relief; he felt stronger, the purging and vomiting ceased, and the swelling of the tongue subsided in about half-an-hour after taking the first dose. He thinks he should have died but for this. (Thinking that the medicine might be sulphuric ether, I gave him some to smell, and he feels certain that it is the same medicine as that which he took). The hand and arm continued to swell during the night, and the report states that, ' he was unable to pass his water on Friday, after the bite : he tried as many as ten times in the course of Friday night, but did not pass more than a few drops at a time ; the strangury continued until yesterday (Saturday) morning, when he passed about threefourths of a pint ; there was nothing peculiar in its appearance, except that it was very yellow, ' as yellow as gold.' ' At the time of his admission all constitutional symp- k2 132 THE PATHOLOGY OP Toms had subsided, but his right arm was twice the size of the other, and the skin yellow and blue with ecchymosis; the swelling soon subsided under the influence of fomentations, and he left the hospital well, on the eighth day after his admission. In this case, then, there was not only vomiting, purging, and great prostration, with dyspnoea, but also suppression of urine; so that there appears much reason for the remark of Mr. Coates, who, according to Orton (iv. p. 142), in a report to the Medical Board of Bombay, observes, ' I should have pronounced that some of my patients (with cholera) had been labouring under snake-bites, had I not been better informed.' The results of some experiments with the poison of snakes, which were performed by Dr. John Davy, possess considerable interest in connection with the pathology of cholera. He thus describes the symptoms produced in a hen by the bite of the hooded snake (naia tripudiens), (xiv., vol. 1, p. 114) : — 'At the moment (after the bite), the hen appeared to be but little affected ; she seemed rather uneasy and restless, and was every now and then pecking the part bitten. Some corn being thrown on the ground, she ate only a very little ; in two hours she was worse, but even then the action of the poison was not apparent from any remarkable symptom — merely from a certain degree of debility and languor, indicated by her being easily caught, and by her crouching when not disturbed. There was no swelling or appearance of inflammation round the punctured wound. Her temperature ascertained before the experiment, and now by the thermometer in cloaca, was found to have fallen from 109 0 to 108 0 . In four hours she was much worse ; her breathing had become quick and laborious ; venous blood seemed to predominate in the circulation ; the comb was bluish and turgid ; there was very great prostration of strength ; she was 133 EPIDEMIC DIARRHOEA AND CHOLERA. unable to stand ; the sensorial functions were not apparently deranged ; the pupil was rather dilated than contracted ; there were no convulsions, no rigors ; several liquid dejections occurred, and some watery fluid was thrown up. Her temperature was now reduced to 106 0 . She expired eight hours after she was bitten.' There are many points of resemblance between the symptoms thus described by Dr. Davy and those which occur in cholera, and it is particularly interesting to observe the gradual invasion of the more serious symptoms, indicating, as may be supposed, a slow but progressive change in the animal's blood. From the general resemblance, therefore, between the symptoms of cholera and the effects of animal poisons, which enter the blood and change its vital properties, we might infer, with a considerable degree of probability, that the cholera-poison enters the circulation and operates in an analogous manner. And the reasons for such an inference will be found to increase when we have made a minute examination oi the changes in the blood and other parts, induced by the cholera-poison. Sec. VIII. Condition of the blood in Cholera. The physical and chemical characters of the blood in cholera have been examined with much care by O'Shaughnessy (xvii.), Parkes (i.j, Garrod (xv.), Schmidt (xvi.), and others. A full abstract of the results obtained by various observers will be found in Dr. Gull's Report (vii.) . The following general statement is derived chiefly from Dr. Garrod's review of the results of his own inquiries (xv. p. 432) as compared with those of previous observers. All recent observations agree with those formerly made, and indicate that from the commencement of the disease the blood becomes more tenacious, of a 134 THE PATHOLOGY OF darker colour, with less disposition to coagulate, and that its specific gravity is greatly increased. According to Becquerel and Bodier, the maximum specific gravity of the Mood in the healthy male is 1062, and in the female 1060. In cholera cases Dr. Garrod found the specific gravity in adult males to be, in round numbers, 1076 and 1081, and in females 1068, 1074, and 1076. There is a diminution of the watery portion, and a corresponding increase of the solids. The blood-globules are in excess, being as high as 166 and 171 in 1000 parts, instead of 140, which is considered a high healthy average. As to the fibrine, it is either reduced in quantity or so changed in quality that after a time it can no longer be collected by coagulation. The density of the serum is increased. Healthy serum being of specific gravity 1028, it was found in cholera to be 1039 and 1041. The albumen is increased The salts of the blood are relatively to the other constituents in excess. This result is in opposition to the conclusions of Dr. O'Shaughnessy (xvii.), who believed that there was a deficiency of the salts. Of necessity the total amount of salts is lessened, but so also is the total bulk of the blood. The blood tends to lose its alkaline reaction, and becomes neutral, or even acid, — a result which is probably due to the impeded excretion of organic acids, which are constantly being formed in the system. Urea usually exists in increased quantities in cholera blood ; but the amount differs considerably in the different stages of the disease, being but small in quantity in the intense stages of collapse, increasing during reaction, and in excess when consecutive febrile symptoms are associated with a defective excretion by the kidneys. Dr. Garrod's explanation of the variable proportion of urea, according to the stage of the disease, is in all probability correct. He says — ' I should imagine that in intense and sudden collapse, not only is the function of the urinary excreting organ 135 EPIDEMIC DIARRHCEA AND CHOLERA. diminished or suppressed, but also the vital metamorphoses and therefore the formation of urea are likewise suspended. This would account for the small amount usuallyfound in collapse, and probably the quantity varies inversely with this state ; but when partial reaction ensues and the vital changes take place with greater activity, should the function of the kidney not be at the same time restored, urea must accumulate in the blood, and the amount must depend on the degree of reaction (febrile or not) and the extent of suppression of the urinary secretion.' With respect to the composition of the blood in ordinary diarrhoea, Dr. O'Shaughnessy states, that in all the cases he had an opportunity of examining, amounting to seven in number, the various constituents of the blood preserved their normal proportions (xvii. p. 71). Now, the explanation which is usually given of the increased density of the blood in cholera is, that it is due to the loss of fluid by the intestinal canal, and in order to account for the different results of this drain, in cases of cholera and in bilious diarrhoea, it is assumed that in the former class of cases the endosmotic, or absorbing power is suspended, while in the latter it is unaffected. This is the explanation adopted by Dr. Garrod. He makes, however, the important admission, that, according to his experience, ' the amount of intestinal evacuations, in any case, is by no means an indication of the extent to which the blood has become altered.' Now, in the present stage of our inquiry, it may be stated that there appear two reasons for doubting the complete accuracy of the received explanation of the dense and thickened condition of cholera blood; one being the fact admitted by Dr. Garrod, that there appears to be no constant relation between the degree of change in the blood and the amount of intestinal evacuations, and the other the different results of the drain in oases of 136 THE PATHOLOGY OF cholera and in bilious diarrhoea, — a difference which cannot be satisfactorily explained by the entirely hypothetical statement that in one case the power of absorbing fluid is retained, while in the other it is lost. And here it is not without interest to remark that the fact of the want of relation between the loss of fluid and the degree of change in the blood appears to have a peculiar significance when taken in conjunction with another class of facts before referred to — namely, the want of relation, or rather, as it would appear, the inverse ratio between the degree of collapse and the amount of vomiting and purging. That the loss of water by the bowel must have some influence on the composition of the blood it would be unreasonable to doubt, but is there not some other coexisting cause for the striking changes in the physical and chemical characters of that fluid ? We shall reply to this question hereafter. Sec. IX. Physical and chemical characters of the intestinal discharges. The general physical characters of the intestinal discharges are well known, but there are some varieties which are not noticed by most writers on the subject of cholera. The most frequent appearance of the stools during collapse, is that of the characteristic ' rice-water,' namely, a colourless, rather turbid fluid, in which there are suspended a variable number of white flocculi. The relative proportion of the solid and liquid constituents varies considerably, in some cases the stools apjjearing to consist of nearly pure water ; and it is probable that when the patient drinks water copiously, without vomiting, this liquid dilutes the stools. In other cases, the stools, especially those which are brought away by an 137 EPIDEMIC DIARRHOEA AND CHOLERA. aperient, after the acute watery purging has ceased, have the appearance and consistence of jelly, or blanc-mange (see Cases 36, p. 63, and 40, p. 70). In some cases the earlier stools have very much the colour of porter (see Cases 5, p. 7, 35, p. 60, 37, p. 65, and 38, p. 67). Dr. Mackintosh (xii. vol. i. p. 338) compares these stools to the lees of port wine, and he remarked that almost none recovered who had the ' port wine stools.' Two out of the four patients under my care, -who had stools of this character, recovered. It is probable that the colour depends on the admixture of blood, but I did not ascertain by chemical or microscopical examination that such was the fact. Sometimes the stools have a pink tinge (see Cases 9, p. 13, and 35, p. 60). Both the cases in which these stools occurred, were fatal. In the second of the two cases (No. 35) the ' port wine stools ' occurred during the early period of collapse, and the pink stools during reaction. No blood corpuscles were visible in the pink stools of either patient, and it is probable that the colouring matter having become disintegrated in the vessels, escaped together with the albuminous constituents. The pink fluid was highly coagulable by heat and nitric acid. The high coagulability of cholera stools is, however, a rare exception to a general rule ; and though it is the custom to describe the cholera stools as ' serous,' yet it is, as Dr. Parkes observes, ' incorrect to speak of the cholera fluid as the serum of the blood ; the fluid is derived from the serum, but is not composed of all its ingredients ; it consists of its water, and of its salts, ivith a very small proportion of its organic elements.' The high specific gravity of the blood serum, is obviously, therefore, in part due to the escape of its water, while its albumen is retained in the vessels. The following table, extracted from Dr. Parkes's paper 138 THE PATHOLOGY OF (xviii.) shows the specific gravity and the proportion of the'chief constituents at different periods of the disease. Period of disease ~ •« Albumen Extractive Soluble Total of in which the p .. in in salts in solids in stool was passed. *' iooo parts. 1000 parts, iooo parts, iooo parts. Diarrhceal period 1012.9 0.466 3.846 9-°4 1 3-° Diarrhceal period 0.29 6.82 5-99 1 3- r Early algide stage 1009 2.4 1.27 10.98 14.65 Developed and j intense algide stage . . . 1009.5 1. 18 0.55 9.14 10.87 Developed and intense algide stage . . . 2.186 7.52 9.706 Developed and moderate ditto ¦ 1008.3 0.27 2.23 8.33 10.83 Developed and ! moderate ditto 1005.8 3.2 5-827 8.947 Commencement of reaction. . , 1014.0 20.84 6.34 27.18 Commencement of reaction. . 1008.91 1.48 6.055 9.085 16.62 Relapse .. . . 1017.83 0.855 17.355 1.821 Relapse . . . ¦ - 4.589 3.881 8.47 It appears from these ohservations that there is no essential difference in the composition of the stools during the various stages of diarrhoea, collapse, reaction, and relapse, hut that the amount of organic matter is greatest during the period of reaction. The greatest amount of the albumen is, as Dr. Parkes observes, ' very trifling ;' in fact, it is probable that many patients, with some of the forms of Bright' s disease of the kidney, pass as much albumen with the urine in the course of twelve hours as most patients in the collapse of cholera lose during the same period by the intestinal canal. And the term 'serous haemorrhage' appears to be just as much applicable to one case as to the other. The soluble salts of the cholera stools consist of the chlorides, phosphates, and sulphates of soda and potash. The reaction of the fluid is alkaline or neutral. 139 EPIDEMIC DIARRHCEA AND CHOLERA. In some cases a pink or violet tint is produced on the addition of nitric acid, a result which is probablydue to the presence of bile in minute quantities. In one analysis Dr. Garrod observed faint traces of uric acid, but neither he nor Dr. Parkes could detect this substance in other specimens of the stools. No trace of urea was found by these observers in any specimen. Schmidt accounts for the absence of urea by its rapid decomposition into carbonate of ammonia, the presence of which, he says, often produces slight effervescence, when nitric acid is added (Dr. Gull's Report, p. 37). With respect to the physical characters of the intestinal discharges, they are usually, as has already been stated, quite colourless until they become tinged by the returning secretion of bile ; and they have frequently been described as being odourless. I am at a loss to understand how this notion could have originated, for unquestionably it is, so far as my experience goes, without foundation in fact. The odour of the rice-water stools is certainly not fseculent, but it is quite peculiar, and extremely disagreeable. Dr. Mackintosh compares it to the odour produced by macerating fish in water, and the comparison is not an inapt one. It is so strikingly peculiar that it alone would suffice for the diagnosis of cholera. It is evidently in the solid portions of the stool that the odour chiefly resides, for it is more intense in proportion to the number of flocculi, and it is especially developed in the flaky gelatinous stools before referred to. One reason of this probably is, that this more solid portion having remained for some time in the bowel, after the escape of the liquid, has undergone more or less of putrefactive change. There appears good reason to believe that the removal from the bowel of matters so highly offensive, must be essential for the patient's safety. 140 THE PATHOLOGY OF The microscopical characters of the stools will come under consideration hereafter, in connexion with the pathology of the intestinal discharges. Sec. X. Pathology of the stage of Collapse. After the consideration which has been given to the various subjects which have passed under review, we are prepared to inquire, whether the essential symptoms of cholera — the symptoms of collapse — admit of an explanation which shall be at once intelligible and consistent with the well-ascertained facts of the disease. In attempting such an explanation, I purpose to defer for the present the consideration of diarrhoea, whether as a distinct disease or as an earlier stage of cholera, and to confine my attention to the symptoms of collapse. These symptoms are so well known as to need no minute description. The most important of them are coldness and blueness of the surface; great diminution of the volume and force of the pulse; shrinking of the tissues, and especially collapse of the features, with sinking of the eyeballs ; more or less of difficulty of breathing, with a short, dry cough ; feebleness of the voice ; coldness of the tongue and breath ; burning heat in the epigastric region; great thirst; suppression of bile and urine ; vomiting and purging of a rice-water fluid ; torpor and drowsiness in a variable degree, but without delirium ; cramps in the muscles. Most of these symptoms are present in every case of collapse j some, however, may be absent. We have now to consider in what way these symptoms are connected with each other, and how they originate. Now, I trust to be able to prove that the function of respiration is that which is first and most seriously affected during this stage of the disease. The symptoms EPIDEMIC DIARRHCEA AND CHOLERA. 141 indicating a disturbance of the respiratory functions are so striking that they could scarcely escape the notice of the most superficial observer ; and most writers on cholera have directed more or less attention to this part of the subject. It can be shown by evidence of the most conclusive kind, that in every case of cholera* the passage of blood through the lungs from the right to the left side of the heart is in a greater or less degree impeded. We have now to establish the fact of there being an impediment to the passage of blood through the lungs ; and having done so, to ascertain its cause and to indicate its consequences. The fact of there having been an impeded pulmonary circulation during life is indicated by the appearances discovered in the heart, blood-vessels, and lungs, after death. An empty condition of the left cavities of the heart and of the arteries, together with great fulness of the right side of the heart and of the veins, is acknowledged to be nearly conclusive evidence that the blood has been arrested in its passage through the lungs. Now, such a condition of the heart and blood-vessels in subjects dead from cholera, has been described with more or less distinctness by several authors, but by no one, I believe, with so much care and precision as by Dr. Parkes, to whose facts and inferences I shall now make frequent reference ; and this not only as an act of justice to that gentleman, but because the evidence which he has furnished is, up to a certain point, more complete than can be found elsewhere. In the great majority of cases Dr. Parkes found the right side of the heart and the pulmonary arteries filled, and in some instances distended with blood, while the * It will be understood that the word cholera in this chapter is synonymous with collapse. 142 THE PATHOLOGY OP left cavities of the heart were generally empty, or contained only a small quantity of dark blood, the auricle being partially, and the ventricle completely and firmly contracted: — 'On cutting through the roots of the lungs, a quantity of blood usually escaped from the divided vessels, and particularly from the pulmonary artery. In one case the quantity of this was two pints, in one case one pint, in one twenty-four ounces, in one eight ounces, in one six ounces, in nine between two and five ounces, &c.' (i. p. 14). The tissue of the lungs was, in most cases, of pale colour, dense in texture, and contained less than usual, both of blood and air. 'In fourteen cases the lunars were completely collapsed, appearing in some cases almost like the lungs of a foetus. In three cases they were considerably, and in eight cases they were slightly collapsed; and in the remaining fourteen cases the collapse was in some cases altogether, and in other cases partially prevented by old adhesions' (p. 16). The deficiency of blood in the texture of the lungs is shown by their weight, as compared with that of the lung in the normal condition. The average weight of the right lung in twenty-two Europeans was fourteen ounces, while that of the left was twelve ounces and six drachms. If, therefore, ' the average weight of both lungs in adult males be considered to be forty-six ounces, according to Dr. Clendinning, or forty-three ounces, according Dr. Reid, then the diminution in the case of both lungs in cholera will be seventeen or twenty ounces' (p. 13). The small quantity of blood in the minute vessels was also shown by the slight loss of weight consequent on incising, washing, and draining the lung. ' The loss of weight was only siij. on an average of thirteen cases' (p. 15). In consequence of the ' singular deficiency of air in 143 EPIDEMIC DIARRHOEA AND CHOLERA. the tubes and cells, there was a partial or complete want of crepitation when the pulmonary tissue was compressed. In twenty-four cases the crepitation was totally abolished; in fifteen cases it was notably diminished in some part of the lung, and in one of these cases abolished completely in the upper lobes. The want of air was not owing to mechanical impediment, as, on artificial respiration, air passed readily in, distended the before collapsed lung, and partially or wholly restored the crepitation. This I proved by many trials' (p. 17). 'The lung, although apparently denser than usual, floated in water, was not granular, did not break down under the finger, and, in fact, its condition was very different from the stages or the results of pneumonia' (p. 18). ' The colour of the lung, both on the surface and on section, varied considerably. In many cases it was dark on the surface and pale on section ; in some it was dark throughout ; in the most collapsed cases it was generally pale, becoming red on exposure to the air' (p. 18.) And not only did the colour ' become redder on exposure to the air, but on inflation it became vividly red. In every instance in which this process was used, the pale lung became redder, and the dark lung lighter in colour' (P- 19)- With respect to the extremely anaemic condition of the lung when death has occurred during the stage of collapse, there is an entire agreement amongst those authors who have most accurately described the postmortem appearances. My own observations, although made with much less attention to detail than those of Dr. Parkes, are in strict accordance with his. There is something surprising, as Briquet and Mignot observe, (xxx. p. 415), in the contrast between the almost constant occurrence of this extremely anaemic condition of the lung, from which scarcely even a few drops of blood 144 THE PATHOLOGY OF flow when the tissue is cut, and the hypersemia of most of the other viscera. Magendie has proved that the hlood-vessels of the lung are free from any deposit which would ohliterate their cavities and so arrest the Mood, hy demonstrating that water, injected into the pulmonary artery after death, passes readily through the vessels into the left side of the heart' (vi. p. 103). In a subsequent chapter of his treatise, Dr. Parkes attempts an 'hypothetical arrangement of the phenomena,' and after alluding to the post-mortem appearances abovementione — the contracted condition of the left cavities of the heart, the distension of the right cavities and pulmonary artery, and the deficiency of air and blood in the minute texture of the lungs — he says (p. 104), ' The conditions of the heart and lungs seem to point out unequivocally that in cholera the blood does not pass (freely) through the lungs ; and this agrees with the independent inference drawn from the symptoms, that the essential signs of loss of animal heat, embarrassment of the respiration, and gradual arrest of circulation are produced by some aberration of, or impediment to, the proper respiratory changes.' Then after alluding to the chief symptoms of the disease, he arrives at the following conclusion : — ' As, therefore, the mechanical part of the respiration is perfect, and as there is no impairment in the voluntary command of the respiratory muscles, and as the heart evidently beats, in many cases, till stopped by the want of blood on the left side, and by its accumulation on the right side, we are compelled to look for the cause of such arrest of circulation in the only remaining element of respiration, namely, in the blood itself. So far the induction appears to me authorized and legitimate; beyond this, it is doubtful and obscure' (p. 107). Before attempting to carry the induction beyond the 145 EPIDEMIC DIARRHCEA AND CHOLERA. point to which it has been brought by Dr. Parkes, it may be well to allude briefly to certain phenomena in the living subject which afford confirmatory evidence that the pulmonary circulation is impeded in the manner described. The smallness of the volume and force of the pulse in the arteries during collapse has very commonly been attributed to the diminished power of the heart. We have seen, however, that the pulse often improves very rapidly under the influence of venesection, and that stimulants do not affect it, as they should do, if the character of the pulse depended on a condition allied to syncope. Now an impeded circulation through the lungs, resulting in a very scanty supply of blood to the arteries, would account for the character of the pulse in cholera ; and this explanation, too, is quite consistent with what is known of the influence of venesection and alcoholic stimulants, as we shall endeavour to show hereafter.* Another appearance which receives explanation from the small stream of blood in the arteries, is that of the shrinking of the integuments, and especially the collapse of the features and the sinking of the eye-balls. The eye-balls of a patient in deep collapse are often as much sunk as those of a corpse, and the chief cause of this appearance in both cases is the more or less complete emptiness of the branches of the ophthalmic artery. If any one doubts the sufficiency of the explanation, let him inject the ophthalmic artery of a corpse while the eye is in situ, and he will find that a moderate distension of the artery renders the eye-ball as prominent as in the living subject.f * Dickson explains the character of the pulse during collapse by an impeded flow of blood through the lungs, which he supposes to result from paralysis of the pneumo-gastric nerve. — (liv. p. 30.) f I find that Magendie, in 1832, (vi. p. 54), attributed the col- L 146 THE PATHOLOGY OP That the arterial stream during collapse is reduced to a minimum is proved by the fact that arteries of considerable size have been opened during life without the escape of more than the smallest quantity of blood. Magendie states (vi. p. 21, and xix. vol. 3, p. 116) that on one occasion he cut across the temporal artery of a patient in collapse and no blood escaped — (' II ne s'ecoula pas une goutte de liquide). And still more remarkable is a statement by Scot (ii. p. xxx.), to the effect that a surgeon, ' despairing of other means, cut down upon the brachial artery, but so completely had the circulation failed that no blood flowed.' While, therefore, the character of the pulse, the collapse of the features, and the occasional absence of haemorrhage when an artery has been wounded, are explicable on the supposition that the arteries receive a very scanty supply of blood, these phenomena afford evidence confirmatory of that derived from post-mortem, appearances that the passage of the blood from the right to the left side of the heart is in some way impeded. The question then arises, what is the precise point at which the pulmonary circulation is impeded ? Does the impediment occur in the arteries, in the veins, or in the capillaries of the lung, — and what is the cause of the impediment ? These are questions which admit of a tolerably satisfactory answer. The evidence upon which the solution of the problem depends is deduced from certain well-established facts and principles, to which I must beg the careful attention of my readers before I come to the immediate subject of inquiry. The researches of modern physiologists and pathologists tend to show with more and more distinctness the great importance of a fact recognised by Haller (xx.), that the lapse of the features to the small quantity of blood in the arteries, but he erroneously referred this latter condition to a loss of power in the left ventricle. 147 EPIDEMIC DIARRHOEA AND CHOLERA. circulation of the blood is influenced not only by the contractions of the heart and the large arterial trunks, but also by a power which resides in the most minute blood-vessels. The fact that the minute bloodvessels exert an important control over the movements of their contents may be demonstrated by the aid of numerous and unquestionable facts ; and first I shall refer to the phenomena of asphyxia. It is well known that when an animal is killed by any of those means which cut off the supply of atmospheric air, there is found, after death, a great accumulation of blood in the veins and in the right cavities of the heart, while the left side of the heart and the arteries are comparatively empty. Dr. John Reid has performed some experiments which throw considerable light upon the phenomena attending this mode of death, and which have an important bearing upon the subject of our present inquiry. The report of these experiments is contained in his essay On the Order of Succession in ivhich the Vital Phenomena cease in Asphyxia (xxi. p. 17) ; and the following is an abstract of the facts and the inferences which he deduces from them : — When the trachea of a dog has been obstructed by turning the stop-cock of a tube previously inserted therein, the respiratory functions are of course suspended, and dark blood, which is at first transmitted freely through the lungs, reaches the left side of the heart, and is thence distributed through all the textures of the body. As the blood becomes blacker and assumes more of the venous character, its circulation through the vessels of the brain deranges the sensorial functions and rapidly suspends them, so that the animal becomes unconscious of all external impressions. For a period of about two minutes after the animal has become insensible, and when the blood in an exposed artery appears equally black with that in the accompanying vein, the large arteries become more distended than L 2 148 THE PATHOLOGY OP before the air was excluded from the lung by the closure of the tube in the animal's trachea. If now a hamadynamometer* is placed in the femoral artery of one limb, and a similar instrument in the corresponding vein of the other, the former indicates an increase and the latter a diminution of pressure, as compared with that observed in the same vessels before the air was excluded from the lungs. It is evident, therefore, that the black blood meets with some impediment to its passage from the arteries into the veins. At the expiration of the time before mentioned — viz., about two minutes, the instrument in the artery indicates a diminution of pressure; the mercury at first falling slowly, and then very rapidly, in consequence of the continually increasing impediment to the flow of blood through the lungs, and the small quantity which is sent into the arteries. If now the stopcock be opened, so as to admit air into the lungs, the blood, which had become nearly stagnant, is instantly transmitted, and the instrument in the artery again indicates an increased pressure upon the walls of the vessel. Now, we learn from these experiments, that when the air is excluded from the lung, black blood passes into the arteries, poisons the brain, is impeded in its passage from the arteries into the veins, and finally is arrested in the lungs ; and on examination after death the right side of the heart, the veins, and the pulmonary arteries, are full of black blood, while the left side of the heart and the aorta are empty, or nearly so. The lungs are of a deep purple colour, from the large quantity of blood * The heemadynamometer, or blood-power-measurer, is an instrument invented by Poiseuille, and since somewhat modified and improved by Volkman, for measuring the pressure of the blood in the arteries and veins. For a good description and representation of the instrument see Todd and Bowman's Physiological Anatomy and Physiology of Man, p. 360. 149 EPIDEMIC DIARRHCEA AND CHOLERA. contained in their minute vessels, and the air-cells are often filled with frothy serum. It will he seen that the points of agreement hetween the post-mortem appearances in animals killed by suffocation, and those observed in patients who have died during the collapse of cholera, are, that the right side of the heart and the large veins are full, while the left cavities and the aorta are empty. The difference is in the state of the lung, which, in cholera, contains scarcely any blood in its minute texture, while in the suffocated animal the minute vessels are gorged with blood. These different conditions of lung are not accidental, but essential, as will be seen hereafter. Now, it is admitted by most physiologists that the arrest of the pulmonary circulation, in cases of asphyxia, is occasioned by the suspension of the chemical changes which normally occur in the capillaries of the lung where the blood is exposed to the influence of the air ; so long as those changes are uninterrupted, the blood is freely transmitted into the left cavities of the heart, but suspension of those chemical actions is immediately attended by a diminished flow of blood through the lung. The movement of the blood appears to be dependent, as Dr. Alison maintains (xxi. p. 42) 'on the vital attractions connected with the chemical changes constantly going on in the capillary vessels.' Dr. Draper explains the movement of blood through the capillary vessels by a reference to the following general principle (xxii. p 29) : 'If two liquids communicate with one another in a capillary tube, and have for that tube different chemical affinities, movement will ensue ; that liquid which has the most energetic affinity will move with the greatest velocity, and may even drive the other liquid entirely before it.' The application of this principle to the pulmonary circulation, and to the phenomena of asphyxia, is this : 150 THE PATHOLOGY OF there exists an attraction between the blood in the pulmonary artery and the atmospheric air in the cells of the lung, which attraction tends to bring the blood into the capillaries surrounding the cells; when the interchange of gases has taken place, i. c., when the carbonic acid in the blood has been exchanged for the oxygen of the air, the attraction ceases, and the oxygenised blood may be pushed onwards by the next particle of black blood which is drawn towards the air in the cells. This is the normal condition ; but when from any cause the aeration of the venous blood is interrupted, it continues to be attracted towards the air-cells, or the walls of the capillaries, and thus offers an impediment to the onward flow, which increases until the right ventricle is unable to overcome the obstacle, and so the circulation ceases. Mr. Wharton Jones has actually observed, under the microscope, the arrest of the circulation in the lung of the frog, produced by directing a stream of carbonic acid gas against the exposed lung. The red corpuscles were seen to agglomerate together, apply themselves flat against the wall of the vessel mid adhere to it (xxiii. p. 600). Now, whatever may be the nature of this attraction — whether it be electrical or chemical, or both — it is quite certain that it impedes the passage of the blood. In fact, it is more easy to prove that the capillaries have the power of impeding the circulation in abnormal circumstances than to demonstrate their normal influence in favouring it. In watching cases of chronic disease of the lung, we have frequent opportunities of observing the consequences of a slow asphyxia. One of the most interesting of these consequences is the change which the right cavities of the heart undergo. A patient who has suffered for many months, or it may be for years, with emphysema of the lung and chronic bronchitis, whose blood is imperfectly EPIDEMIC DIARRHCEA AND CHOLERA. 151 aerated, and whose pulmonary circulation is consequently impeded, almost invariably has the right cavities of the heart dilated; and the "walls, especially those of the ventricle, hypertrophied. The insufficiently-oxygenised blood is impeded in its passage through the minute vessels of the lung ; the impediment reacts upon the heart, and this organ, having to make increased efforts to overcome the obstacle, undergoes the changes in question. Another morbid change in the lung illustrates in an interesting manner the dependence of the circulation on the free admission of air. In cases of bronchitis, it sometimes happens that one of the smaller divisions of a bronchial tube becomes obstructed by an accumulation of viscid secretion. The result of this accident is the collapse of the portion of lung supplied by that division of the tube ; the supply of air having been cut off, the blood ceases to flow to that part, and a circumscribed portion of the lung becomes non-crepitant, dry and pale, reverting, in fact, to the condition of the festal lung. And here it is not without interest to observe that, as the pulmonary circulation commences at birth, simultaneously with the admission of atmospheric air, — as the first rush of air which expands the tissue of the lung draws into it, as it were, by an attractive power, the stream of blood, — so, during the whole period of life, the supply of air and of blood are mutually interdependent. I shall presently show in what way these physiological facts may assist us in comprehending the pathology of cholera; but before doing so, I am desirous to direct attention to some other facts which tend to prove that the circulation through the minute vessels of every organ is dependent on the due performance of the function of each organ or tissue to which the blood is sent. One of the most interesting illustrations of this occurs in the kidney. The office of this gland is to separate 152 THE PATHOLOGY OF from the blood, urea, uric acid, and other materials which exist ready formed in the blood, and which accumulate there if, from any cause, the functions of the kidney are suspended. Now the kidney is subject to various diseases, which gradually destroy the secreting tissue of the gland, and in the same degree, of course, impair its functional power. The consequence is, that the blood which is sent to the kidney, charged with urinary constituents, which the damaged gland can but partially separate, suffers a continual retardation in its passage through the vessels of the kidney. The proofs that the renal circulation is impeded, and of the precise point at which the impediment occurs, are very complete. They are obtained partly from the condition of the urine, but chiefly from minute anatomical changes in the kidney itself. The arrangement of the blood-vessels in the kidney, and the course of the circulation through the gland, are very peculiar.* The blood passes from the renal artery through a small ' afferent' vessel into the Malpighian capillary tuft, which is placed within the dilated end of the uriniferous tube, thence it passes by a single ' efferent' vessel, into a plexus of capillaries which lies on the outer surface of the uriniferous tube, and finally the blood passes from these capillaries into the renal vein, and so escapes from the kidney. Mr. Bowman, to whom we owe our knowledge of the minute structure of the kidney (xxiv.), has shown with a great degree of probability that while the peculiar solid constituents of the urine (the urea, uric acid, &c.) are separated from the blood of the intertubular plexus by the gland-cells which line the uriniferous tubes, the water which forms so large a portion of the urine is poured into the ex- # See the illustrations in the author's treatise On the Diseases of the Kidney, pp. 28, 29. EPIDEMIC DIARRHCEA AND CHOLERA. 153 tremities of the tubes from the vessels of the Malpighian tuft, which are not covered by cells of any kind. Now, the various forms of what is commonly called Bright's disease of the kidney, differing as they do in many important particulars — sometimes producing great enlargement, and in other cases extreme contraction of the gland, — have this in common, that they destroy the gland-cells which line the uriniferous tubes, and which constitute the essential part of the proper secretory apparatus. The consequence is, that the blood, not being freed from the excreta which it is the office of the glandcells to abstract from it, is retarded in its passage through the intertubular capillaries, in a manner strictly analogous to that in which the blood in the pulmonary capil laries is retarded when the escape of carbonic acid is prevented. It is obviously impossible that this retardation of blood in the renal blood-vessels can be seen by the eye, as Mr. Wharton Jones has witnessed the obstruction in the vessels of the frog's lung, but the evidence that the impediment actually occurs in the circumstances referred to, is scarcely less than demonstrative. In all cases of the disease in question, either some or all the constituents of the blood escape from the Malpighian vessels which lie behind the seat of obstruction, and these materials, being thus poured into the tubes, and mingling with the urine, render that secretion albuminous. This is precisely such a result as the experiment of putting a ligature on the renal vein of a living rabbit, proves that an impediment to the circulation will produce. The animals subjected to this experiment invariably have their urine mixed with albumen and blood, as Dr. George Kobinson was the first to show (xxv. p. 243). But there is evidence of another kind, and equally decisive, as to the existence of an impeded circulation. 154 THE PATHOLOGY OF In all the forms of chronic renal disease, when the destruction of secreting tissue has been extensive, I have ascertained that the coats of the Malpighian capillaries, and more especially those of the minute renal arteries, are very much thickened. The coats of the minute arteries are of the nature of unstriped muscle, they consist of two layers of fibres — an inner longitudinal and an outer circular, — both of which become much hypertrophied, so as often to assume a thickness three times greater than in the normal state ; at the same time that the arteries become tortuous, and their canals in some instances dilated. The inference from these anatomical facts is obvious : there must have existed a long-continued impediment to the escape of blood from the vessels which, in the order of the circulation, lie in front of the Malpighian capillaries — viz., in the intertubular capillaries. The circulation is retarded at the point where the function of the gland fails, and the impediment acting backwards leads to the escape of serum from the Malpighian capillaries, and a simultaneous gradual thickening of the walls of those vessels and of the arteries. It is immaterial for our present purpose to inquire whether the hypertrophy of the arterial walls is calculated to assist the onward movement of the blood, or whether its purpose is simply to enable the vessels to resist the increased pressure to which they are subjected ; it may not, however, be out of place to remark that there appears to be an analogy between this thickening with occasional dilatation of the renal arteries and the dilatation with hypertrophy of the right side of the heart in cases of chronic pulmonary disease. Amongst the phenomena observed by Dr. Eeid, in the course of his experiments on asphyxia, there is one to which I have not yet particularly referred — I allude to the fact that when the black unoxygenized blood begins 155 EPIDEMIC DIARRH(EA AND CHOLERA. to flow through the systemic arteries the passage of this blood from the arteries into the veins is impeded. The proofs of the impediment are the great fulness and tension of the arteries, the increased pressure upon their walls, and, simultaneously, the diminished pressure on the walls of the veins, as shown by the hsemadynamometer. The increased pressure upon the arterial walls continues until the supply of blood to the arteries is rapidly lessened by the increasing impediment to the flow of blood through the lungs. There can be no question as to the accuracy of Dr. Reid's observations, and the same experiments have been repeated, with precisely similar results, by others, and particularly by Mr. Erichsen (xxvi. vol. 6s). While, however, there is an entire agreement as to the facts, there is some difference of opinion as to the interpretation of the phenomena. These experiments unquestionably demonstrate the fact that venous blood meets with some impediment in its passage from the systemic arteries into the veins ; but the question arises — In what particular part of the vascular system does the impediment occur ? It obviously might occur at any point between the hsemadynamometer in the artery and that in the vein. Does the obstruction, then, exist in the minute arteries, or in the capillaries, or in the minute veins ? lam not aware that it has ever been supposed to originate in the veins, and there is nothing to support such a theory ; but it is not so easy to determine whether the impediment exists in the capillaries or in the minute arteries. Dr. Reid believes that it is in the former class of vessels, while Mr. Erichsen assigns it to the latter. Dr. Draper, to whose explanation of the pulmonary circulation I have before referred (p. 149), believes, with Dr. Reid, that the impediment exists in the capillaries, and he explains it by saying that whereas 'the arterial blood in the systemic vessels has a strong affinity for the 156 THE PATHOLOGY OF tissues with which it is brought into contact, the venous blood has none. It must, however, be admitted that we have no proof that the venous character of the blood in the systemic capillaries would entirely destroy its attraction for the surrounding tissues, and that the result of this suspended attraction would be an impediment to the circulation equal to that which occurs in the case of asphyxia. It appears, therefore, that there is something incomplete in this explanation, and Mr. Erichsen maintains that the contraction of the minute arteries upon their contents is the chief if not the sole agent in retarding the circulation. There are some facts which show the extreme probability of this explanation. It is well known that the coats of the minute blood-vessels, both arteries and veins,* contain muscular tissue, and that they contract powerfully under the influence of various stimulants. Mr. Paget states (xxvii. vol. i, p. 302) that when the point of a fine needle was gently drawn across the artery and vein in a bat's wing ; he saw under the microscope the gradual contraction of both vessels, which proceeded to the extent of closing their cavity. Mr. Wharton Jones (xxviii. vol. viii.) describes similar phenomena as occurring in the web of the frog's foot. He observed, too, that the circulation in the artery and in the capillaries connected with it was retarded exactly in proportion to the degree in which the canal of the artery was narrowed by the contraction of its coats. I extract from Mr. Simon's Lectures on General Pathology (p. 70) an account of two different experiments, each demonstrative of the contractile power of the minute arteries. The first experiment was performed by Schwann : — ' On one very hot day, furnished with some * See an excellent description of the structure of veins in tlie Cyclopaedia of Anatomy and Physiology. Article — Vein. By Mr. S. J. A. "Salter. 157 EPIDEMIC DIARE,H(EA AND CHOLERA. very cold water, he brought the mesentery of a living frog into the field of the microscope, and adjusted his focus to an artery of about y^ inch in diameter. He then let the cold water fall, drop by drop, on the membrane, and presently found the artery contracted to a third of its previous diameter. He desisted from the application, and in half-an-hour the artery had resumed its former size. He then again reduced it by cold, and he continued for some time thus alternately making the artery contract and letting it dilate, just as you may do with your iris, in alternately turning your eye to light or to shade.' Mr. Simon adds — ' The brothers Weber have demonstrated that the muscular coat of arteries is susceptible of galvanic stimulation. By passing a current through small arteries (diameter -^ to -$1-$ inch) in the mesentery of frogs, they have found that within a few seconds contraction ensues, which reduces the canal of the artery to half its previous capacity, and that a continuation of the same stimulus would, by degrees, completely obliterate the vessel.' Now, these experiments demonstrating, as they do, the contractility of arteries under the influence of various stimuli, are of great physiological interest, and admit of important applications in pathology. They tend to confirm the observations of Mr. Erichsen, who sought for evidence as to the condition of the arteries in cases of asphyxia, by placing under the microscope a portion of the mesentery of a rabbit, while the animal was being suffocated. He describes the results in the following words (xxvi. vol. 63, p. 28) : — ' For about a minute after the struggles of the animal have ceased the circulation appears to be going on with its usual rapidity ; it then gradually becomes somewhat slower, the arteries contracting in size, containing less blood, and assuming a lighter and more tawny colour than before, whilst the veins become congested and evidently fuller. As the 158 THE PATHOLOGY OF circulation becomes more languid the arteries continue contracting, and acquire a lighter colour, the diminution in their size and the difference in the quantity of blood contained in them and in the veins, being most marked.' While these changes were going on he could see nothing like movement in the capillaries, or adhesion of globules to their sides. Mr. Erichsen, therefore, has afforded some confirmation of his theory, that the chief, if not the sole cause of the impeded systemic circulation in asphyxia is the contraction of the minute arteries, which appear thus to retard the transmission of venous blood — a fluid which, of course, they are entirely unaccustomed to receive. Again, there are some experiments which prove that the minute arteries, after death, so long as they retain their contractile power, offer considerable resistance to the passage through them of various stimulating liquids. Thus, it is a well-known fact, that the tissues of an animal, immediately after death, cannot, without a force which endangers the integrity of the vessels, be injected with any of the fluids commonly used for that purpose, for the simple reason that the coats of the arteries, so long as their vital tonicity remains, contract upon their strange contents and impede the passage of the injection into the capillaries. This fact is evidently analogous to the resistance offered by the systemic arteries to the passage of venous blood. Some experiments performed by Hales (xxix.), illustrate in a very conclusive manner the power which the arteries possess to control the flow of liquids through them. His method of proceeding was this: having bled a dog to death by cutting the jugular veins, he immediately opened the thorax and abdomen, and having fixed a glass tube, four-and-a-half feet high, in the descending aorta, he 'slit open the guts from end to end opposite the 159 EPIDEMIC DIARRHOEA AND CHOLERA. attachment of the mesentery ;' he then ohserved, hy the aid of a pendulum which beat seconds, in what period of time various fluids, poured into the glass tube, escaped through the cut margins of the bowel. When a large artery had been accidentally divided, he tied this so as to confine the passage of the fluid to the smallest vessels. Some of his results, which I shall give as much as possible in his own words, possess considerable interest, and I shall have to refer to them on more than one occasion hereafter. In one experiment he says: — 'I first poured in seven pots-full of warm water, the first of which passed off in fifty-two seconds, and the remaining six gradually in less time, to the last, which passed in forty-six seconds. Then I poured in five pots of common brandy, or unrectified spirit of malt, the first of which was sixty-eight seconds in passing, the last seventy-two seconds. Then I poured in a pot of warm water, which was fifty-four seconds in passing.' — His inference is, that ' brandy contracts the fine capillary arteries of the guts, and that water soon relaxes them again by diluting and carrying off the spirituous part of the brandy.' In another experiment he says : — ' When cold pumpwater, which was fourteen degrees above freezing-point, was poured on the guts, and some of it at the same time poured through the tunnel into the arteries, those capillary arteries would, on a sudden, be so contracted as that the fourth pot of cold water was eighty seconds longer in passing through than the like quantity of warm water was just before; and the fifth pot being warm water, and the guts at the same time being warmed by water poured on them, it passed in seventyseven seconds sooner than the former pot of cold water did.' ' Hence we plainly see how greatly heat and cold dilate and contract our pores.' The above experiment 160 THE PATHOLOGY OF was repeated on other occasions with precisely similar results. It is interesting to observe that the contractility of the minute arteries under the influence of cold, which Schwann (see antea p. 156) has since demonstrated by the aid of the microscope, was confidently and correctly inferred by Hales, from the results of his experiments. On another occasion he performed the following experiment. ' I first poured into the tube, which was fixed to the aorta, four pots of warm water, containing eighteen cubic inches each, the last of which passed off in sixtytwo seconds of time. Then I poured in successively, sixteen pots of equally warm decoction of bark, the first of which passed off in seventy-two seconds, and the following slower and slower, in proportion as the vessels grew more and more contracted by the styptic quality of the decoction, so that the sixteenth pot was 234 seconds in passing. Then I poured in successively, eleven pots of water, of the same heat with the decoction, the first of which pots was 198 seconds in passing, and the succeeding ones passed sooner and sooner, in proportion as they washed off the decoction, and thereby relaxed the coats of the vessels, till the eighth pot, which passed in ninety-six seconds. I then poured in successively five pots of cold pump water, which was fourteen degrees above the freezing point ; and whereas the preceding pot of warm water passed in ninety-six seconds, the fifth pot of this cold water was 136 seconds in passing.' Again, ' I tried in like manner a strong decoction of oak-bark, on another dog, in which the preceding pot of warm water was thirty-eight seconds in passing ; but the following six pots of decoction so contracted the vessels that the last of them was 136 seconds in passing.' These experiments, together with some others, which have been performed on living animals, and to which reference will be made hereafter, are all confirmatory of the EPIDEMIC DIARRHffiA AND CHOLERA. 161 view which attributes to the contractile power of the minute arteries, the retarded flow of venous blood from the branches of the aorta into the veins. I have already shown that the circulation through the kidney is retarded when structural disease of that organ is attended with an incomplete separation of urine from the blood, and that this retardation of the circulation is analogous to that which affects the pulmonary circulation in cases of asphyxia. There is yet another point of agreement between the phenomena of asphyxia and those of renal disease, which is that in cases of chronic renal disease the blood, containing an excess of urinary constituents, is impeded in its passage through the minute blood-vessels of the body generally, as the blood charged with carbonic acid is impeded in cases of asphyxia. At least, this appears to be the only reasonable interpretation of a fact first pointed out by Dr. Bright, that in a large proportion of cases of chronic renal disease, the left ventricle of the heart is hypertrophied, even when there exists no obvious disease of the valves or large arteries. Now, as the physiological interpretation of hypertrophy implies an increased effort on the part of the heart, and, therefore, the existence of an impediment in some part of the circulation, we can only conclude, from analogy, that in the cases referred to ' the altered quality of the blood,' to use the words of Dr. Bright, 'so affects the minute and capillary circulation as to render greater action necessary to force the blood through the distant subdivisions of the vascular system.' The coexistence — in a considerable number of instances — of dilatation and tortuosity of the systemic arteries, with thickening of their walls, affords additional evidence of obstruction in the smaller vessels ; and it appears in the highest degree probable that as the minute arteries contract upon and retard the onward progress of blood M 162 THE PATHOLOGY OF charged with carbonic acid, so they behave in a similar manner when the quality of the blood is altered by the admixture of large quantities of the urinary constituents. And the resemblance between the two conditions is rendered more complete by the fact, that in cases of chronic asthma and bronchitis, not only does the right ventricle become dilated and hyterprophied, in consequence of the impeded pulmonary circulation, but a similar change is often induced in the left ventricle by the increased efforts which are required to drive imperfectly aerated blood through the minute systemic vessels. Moreover, there are some facts, for the knowledge of which we are chiefly indebted to Mr. Paget (lv. vols. 27 and 28), which tend to show that in cases of Bright's disease of the kidney, ' urea, or some other retained constituent of the urine,' may give rise to an impediment to the flow of blood through the pulmonary arteries, analogous to that which it occasions in the systemic vessels. The movement of blood through the pulmonary arteries in some cases of chronic renal disease referred to by Mr. Paget, was apparently so much retarded as to result in the formation of coagula within the vessels ; while the coexistence of dilatation of the right cavities of the heart either with or without hypertrophy of the muscular walls, afforded conclusive evidence as to the long duration of the obstruction. Mr. Paget, in illustration of his suggestion that the impeded circulation through the pulmonary vessels was occasioned by a morbid change in the constitution of the blood, refers to some experiments by Mr. Blake, who ascertained, as we shall presently see, that certain salts, when injected into the blood of living animals, have the power to hinder or entirely arrest its passage through the small vessels, even while the heart is acting with full force. The general conclusions which may be drawn from EPIDEMIC DIARRHOEA AND CHOLERA. 163 the facts which we have passed in review are, first, that the blood may be retarded in its passage through either the capillaries or the minute arteries. Second, that the blood is retarded in the capillaries of an excretory organ, such as the lung or kidney, when, from any cause, the function of the organ is so impaired that its peculiar excreta accumulate in the blood. Third, that the blood is retarded in its passage through the minute arteries when the qualities of the circulating fluid are so changed as to excite contraction of the muscular walls, and a consequent narrowing of the canals of those vessels. We proceed now to show in what way these facts, and the conclusions to which they lead, are applicable to the condition of the pulmonary circulation in cholera. We have seen that when death has occurred during the stage of collapse the minute texture of the lungs is found to be remarkably pale and bloodless, while the larger branches of the pulmonary artery, as well as the right cavities of the heart are filled with blood, which often escapes in considerable quantity when the roots of the lungs are divided. We have here, then, a positive fact, — the blood has been sent into the pulmonary artery, but it has not reached the capillaries of the lungs ; it must, therefore, have been arrested in the minute branches of the pulmonary artery. This, 1 repeat, is a fact demonstrated by various able and accurate observers, and stated to be of almost constant occurrence. The question then arises, in what way can this stoppage of blood in the pulmonary arteries be explained ? In what way, if not thus : that the blood, being morbidly changed in its qualities by the action of the cholera poison, is retarded and finally arrested in its passage through the minute branches of the pulmonary artery, the muscular coats of the vessels being excited to contract upon their abnormal contents, as we have found reason to believe that the minute M 2 164 THE PATHOLOGY OF branches of the systemic arteries contract upon anu impede the passage of blood which contains an excess of carbonic acid ; as both the systemic and the pulmonary arteries are probably stimulated to contract upon blood which is charged with urinary excrement; and as the arteries of an animal recently killed oppose in different degrees, the passage of cold, astringent, or otherwise stimulating liquids ? Before I point out the sufficiency and the extreme probability of this explanation of the impeded flow of blood through the lungs, let us for a moment consider some of the necessary consequences which would result from a scanty stream of blood through the lungs occurring in the manner supposed. We have already (p. 145) alluded to some of the phenomena which are thereby explained ; namely, the comparative emptiness of the arteries ; the deficiency in the volume and force of the pulse ; the occasional absence of haemorrhage, even when arteries of considerable size have been wounded ; the collapse of the features and the sinking of the eyeballs. Another result of great interest and importance necessarily accompanies the defective pulmonary circulation. It is obvious that the stream of blood from the pulmonary capillaries into the left side of the heart is the channel by which the supply of oxygen is introduced into the system, and it appears to be a necessary consequence of a great diminution in the volume of blood transmitted to the left cavities of the heart and the arteries, that the amount of oxygen is in a corresponding degree lessened. Again, the consequences of so defective a supply of oxygen can scarcely be considered doubtful ; the combustion of those constituents of the blood which are normally subject to the action of oxygen, will be diminished in proportion to the deficiency of that gas, and thence follow simultaneously a reduction of temperature, EPIDEMIC DIARRHCEA AND CHOLERA. 165 and so scanty a formation of the urinary and biliary constituents, that so long as this condition of things continues, the functions of the kidneys and liver are virtually suspended. I repeat that each of these results obviously and necessarily follows upon a greatly diminished flow of blood through the lungs. We shall presently see that many important phenomena of cholera which have hitherto received no satisfactory explanation, are rendered intelligible by a consideration of the facts here referred to. In the meantime, additional proofs of this arrest of blood in the branches of the pulmonary artery, and some insight into the mode in which the impediment arises, may be derived from a comparison of some wellestablished facts which have not yet been alluded to. It has sometimes happened during the performance of a surgical operation at the root of the neck or in the axilla, that atmospheric air has entered a wounded vein, and occasioned the most serious consequences. The entrance of the air has usually been indicated by a peculiar gurgling sound in the wound, and the symptoms which rapidly follow are thus described (xxi. p. 553) "• — ' Speedy occurrence of syncope, which is either preceded by a cry, with the expression, ' I die ;' ' I am dead ;' ' I suffocate,' or by anxiety and tremblings, or without any such precursors. The syncope* rapidly reaches such a degree that all consciousness is lost, and the patient falls down, cold sweat breaks out on the forehead, and in a quarter of an hour, sometimes sooner, sometimes later, he is dead.' After death, both in the human subject and in animals who have been the subjects of experiment, the right side of the heart is found to be * The term ' syncope' is not strictly applicable in this case ; the pathological condition being in fact of the nature of asphyxia, although it is probable that the immediate cause of death is a defective supply of blood to the left side of the heart and the brain. 166 THE PATHOLOGY OF much distended, its cavities being filled with frothy blood ; and the same mixture of air and blood is usually found in the pulmonary arteries. The left side of the heart is nearly empty, but a small quantity of air is occasionally found in the left cavities and in the arteries. The cause of death is the distension of the right side of the heart, which results from the great difficulty of transmitting frothy blood through the vessels of the lungs. Mr. Erichsen found by experiment upon a dog recently killed, that beat bullock's blood mixed with air required nearly twice the pressure to drive it through the pulmonary vessels, that would suffice to drive unmixed blood through the lungs (xxvi. vol. 61). The effects of the entrance of atmospheric air into the veins, afford us then one remarkable illustration of the sudden arrest of the circulation, through an impediment in the pulmonary vessels. Various liquids injected into the veins cause sudden death in a somewhat similar manner by arresting the blood in the lungs. Thus Magendie (xix.) injected into the veins of dogs in some cases olive oil, in others carbonate of soda, and in others again, dilute sulphuric acid. In each case death ensued from the speedy arrest of the pulmonary circulation. But the most interesting experiments are those performed by Mr. Blake (xxxi. vols. liii. liv. and lvi.), to determine the effects of different inorganic compounds when injected into the blood. Thus, he found that a solution of soda, or of its salts, when injected into the jugular vein, killed a dog in less than a minute. On examination after death, the right side of the heart was found greatly distended, while the left contained only a little black blood. A few grains of nitrate of silver in solution destroyed life in precisely the same way. Other substances act in a totally different 167 EPIDEMIC DIARRH(EA AND CHOLERA. manner. Thus potash and its salts, when injected into the veins, pass readily through the lungs, and then destroy the contractility of the heart. The left ventricle, instead of being empty or containing a small quantity of black blood, as happens when the circulation has been arrested in the lungs, was found to contain a considerable quantity of scarlet blood ; the lungs having continued to act until the heart had ceased to contract upon its contents. In these cases, death occurs from syncope; in the others, from asphyxia. Mr. Blake, when performing his experiments, measured the pressure on the blood vessels by the haemadynamometer, and thus determined with more precision the effects of various substances on the circulation. For instance, when a salt of soda was injected into a vein, the instrument in the artery quickly indicated a diminution of pressure on account of the blood being retarded in the lungs ; but a heemadynainometer in the femoral vein during the time of the injection, showed an increase of pressure in consequence of the accumulation of blood in the veins and in the right cavities of the heart. He found by the same means, that when the salts of soda were injected backwards through the axillary artery into the aorta, the blood was retarded in passing from the systemic arteries into the veins; also, that the salts of silver occasioned a similar retardation. These results are analogous to the impeded flow of blood charged with carbonic acid or urea, from the systemic arteries into the veins; and the most probable explanation of them appears to be, that the blood, when it contains certain foreign ingredients, excites the contractility of the minute arteries. Blake ascertained, that while some salts, such as those of zinc, give rise to no impediment in their passage through either the pulmonary or the systemic vessels, and while the salts of soda and silver are impeded in passing through both sets of vessels, 168 THE PATHOLOGY OF there are some which pass freely through one set of vessels but are retarded in the other. Thus the salts of potash and ammonia meet with no impediment in passing through the lungs, but they are retarded in their passage through the minute systemic vessels. The tendency of these facts is to show that the circulation of the blood, and, in particular, its passage through the minute vessels, is greatly influenced by the composition of that fluid, and that a modification of the blood occasioned by the admixture of atmospheric air, or certain inorganic compounds, may lead to its speedy and complete arrest in the minute vessels of the lung. It is not unlikely that some pathologists will maintain that the impeded flow of blood through the lungs during the collapse of cholera, is simply a result of the blood having been rendered thick and viscid by the loss of its water. Now, this theory entirely overlooks the fact, that the pulmonary circulation is often relieved from all embarrassment, and the symptoms of collapse disappear, while the drain of fluid by vomiting and purging continues, as may be seen in the reports of several of my own cases. I shall presently show that the thickened appearance of the blood is rather a consequence than a cause of the impeded pulmonary circulation; and it is obvious that the symptoms of extreme collapse often occur with far greater rapidity than can be explained on the supposition that thickening of the blood by the loss of its water is the cause of that condition. In illustration of the sudden occurrence of collapse, I may refer to the following passages in Sir William Burnet's Report, relative to the cholera which attacked the fleet in the Black Sea, in August 1854. ' The first to be attacked were the men already on the list for diarrhoea, several of whom fell into a state of collapse, one after the other ; but about the same time, rohust, healthy men, who had fallen suddenly down in a state of collapse, EPIDEMIC DIARRHCEA AND CHOLERA. 169 began to be brought in from various parts of the ship (the Britannia), even from the yards, where they ivere seized ivhile reefing sails.' And the surgeon on board the Albion reported that, ' the attacks in many instances were so sudden, that many men fell as if they had drunk the concentrated poison of the Upas-tree.' This sudden falling into collapse bears a striking resemblance to the symptoms occurring after the admission of atmospheric air into the veins (see antea p. 165), and admits of a complete and satisfactory explanation by supposing that the blood — rendered morbid by the entrance of the cholera-poison — meets with a sudden and great impediment to its passage through the lungs; while the hypothesis of a thickening of the blood by the loss of its liquid, is quite inadequate to account for the phenomena. The probability that the impeded flow of blood through the lungs is occasioned by some other cause than the loss of its water, is increased by a comparison of the collapse of cholera with the cold stage of an ague fit. The resemblance between the two conditions is so very obvious that scarcely any one who has witnessed both diseases could fail to observe it. But there is much more than a superficial likeness, and some light may be thrown on the pathology of both diseases by a comparison of their leading phenomena. With this view, then, let me direct attention to the symptoms of an ague fit, as they are described by Dr. Watson (xxxv. vol. 1, p. 719)«7 1 9)« ' A person who is on the brink of a paroxysm of ague, experiences a sensation of debility and distress about his epigastrium, becomes weak, languid, listless, and unequal to mental or bodily exertion. He begins to sigh and yawn, and stretch himself, and he soon feels chilly, particularly in the back, along the course of the spine ; the blood deserts the superficial capillaries ; he grows pale, his features shrink, and his skin is rendered dry and 170 THE PATHOLOGY OF rough. Presently the slight and fleeting sensation of cold, first felt creeping along the hack, becomes more decided and more general ; the patient feels very cold, and he acts and looks just as a person does who is exposed to intense cold, and subdued by it ; he trembles and shivers all over; his teeth chatter, sometimes so violently that such as were loose have been shaken out ; his knees knock together ; his hair bristles slightly, from the constricted state of the integuments of the scalp ; his cheeks, lips, ears, and nails, turn blue ; rings which before fitted closely to his fingers, become loose ; his respiration is quick and anxious ; his pulse frequent, sometimes, but feeble ; and he complains of pains in the head, back, and loins; all the secretions are usually diminished; he may make water often, though generally he voids but little, and it is pale and aqueous ; his bowels are confined, aud his tongue is dry and white. ' After this state of general distress has lasted for a certain time, it is succeeded by another of quite an opposite kind. The cold shivering begins to alternate with flushes of heat, which usually commence about the face and neck. By degrees the coldness ceases entirely, the skin recovers its natural colour and smoothness, the collapsed features and the shrunken extremities resume their ordinary condition and bulk. But the reaction does not stop here ; it goes beyond the healthy line : the face becomes red and turgid ; the general surface hot, and pungent, and dry ; the temples throb ; a new kind of head-ache is induced ; the pulse becomes full and strong, as well as rapid ; the breathing is again deep, but oppressed ; the urine is still scanty, but it is now high-coloured ; the patient is exceedingly uncomfortable and restless. At length another change comes over him : the skin, which from being pale and rough had become hot and level, but harsh, now recovers its natural softness ; a moisture appears on the forehead and 171 EPIDEMIC DIARRH(EA AND CHOLERA. face ; presently a copious and universal sweat breaks forth, with great relief to the feelings of the patient ; the thirst ceases, the tongue becomes moist ; the urine plentiful, but turbid ; the pulse regains its natural force and frequency ; the pains depart, and by-and-bye the sweating also terminates, and the patient is again as well, or nearly as well, as ever.' It sometimes happens that the patient dies during the cold stage. Bell mentions a case of this kind (iii. p. 28). The patient, a native of India, ' had a severe fit of ague, but instead of the hot fit ensuing, the symptoms of collapse continued, the coldness of the extremities became death-like, the pulse failed, the countenance sank, and the man died in the evening.' Now the points of resemblance between the cold stage of ague and the collapse of cholera, are numerous and very striking. And, first, it is interesting to observe, that the symptoms which indicate the onset of the paroxysm, are almost identical with those which have been before referred to (p. 134), as frequently marking the invasion of cholera. Then, the difficulty of breathing, the coldness, blueness, collapse of features, and feebleness of pulse are common to the two diseases. The violent rigors are less frequently observed in cholera, but they are sometimes present in as great a degree as in ague, and it will be remembered that in the description previously given (p. 114), of the effects of saline injections into the veins, it was stated on the authority of Dr. Mackintosh, that severe rigors almost invariably followed the operation. Now, as the patient had, at the same time, usually become warmer, it is reasonable to infer that rigors are dependent on some cause besides a reduction of temperature. I shall, hereafter, when describing the modus operandi of the saline injections, suggest a possible explanation of the rigors which follow them. The scanty secretion of pale urine is an indication that the characteristic 172 THE PATHOLOGY OF solids of the urine are as deficient during the cold stage of ague as in the collapse of cholera. The absence of the liquid portion during cholera is accounted for by the drain of fluid through the bowels. We have no means of ascertaining whether — as is probable — the secretion of bile is suspended equally with tfiat of the urine, for the simple reason, that ague is not usually attended with diarrhoea, and as the cold stage is of comparatively short duration, the evacuations are tinged with fsecal matters, previously in the bowel, as well as with the bile secreted, as it probably is abundantly, during the hot and the sweating stages. Now, between two pathological conditions so remarkably alike in outward appearance, there must surely be some deeper resemblance, and it cannot be uninstructive to inquire how far this is the case. The embarrassment of the respiratory function during the cold stage of ague is sufficiently obvious, and is usually attended with a short, dry cough, which is a common symptom in cholera. Then, the post-mortem appearances, as they are described by various authors, show an accumulation of blood in the right cavities of the heart and in the venous trunks, with more or less congestion of the lungs. There is, therefore, anatomical evidence to show, that as in cholera so in ague, the pulmonary circulation has been impeded. Harvey, who had more frequent opportunities of seeing ague in London than, happily, we have in the present day, bears testimony to this point in the pathology of ague, in the following interesting passage of his treatise On the Motion of the Blood and Heart (xxxvi. p. 71): — 'In tertian fever, the morbific cause seeking the heart in the first instance, and hanging about the heart and lungs, renders the patient short-winded, disposed to sighing, indisposed to exertion ; because the vital principle is oppressed, and the blood forced into the lungs and rendered thick, EPIDEMIC DIARRHCEA AND CHOLERA. 173 does not pass through their substance (as I have myself seen in opening the bodies of those who have died in the beginning of the attack) , when the pulse is always frequent, small, and occasionally irregular; but the heat increasing, the matter becoming attenuated, the passages forced, and the transit made, the whole body begins to rise in temperature, and the pulse becomes fuller, stronger ; the febrile paroxysm is fully formed, whilst the preternatural heat kindled in the heart is thence diffused by the arteries through the whole body along with the morbific matter, which is in this way overcome and dissolved by nature.' It is evident from this extract that Harvey had a very clear perception of the fact, that during the cold stage the blood does not pass freely through the lungs, and that it does so during the subsequent stages. In respect, then, of the impeded pulmonary circulation, there is a close correspondence between the collapse of cholera and the cold stage of ague. Now, if the blood in ague is ' rendered thick,' as Harvey states, this condition cannot have resulted from the loss of its fluid constituents, for in this disease no loss of fluid occurs until after the cold and the hot stage are over. There is evidently, then, some other means by which the blood may be thickened than by the loss of liquid ; and if this be the case in the cold stage of an ague fit, may it not be so in the collapse of cholera? We shall presently be in a position to answer this question. In the mean time, bearing in mind what has previously been said of the effects of venesection in cholera (p. 107), let us see what has been the result of this experiment in ague. The practice of bleeding in the cold stage of ague, though it did not originate with Dr. Mackintosh, was revived by him; and the following is his account of the effects of the remedy (xii. vol. i. p. 86) : — 'Bleeding, in the cold stage, will in a great majority of instances cut it 174 THE PATHOLOGY OF short ; in fact, it will rarely fail in stopping the existing paroxysm, and, on many occasions, it has prevented a return of the disease to which the patients had been long subject, and by which they were nearly worn out. It is difficult to determine what quantity of blood it will be necessary to draw in any given case; sometimes it requires twenty-four ounces; I have known three ounces suffice, and in one case an ounce-and-a-half produced the full effect. The larger the orifice in the vein, the greater is the chance of arresting the disease at a small expense of blood. The blood sometimes only trickles clown the arm, and, as the system is relieved, the stream becomes larger and stronger, till at last it springs from the orifice ; and frequently before six ounces are taken the patient will express relief from violent pain in the head and loi?is, and it will soon be observed that he breathes more freely. The tremors become slighter and slighter, and by the time a few more ounces are abstracted, they will cease altogether, and with them will vanish the painful sensation of cold ; the pulse will be found stronger, and a gentle moisture will be observed on the body. If the patient be properly managed with respect to bed-clothes, neither hot nor sweating stage will in general follow. Most of the patients who have been treated by myself, or by my pupils under my immediate inspection, have fallen asleep immediately after the operation ; but some have even got up and dressed themselves.' He explains the action of the remedy in this manner (p. 124): — ' The lungs cannot perform their functions; does it not therefore follow, that the blood cannot undergo the usual and necessary changes? The blood, then, must be in a morbid condition, and when taken from a vein in very severe cases, it looks black, and does not coagulate. In such circumstances, when bleeding is had recourse to, it relieves the circulation, unloads the vessels of the lungs, and thereby enables them to perform 175 EPIDEMIC DIARRHCEA AND CHOLERA. their functions ; the blood is acted upon, and the usual changes are effected.' Dr. Mackintosh reports a large number of cases treated according to his method, both by himself and by other practitioners, and the results were in many instances very striking. Thus, in the case of one man, it is said that 'he was still shivering violently, and walked to the hospital with great difficulty, from extreme weakness, and his gait was like that of a drunken man. After he was placed in one of the wards, his extremities were found to be cold ; heat under the tongue 95 degrees ; respiration 38 — and performed with an effort; pulse scarcely to be felt at the wrist — beating 6s. He complained of an insupportable sense of coldness, of excruciating head-ache between the temples, difficulty of breathing, oppression at the chest, and debility. A vein was quickly opened ; the blood did not flow readily at first, although the orifice was well made. When about five ounces of blood were abstracted, the respiration was performed with more ease, the pain of head was less, and the tremors were slighter. The blood now began to flow in a better stream, and when ten ounces were taken, the patient declared he had no complaint but giddiness and sense of faintness. He was now placed in the recumbent posture, and the arm was tied up. The pulse was much stronger — beating 96 ; the thermometer placed under the tongue rose to 99 degrees. In the course of five minutes afterwards, a slight rigor supervened, with a return of head-ache ; and as the pulse was strong and firm, the blood was again allowed to flow from the same orifice to the extent of six ounces, with complete and permanent relief. He now felt ' comfortable,' to use his own expression. Pulse 80 — of good strength. Had a drink of warm gruel, and in a short time a slight moisture appeared on the surface of the body.' He had no return of the paroxysm. In another case, the pulse was 64 — weak and oppressed; 176 THE PATHOLOGY OF heat under the tongue 92 degrees, in the hand 72 degrees. A vein was now opened, and he was quite relieved hefore six ounces were abstracted, and the tremors ceased when twelve ounces were taken, which occupied three minutes of time. The thermometer was now again placed under the tongue, and the heat found to be 96 degrees, in the hand 75 degrees. There had been no application of heat, nor had any .warm drink been given. There was a slight moisture over the surface. He had not another paroxysm. In another case, the cold stage was very severe, the rigors violent, and the sense of cold insupportable. He complained much of his head and loins, the face was of a livid colour, and the vessels of the conjunctiva turgid with blood ; pulse 100 — oppressed ; breathing short and anxious ; and, to use his own expression, he felt ' a heavy load about his heart.' When the vein was opened, the blood trickled slowly from the wound, but it soon came in a jet. When eight ounces were taken, the rigors ceased, and he expressed great surprise at the suddenness of the relief; when twelve ounces were abstracted, he was free from all complaint, and his skin had a comfortable, moist feel. He enjoyed a good night ; he had no return of the intermittent, and his recovery was rapid. Twining's opinion is that the practice of bleeding at the commencement of the cold stage is always safe, and generally more successful than any other remedy (v. vol 2, p. 216). He has known cases, in which quinine had failed, cured by a single bleeding in the cold stage, He states, too, that the practice is well known and appreciated in India. ' The requisites to ensure the success of bleeding are — first, a preliminary course of moderate purging ; second, that the blood be taken from a large orifice quite as soon as the coldness and rigor are fairly established ; third, that the patient be bled in the recumbent EPIDEMIC DIARRHCEA AND CHOLERA. 177 posture, and no more blood taken than is sufficient to arrest the paroxysm.' One case thus treated was a tall and delicate lad, aged 1 6. On three previous days the fits had been very severe. At four p.m., on the fourth day, he was pale, and his features were shrunk ; he had a frequent slight cough ; his pulse was 116, and feeble; the nails were blue, the hands cold, and a slight shivering had commenced. As soon as the rigor increased, a vein was opened, and five ounces of blood were taken, and at the same time of spirit, ammon. arom. was given in a wineglass of tepid water. The rigor ceased while the blood was flowing ; he had a very slight pyrexia in the evening, and slept better than usual at night. The relief was remarkable and immediate ; he had no return of the ague. Another case was that of a lady, aged 32. She had suffered three most violent and distressing paroxysms of tertian ague. In the fourth paroxysm, when she was shivering most vehemently, and though covered with several blankets, calling aloud for more bed-clothes, she was bled by a free opening in the vein. Thirteen ounces of blood flowed quickly, and the relief was almost instantaneous ; the rigor ceased, and she had the bed-clothes removed, except one blanket. Neither hot nor sweating stage followed, and she had no return of the disease. No medicine was requisite after the bleeding, except a few mild aperients of blue-pill and compound extract of colocynth. These cases are selected from a large number of a similar kind, which are reported by Mackintosh and Twining, and it will be seen that the results of venesection in the cold stage of , ague* bear a striking resem- * I scarcely feel called upon to offer any opinion as to the expediency of bleeding as a remedy for ague. Its indiscriminate use must, I should think, be injurious ; although the judicious employment of venesection, especially in the severe forms of N 178 THE PATHOLOGY OF blance to those which have been before described as occurring from the same means in the collapse of cholera. It appears unquestionable that the great relief which is often afforded by the operation in both forms of disease, results from some influence upon the heart and lungs, whereby the passage of blood through the latter organs is assisted. The symptoms which clearly indicate this mode of action are, a greater freedom of breathing, a greater power and volume of pulse, and simultaneously a more rapid flow of blood through the opened vein, together with a speedy rise of temperature ; the latter change having been accurately measured in some of Mackintosh's cases by a thermometer placed in the mouth both before and after the operation. Now, there are two modes in which venesection may possibly afford the assistance which it manifestly does to the pulmonary circulation in cholera and ague — namely, by diminishing the resistance which the vessels of the lung offer to the passage of the blood, or by increasing the power of the right auricle and ventricle. With respect to the latter mode of action, which we will take first in order, there is but one way in which it is probable that the abstraction of venous blood could increase the power of the heart, which is, by relieving the over-distension of the right cavities. We know that great distension of a hollow muscular organ, by an accumulation of its contents — whether of the urinary bladder, or of the bowel, or of the heart — tends to paralyse its fibres and to lessen their contractile power, which can be restored only by the removal of the excessive tension to which the muscular tissue has been sub- intermittent which occur in hot climates, may, as Dr. Watson suggests, ' constitute the most important part of their treatment ; attended as they are with a degree of internal congestion and disturbance, which is dangerous to the integrity of vital organs. 1 (xxxv. vol. i. p. 761.) EPIDEMIC DIARRHOEA AND CHOLERA. 179 jected. That the contractile power of the over- distended right cavities of the heart may be increased by venesection, has been shown by various experiments upon animals. Thus, Dr. Eeid, in his essay 'On the Effects of Venesection in Eenewing and Increasing the Heart's Action, under certain circumstances' (xxi. p. 51), has demonstrated, that when a dog has been killed by any of those means which lead to great engorgement of the right cavities of the heart — by suffocation, or by the injection of certain poisonous agents into the veins — the abstraction of blood from the external jugular vein rapidly emptied the right side of the heart, and at the same time often induced an immediate recommencement of its contractions ; which contractions, in their turn, assisted the evacuation of the cavities by producing a reflux current from the ventricle into the auricle ; the tricuspid valve permitting — as the late Mr. T. W. King has shown — a regurgitation of blood, when the ventricle is over distended. Dr. Eeid, in illustration of the same principle, refers to the observations of Haller (xx. p. 89) who ascertained by repeated experiments on the lower animals, that when a vein is opened the blood rushes towards the opening from the side nearest to the heart, as well as on the distal side, the two currents meeting at the orifice in the vein. It is, therefore, not difficult to perceive that the operation of venesection would have a direct influence upon the contractile power of the heart, by lessening the distension of its cavities, and that it may be as Dr. Keid suggests, ' of considerable practical advantage in promoting the return of the circulation under certain circumstances.' One of Blake's experiments affords very interesting confirmation of this doctrine (xxxi. vol. 56, p. 120). He had ascertained, by repeated experiments, as we have already seen (antea p. 166) that a solution of a salt of n2 180 THE PATHOLOGY OF soda, injected into the vein of a dog, produced death in a few seconds — usually in less than a minute — by causing an arrest of the circulation through the lungs. And he had found that when the distended and motionless right cavities of the heart were punctured immediately after death, the escape of a portion of their contents usually led to a renewal of the heart's contractions. He, therefore, performed the following experiment with a view to ascertain the influence which venesection might have in prolonging life in these circumstances. ' The animal (a dog) was prepared by exposing the two jugular veins. A solution, containing three drachms of nitrate of soda, was injected into the venous system — a quantity more than sufficient to arrest the passage of the blood through the lungs — a few seconds after the injection, violent opisthotonos came on. This was instantly relieved by dividing both the external jugular veins — congestion in the brain being thus prevented. The animal lost a great deal of blood, but notwithstanding this, it survived the experiment two hours. The respiration continued regular, there were no convulsions, in fact, the animal seemed to be suffering only from loss of blood; the presence of so large a quantity of soda in the blood being, apparently, in no way injurious, except by its action on the lungs. At the end of two hours the animal died asphyxiated, owing to the air-cells becoming filled with a frothy secretion.' Now, it appears to me that a consideration of these facts, and of the phenomena of ague and cholera, can leave little room for doubt that the chief, if not the only mode in which venesection relieves the urgent symptoms attending the cold stage and the collapse of those diseases, is by lessening the paralysing influence produced by over-distension of the right cavities of the heart, and thus increasing the contractile power of that organ. Some idea may be formed of the degree of EPIDEMIC DIARRHCEA AND CHOLERA. 181 distension to which the heart and the large veins are subjected, from the statement that the vena cava has actually been ruptured by the pressure upon its coats, which the cold stage of an ague fit has occasioned. — (See Mr. Salter's article ' Vein,' in Cyclopcedia of Anatomy and Physiology.) We come now to the consideration of the other mode in which it has been suggested that venesection may exert its beneficial influence in ague and cholera, namely, by diminishing the resistance which the vessels of the lung offer to the passage of the blood. It appears not improbable that the abstraction of a certain quantity of the morbid blood which is accumulated on the right side of the heart, and to which the pulmonary vessels refuse a free passage, may have an influence of this kind. A result which would be somewhat analogous to that obtained in some of Blake's experiments, who found that a scanty injection of any of those salts which, in large doses, arrest the pulmonary circulation in a few seconds, produced a temporary impediment to the flow of blood which would be more or less completely overcome, unless the injection were repeated in larger quantities. Without attaching much importance to this explanation, I cannot but think that it has some foundation in fact. The effects of venesection can scarcely be supposed to afford support to the theory that the impeded pulmonary circulation is mainly due to the increased thickness and viscidity of the blood. For it would seem probable that, if the blood were rendered nearly stagnant by its viscidity, those parts of it which were most fluid and mobile, would be the first to escape from the wounded vein, while the thicker portions would remain in the vessels. Then, as we have remarked before, since in ague there is no loss of fluid until the cold stage is past, the thickened condition of the blood in that 182 THE PATHOLOGY OF disease must be due to some other cause ; and if this he the case in ague, may it not he so in cholera? And may it not, in both diseases, he rather a consequence than a cause of the impeded flow of blood through the lungs ? Before attempting to reply to these questions, it will be interesting and instructive to look back upon the description which Dr. Mackintosh has given of the effects of saline injections into the veins, (see p. 112,) which, it appears to me, admit of a far more satisfactory explanation than that which is usually given of them. Now, with respect to the modus operandi of the saline injection — every fact, and we have seen many sueh — which throws a doubt upon the theory that the symptoms of collapse result from the loss of the liquid portion of the blood, tends in an equal degree to lessen the probability that the relief which has often been afforded by this operation has been due simply to the increased fluidity of the blood. With regard to the saline element of the injection, since the analyses of Dr. Garrod and others have shown that the relative proportion of the salts of the blood is certainly not lessened in cholera, there is evidently no reason to suppose that the symptoms of collapse can be removed simply by the addition of saline matter to the blood. Further, it must be conceded that just in proportion to the degree in which it has been rendered probable that the chief symptoms of collapse result from an impediment to the flow of blood through the lungs, will be the likelihood that any mode of treatment which removes or greatly lessens those symptoms exerts an influence of some kind upon the pulmonary circulation, as we have seen that the operation of venesection does. Now if we consider the results of the operation in question, as they have been described by those who have witnessed them, we shall find reason to believe that the saline injection has a direct influence upon the flow of blood 183 EPIDEMIC DIARRHOEA AND CHOLERA. through the lungs, and we may then seek to ascertain more precisely its mode of action. Dr. Mackintosh describes (see antea p. 113) the effect upon the pulse as being so remarkably rapid, that by the time only four ounces of fluid were introduced, the pulse, which had previously been imperceptible, could generally be distinctly counted. And this is in strict accordance with the testimony of Mr. Jackson (xxxviii. p. 211) who, describing the effect of the injection, in the case of a pulseless woman, says, 'In one minute and forty seconds from the first push of the syringe, I felt the pulse at the wrist ; soon it could be counted ; and in six or eight minutes it was quite strong and firm, and as full as my own, or nearly so; the blueness had disappeared, the face had become red and quite hot.' Now, it is scarcely credible that the addition of so small a quantity as four ounces of fluid to the blood should so speedily restore the pulse by simply adding to the fluid contents of the vessels, but it is easy to conceive that in passing through the lungs it might, in some way, diminish the impediment which the blood there meets with, and so by contributing to the passage of a fuller stream of blood into the arteries, even that small quantity of injection might render the pulse perceptible ; while the completion of the operation might, in the same way, restore the fulness of the pulse and of the features, and effect all those surprisingly beneficial changes which are involved in the passage of a free current of blood, and with it a full supply of oxygen, from the lungs to the left side of the heart. The speedy effect of the saline injection upon the circulation, reminds one of the equally rapid influence which we have already seen that the admission of atmospheric air into the lungs has in exciting the flow of blood through those organs, and consequently filling the arteries in an asphyxiated animal (see antea p. 148). The effect of the injection upon the lungs, too, 184 THE PATHOLOGY OF is shown by the speedy relief afforded to the feeble and laborious breathing; a relief which, although effected in a somewhat different manner, is yet of a similar character to that which follows the abstraction of blood from the veins. The probability that the action of the saline injection is primarily and chiefly upon the pulmonary circulation, will certainly not be lessened by a consideration of the mode in which it may be supposed to favour the passage of the blood through the lungs. Now, there are three elements in this saline injection — the fluid, the salts, and the temperature, which Dr. Mackintosh states to have been from 106 0 to 120 0 . In the oase referred to by Mr. Jackson (p. 183), and which, as it occurred in Edinburgh in the year 1832, may very likely have been under the care of Dr. Mackintosh, the temperature of the injection was from 11 2° to 115 0 . If the physician could multiply and vary his observations by experiments performed on his patients, as the physiologist experiments on the lower animals, it would not be very difficult to determine the separate influence of the water, the salts, and the temperature of the injection ; but since we are precluded from such a mode of enquiry, our conclusions must be, to a certain extent, conjectural. Now, there are two modes in which the mixture of the aqueous fluid with the blood may be supposed to favour its passage through the lungs. Those who have continual visions of the circulation being retarded by the thickened condition of the blood, may perhaps suppose that the thinning of the blood in the right cavities of the heart, and in the pulmonary artery, accounts for its more ready passage through the lungs. There would be some probability in this view of the matter, were it not for the number of facts — some of which have been already referred to, and others will be mentioned hereafter — which tend to show that the appa- 185 EPIDEMIC DIARRHCEA AND CHOLERA. rently thickened condition of the blood is rather a consequence than a cause of the retarded pulmonary circulation. The operation of venesection can scarcely be supposed to render the blood immediately thinner, yet we know that it has often relieved the pulmonary circulation as speedily and as completely as the saline injection. And, again, it is by no means certain that the blood in cholera is so greatly thickened as it is commonly supposed to be : such, at any rate, is the opinion of Dr. Parkes, who says (i. p. in) — 'The opinion that the blood in cholera is thicker than usual appears to me to have originated in the hypothesis which looks upon the purging as the draining of all the water of the blood, which then ceases to circulate, on account of its density. It is obvious, however, that with reference to those constituents which, after death, give it consistence, the blood, in many cases, is positively thinner than usual.' Dr. Parkes then alludes to the well-known fact that the clot of cholera blood is small and loose, and he suggests that the apparently thickened condition of the blood arises ' from the unseparated portion of fibrine partially losing its solubility, and being suspended, as it were, in the serum.' There does not, therefore, appear much reason to suppose that the beneficial effects of the saline injection can be explained by its diminishing the consistence of the blood. But there is another mode in which the dilution of the blood in the pulmonary artery may possibly favour its transmission through the lungs, and that is by mitigating those morbid qualities of the blood which excite the contractility of the minute arterial tubes. We have learnt from the experiments of Hales, before referred to (p. 159), that the contraction of the vessels which had been excited by a spirituous liquid, may be overcome by the subsequent passage of warm water through the 186 THE PATHOLOGY OP arteries ; we know that the pain and spasm in the neck of the bladder and urethra, which are sometimes occasioned by the contact of very concentrated or otherwise irritating urine may be mitigated, and sometimes entirely removed by the dilution of the secretion which follows the copious imbibition of fluids ; and it may be that the mixture of water with the cholera blood in the vessels of the lung, has some such influence as this. The probability of this mode of action appears to be somewhat increased by the consideration that a dilute solution of any of those salts which, when injected into the veins in a more concentrated form, entirely and speedily arrest the flow of blood through the lungs — merely embarrasses in a comparatively slight degree the pulmonary circulation. That the cholera-poison is more abundant or more virulent in its action in one case than in another, is indisputable, and that its operation is that of an irritant upon some tissues, is evident from its action upon the mucous membrane of the stomach and intestines, as well as from the painful muscular spasms which it excites ; it is, therefore, quite conceivable, not only that this quality of the poison may excite the contractility of the pulmonary arteries, but also that a copious dilution of the morbid blood in those vessels may, for the time, diminish its irritant properties, and in the same degree lessen the impediment to the circulation ; at the same time that the mixture of the warm fluid with the general mass of the blood removes the muscular cramps (see p. 113). With respect to the influence of the saline portion of the injection, nothing positive can be stated. The blood in the pulmonary artery is black, and the addition of chloride of sodium has the effect of giving it a florid red colour. Dr. Parkes states (i. p. 33) that a few drops of the intestinal fluid, which contains the chloride of sodium and some other salts of the blood, when added to the 187 EPIDEMIC DIARRHCEA AND CHOLERA. dark cholera blood, 'immediately produced a colour almost as vivid as when chloride of sodium was added.'* Now it is possible that this change of colour in the blood may be attended with such an alteration in the other properties of that fluid — an approach to the condition of arterial blood in other respects besides colour — as may render the blood more apt to pass through the vessels of the lung. If it were ascertained by experiment that an injection of warm water without the salts failed to afford the relief which the saline solution has done in other cases, there would be some reason to attribute to the salts an influence of the kind suggested ; but since it is not probable that any practitioner will have the hardihood to perform such an experiment upon a human being, the question must remain undetermined. Whatever may be the share which the water or the salts have had in removing the symptoms of collapse, it can scarcely be doubted that the high temperature of the solution injected into the veins must exercise considerable influence upon the movement of the blood through the lungs. This is rendered probable by all that is known of the effect of warmth in promoting, and of cold in retarding, the motion of the blood in the vessels. For instance, we may refer to the experiments of Hales, before cited (p. 159), to show that warm water passes through the vessels more rapidly than cold water. We have an illustration of the same principle in some of the reports given of the operation of venesection in cholera, to the effect that the blood could not be made to flow from the vein until the arm was fomented with hot water. Again, the effect of cold in retarding the circulation has been observed by Poiseuille (xix. vol. 1, p. 217) in the lung of a frog, which he placed under the microscope * It appears very probable that the bright rose tint of the small intestines after death is chiefly clue to this action of the saline contents of the bowel upon the blood in the vessels. 188 THE PATHOLOGY OP ¦while he exposed it to cold ; and he found, as might have teen anticipated, that the circulation became slow in proportion to the depression of temperature. The experiment of Schwann, before cited (p. 156), demonstrates the share which the minute arteries have in retarding the circulation under the influence of cold. We know, too, as a matter of daily observation, how the fingers and other parts of the body shrink and shrivel under the influence of cold, and how they swell and expand when the temperature is raised. The danger, too, of violent and inflammatory reaction when the temperature of frostbitten parts is too suddenly raised is another illustration of the principle that warmth powerfully promotes and quickens the circulation. Now, there can be no question that the temperature of the blood and of the lungs is considerably diminished during the collapse of cholera. The temperature of the breath and of the tongue could not be so much reduced as it often is if the blood and the lungs were not decidedly chilled. Dr. Paine examined the temperature of the mouth in a great number of cases, taking care that the patient had not drunk just previously (ix. p. 115)- He found that so long as pulsation existed in the radial artery the average temperature of the mouth was about 92 0 . In some cases it sunk to 88° or 86°, and in one dying subject it was as low as Bi°. In the case of one patient the temperature of the mouth had fallen to 84 0 in six hours after an attack which commenced without premonitory symptoms. I have met with no observations on the temperature of the blood in cholera, except some by Professor Czermack, of Vienna, which are referred to by MM. Briquet and Mignot (xxx. p. 28a). The temperature of the blood drawn from the veins, in seven cases of cholera, is there given, and the average in round numbers is 83 0 Fahrenheit. Briquet and Mignot found by experiment, 189 EPIDEMIC DIARRHCEA AND CHOLERA. that the blood loses about five degrees of Fahrenheit in passing from the vein into the bleeding-vessel. It may, therefore, be assumed, that the blood in the veins of the arm in these seven patients was asJow as about 88°. It is not probable that the blood in the heart and lungs would be as much cooled as this, but it can scarcely be doubted that the reduction of temperature is sufficient to assist in retarding the flow of blood through the lungs. The effect of the hot saline injection in raising the temperature of the mouth is well shown in the case before cited from Dr. Paine's work (see antea p. 114). The temperature of the mouth was 93 0 before the injection; three pounds of solution, at 114 0 , were transfused, and the temperature of the mouth rose to ioi^°. Although it is in the highest degree probable that the cooling of the blood and of the lungs is an element concerned in retarding the flow of blood, yet this cause of obstruction is certainly not the first in the order of time or of importance. The reduction of temperature is itself a consequence of the impeded flow of blood through the lungs, as I have already intimated, and as I shall show more fully hereafter. Nor, again, is it only such an impediment as may have been occasioned by the cooling of the blood that the hot injections may be supposed to overcome; for it is in the highest degree probable that the contractility of the arteries, by whatsoever cause it may have been excited, would be much lessened by the contact of the solution which, even after mixture with the cool blood in the right cavities of the heart and in the pulmonary artery, would be considerably above the natural temperature of the blood, as Dr. Paine's observation above cited proves. It has been a matter of common observation, that external warmth, as from a hot-air bath, relieves the muscular cramps, and it is by no means 190 THE PATHOLOGY OF improbable that the warmth of the saline injection may have a similar effect upon the muscular coats of the minute branches of the pulmonary artery. The, best illustration which I have seen of the effect of heat alone upon the symptoms of collapse, is afforded by some cases — reported in Mr. Barwell's work (viii. p. 112) — which were treated by the ' hot wet sheet,' i. c., a sheet wrung out of boiling water, in which the naked patient was wrapped, and then covered closely by five or six blankets. He was kept in this covering for an hour, the head and face only being exposed. The effect of this was to relieve the cramps, and frequently to warm the tongue and skin, so that the body came out in a glow. The face sometimes lost its choleraic aspect after about half-an-hour's warming; and when the patient came out of his envelope, the pulse was found to be improved. One case of great collapse 'treated in this manner recovered without taking any medicine. Now, although there are some great disadvantages in this mode of treatment, it affords a good illustration of the assistance which may be given to the circulation by any measure which thoroughly warms a patient in collapse ; and in this respect the influence of the hot wet sheet, although probably less powerful, is yet very similar to that which the mere warmth of the saline injection exerts. In conclusion, then, we may assert, respecting the operation of the saline injection into the veins, that its primary action is upon the movement of the blood through the lungs, which it may assist in various ways; and although it is easier to obtain evidence as to the separate influence of the high temperature of the fluid upon the pulmonary circulation during collapse, it is by no means improbable that the water and the salts may each contribute towards the beneficial result. Whatever may be the precise mode in which it acts in EPIDEMIC DIAERH(EA AND CHOLEEA. 191 promoting the flow of blood through the . lungs, there can be no difficulty in perceiving that the good results would generally be of short duration ; for the primary cause of the impeded circulation — namely, the morbid condition of blood — being still in action, and the originally hot solution being cooled down by its diffusion through the entire mass of the blood, the stream of blood through the lungs will soon again diminish, the temperature will fall, and the patient thus passes into a state of collapse as profound and more hopeless than before. With respect to the severe rigors which usually follow the saline injection (see p. 1 14), and which, as Dr. Mackintosh admits, 'afford proofs the most decisive of a pathological change in the system,' it is impossible to determine with certainty whether they are occasioned by some influence exerted by the solution itself upon the structure and vital properties of the blood, or whether they may not result from the sudden transmission into the arteries of the large amount of morbid blood, which had accumulated in the veins in consequence of the impediment in the lungs. The distressing, and often the fatal results, of the impeded pulmonary circulation, are sufficiently apparent ; but still it is a question whether it is not, on the whole, beneficial that the blood should be sent through the lungs only in small quantities, until it has lost some of its morbid qualities by the elimination of the poison. One great difference between the action of venesection and of the saline injection is, that whereas the former abstracts a portion of the morbid blood, and so procures a free passage for the remainder, the latter simply overcomes the impediment which had kept the greater part of the morbid fluid in the venous system.* * One of my friends has suggested to me that it is difficult to understand how the poison of cholera can reach the intestines and excite purging, on the supposition that it is prevented from passing through the lungs. The answer to this objection is, that 192 THE PATHOLOGY OF Any plan of treatment which removes symptoms without touching their cause and origin, is generally dangerous, and often injurious; and the results of the saline injectio — 131 deaths to 25 recoveries — prove that this forms no exception to the rule. Sec. XI. Consequences of impeded floiv of blood through the lungs. I purpose now to examine more in detail the consequences which must ohviously result from the very remarkable condition of the pulmonary circulation which has been proved to exist during the stage of collapse in cholera. We have seen that the impediment to the passage of the blood occurs in the minute branches of the pulmonary artery ; the consequence is that only a small quantity of blood reaches the capillaries, where the interchange of gases takes place — i.e., where carbonic acid is given off and oxygen taken into the blood, — the result, of necessity, is a reduction of the supply of oxygen proportioned to the smallness of the stream of blood which passes through the lungs to the left side of the heart. The oxidation of those blood-constituents which normally undergo that process must therefore be diminished in the same degree as the supply of oxygen, and the result is that less carbonic acid and less of the con- so long as the patient lives, a portion of morbid blood is continually passing through, the lungs and distributed to every tissue of the body, as black blood circulates through the arteries in cases of ordinary asphyxia. But when, either in the collapse of cholera or in asphyxia from suffocation, the impediment to the flow of blood through the lungs exceeds a certain degree, circulation ceases, and life becomes extinct. So long as life continues, the pulmonary circulation, obviously, is only impeded, and not entirely arrested. But I attribute the cessation of purging, which occurred in one of my cases, (Case 23, p. 40) to the small quantity of blood which passed through the lungs, and the scanty supply which consequently reached the intestines. 193 EPIDEMIC DIARRHCEA AND CHOLERA. stituents of bile and urine are produced. These results might have been predicted by any physiological chemist, as of necessity following such a condition of the pulmonary circulation as exists in cholera; and that such results actually occur can be proved by numerous and very conclusive facts. The reduction of temperature, which is so constant an accompaniment of the stage of collapse, is one of the consequences as well as one of the most conclusive proofs of diminished oxidation or combustion ; and this, too, is in strict agreement with the fact that the quantity of carbonic acid in the expired air is much lessened. ' Dr. Davy has shown that in the cold stage, even when the inspirations are ample and frequent, the air expired is not only colder than usual, but contains less than the ordinary proportion of carbonic acid.'* And Doyere, who repeatedly examined the expired air of a young woman, until the period of her death, found that, in general, the quantity of carbonic acid was much diminished, and that it increased simultaneously with any improvement in the general condition of the patient. (Lehmann, xliii. vol. 3," p. S3 2 ") But tne most careful experiments which I have met with are those recorded by Twining (v. p. 15), who states that, during the cold stage, he has several times found the quantity of carbonic acid in the expired air as low as 1.5 per cent., and seldom so much as 2 per cent. Now, Dr. Carpenter (xiii. p. 530) estimates the normal amount of carbonic acid in the expired air, at the ordinary rate of respiration, at about 4-35 P er cent - But a com P ar i s °n of these numbers affords insufficient data for determining the actual decrease in the amount of carbonic acid formed during collapse. We must also take into consideration the total * Dr. Budd'a article, 'Cholera,' in Library of Practical Medi. cine; vol. iv. p. ill. o 194 THE PATHOLOGY OP quantity of air expired, which is found to be greatly diminished. Twining appears to have experimented with great care, and he states that ' it is often very difficult to procure even ten cubic inches of air, in a satisfactory manner, from the lungs of a person in the stage of lowness and collapse, when restlessness and extreme anxiety prevail.' Whereas the average quantity of air expired by persons in health appears to be about 20 cubic inches. (Carpenter xiii. p. 529.) The result of Twining's experiments is in strict agreement with the incompleteness of the respiratory movements during collapse, the imperfect expansion of the chest, the feebleness and sometimes even the complete absence of the vesicular respiratory murmur,* — phenomena which clearly indicate that much less than the usual amount of air is respired. If, therefore, the amount of expired air is reduced by one-half, and if the proportion of carbonic acid, even in that smaller quantity of air, is less than half the usual amount, it is evident that the amount of carbonic acid exhaled must be less than one-fourth of the normal average. And these results are confirmed in a very interesting manner by physiological considerations. For instance, it is evident, when we compare and contrast the phenomena of cholera with those of asphyxia, that if, with the same degree of impediment to the passage of blood through the lungs, carbonic acid were generated in the blood as rapidly as in ordinary circumstances, the patient would be killed by the narcotic influence of the gas in a few minutes — nay, in a few seconds. * The incomplete entrance of air into the pulmonary cells, in consequence of the diminished supply of blood to the capillary vessels, appears to be, as it were, the counterpart of the fact before referred to, (p. igl), namely, the collapse and exsanguine condition of a portion of lung from which the access of air has been cut off These facts, taken together, appear to prove — what other facts render in the highest degree likely— that there is a mutual attraction between the blood in the capillaries and the air in the cells, so that when the access of one is prevented or limited, the supply of the other is lessened in a corresponding degree. EPIDEMIC DIARRHCEA AND CHOLERA. 195 The passage of blood through the lungs in the extreme collapse of cholera is so much obstructed that the arteries are comparatively empty, and the pulse is often imperceptible. This obstruction occurring in the pulmonary arteries limits the supply of oxygen, and consequently the formation of carbonic acid. In the case of asphyxia, on the contrary, whether it occur slowly, during the progress of disease, or suddenly, from accident — as drowning or other means which arrest the respiratory functions — the obstruction occurs, not in the pulmonary artery (which being accustomed to receive and to transmit black blood, offers no impediment to its passage), but in the pulmonary capillaries ; possibly, too, as Mr. Erichsen has suggested (xxvi. vol. 63), in the minute branches of the pulmonary veins ; and it is a direct consequence of the excess of carbonic acid in the blood. But the animal, whether human or brute, is rendered insensible by the action of the carbonic acid on his brain long before the stream of blood through the lungs can be diminished to the degree in which it is during the collapse of cholera ; indeed, before it is perceptibly diminished in any degree. This statement admits of the most conclusive proof from observations on the lower animals as well as on man. Thus, in Dr. Keid's accurate experiments, before described (p. 147), it was observed that for a period of about two minutes after a dog had been rendered insensible, and had ceased to struggle, in consequence of the air having been shut off from the lungs, the arteries continued to be unusually distended with the black blood which they received from the lungs, and the heemadynamometer showed an increase of pressure upon the arterial walls. Again, in the human subject, when a patient is gradually dying from the slow asphyxia produced by such a disease as emphysema of the lungs, with bronchitis and effusion into the air-tubes, we often find the pulse full and the features swollen and bloated, in consequence of 0 2 196 THE PATHOLOGY OF the impeded flow of the black blood from the arteries into the veins. And long before the volume* of the pulse can be lessened by the limited passage of unoxygenized blood through the lungs, the patient has usually passed from a condition of increasing drowsiness into one of profound and fatal coma. Now, a patient in collapse from cholera, with so scanty a stream of blood through the lungs that the arterial pulse is quite imperceptible, is often as free from drowsiness and as fully in possession of his mental faculties as a person in perfect health. It is obvious, therefore, that in such cases there can be no great accumulation of carbonic acid in the blood, and that this relative deficiency of carbonic acid can be explained only by the supply of oxygen being greatly diminished. " During the progress of the recent epidemic, I noticed a fact which must also have been observed by others, namely, that while some patients in collapse were quite free from any symptoms of drowsiness or cerebral torpor, others manifested these symptoms in different degrees; and, further, it appeared that the drowsiness was greater in proportion as the depression of temperature was less. One patient, whose skin was not cold, but rather warm, was so drowsy that I was apprehensive that he would become hopelessly comatose (see case 18, p. 32), while others who were icy-cold — as, for instance, case 1.7, q }> 29) — were invariably free from drowsiness. Others, again, in whom there was a less reduction of temperature, were torpid, but readily roused when spoken to. I frequently pointed out these differences before I could obtain any explanation ; but at length my friend Dr. Beale suggested, that as the higher temperature indicated * The force of the pulse, in these cases, is often much diminished by the circulation of black blood through the muscular structure of the heart. 197 EPIDEMIC DIARRHOEA AND CHOLERA. a more active combustion, so the cerebral torpor might be occasioned by the influence upon the brain of blood charged with the products of combustion. It can scarcely be doubted that this is the true explanation of the phenomena. If the cerebral torpor depended merely on venous congestion, it should, obviously, bear a direct relation to the amount of obstruction in the lungs; but it is not so, for this reason — that a scanty stream of blood through the lungs involves a small supply of oxygen, consequently, little carbonic acid and heat are formed, and there is little tendency to drowsiness. It is not to be supposed that with so scanty a stream of blood through the lungs, the carbonic acid escapes as readily in proportion to the quantity existing in the blood as it does in health. Indeed, that there is some accumulation in the blood, in certain cases at least, is probable, from the occasional drowsiness just now referred to. And the same observation applies, as we shall presently see, to the constituents of bile and urine. The physiological difference between the condition of a patient in any of the ordinary forms of asphyxia and in cholera asphyxia* is, in some degree, illustrated by the results of the following experiments, which were performed by Dr. Davy, with a view of showing what he calls the 'secreting power of the lungs;' in other words, their power of separating carbonic acid from the blood, * The term ' asphyxia' appears to have been first applied to cholera by an Indian surgeon, Mr. Cruikshank, in 1814, and the term ' cholera asphyxia' was first suggested by Scot. (See his Report, pp. xv. and xx.) Both these gentlemen, as well as Bell and others, applied the term in its literal sense (weakness or absence of pulse). It now, however, appears that this term is applicable in a double sense, not only as implying a pulseless condition, but also a form of suffocation — the latter being the sense in which the word asphyxia is now commonly used. The term cholera asphyxia, therefore, has a peculiar appropriateness and significance when applied to the collapsed stage of cholera. 198 THE PATHOLOGY OF (xiv. vol. 2, p. 171): — 'A full-grown guinea-pig was killed by strangulation; the animal died in about a minute after a cord had been drawn tightly round its neck. Another animal of the same kind, placed on the plate of the air-pump and confined by a receiver just large enough to hold it, lived about five minutes after the exhaustion had been commenced ; the pump, the whole time, having been worked rapidly. The bodies were immediately examined. The heart of the strangled animal was motionless ; it was distended with dark blood ; twelve measures of the blood broken up and agitated with twenty-nine of carbonic acid gas, absorbed eighteen measures, or 150 per cent. The heart of the other guinea-pig was also distended with blood, but of a less dark hue — its auricles were feebly acting; the lungs were 'paler than in the former, and more collapsed; ten measures of blood from the heart broken up and agitated with fifty of carbonic acid, absorbed thirty-seven measures, or 370 per cent. Now, it is evident, that in the case of the first animal the elimination of the carbonic acid was suspended immediately and entirely by the ligature ; the consequence was, that the gas continued to increase through the agency of the oxygen remaining in the lungs, and the heart quickly ceased to beat. In the second animal the carbonic acid would be less abundantly formed in proportion to the rarefaction of the air, and it would continue to be eliminated so long as any air remained in the receiver ; the consequence was, that the animal lived five times as long as the other, and after death the blood contained less than half the quantity of carbonic acid, as shown by the volume of gas which it was still capable of absorbing. The cause of death in this case was probably not so much the carbonic acid in the blood as the total abstraction of the atmospheric air from the receiver. It may, perhaps, be thought that the more speedy 199 EPIDEMIC DIARRH(EA AND CHOLERA. death of the strangulated animal was occasioned by the compression of the blood-vessels simultaneously with the trachea. The following experiment, performed by Sir Benjamin Brodie (xliv. p. 58) will suffice to prove the inaccuracy of that explanation : — ' I passed a ligature under the trachea of a guinea-pig, and having drawn it as tight as possible, I secured it with a knot at the back of the neck, so that it included all the parts situated in the neck, with the exception of the trachea. The animal seemed uneasy, but breathed and moved about, and continued to do so after the ligature was removed at the end of a quarter of an hour from the period of its application.' The explanation of this result is, that the circulation was carried on through the vertebral vessels, which are out of the reach of pressure. The nearest approach to the condition of a cholera patient — so far as regards the respiratory phenomena — in which an animal could be artificially placed, would be by keeping him in an atmosphere which contains much less than the usual proportion of oxygen, and at the same time continually changing the air, so that the carbonic acid should not be allowed to accumulate. The difference between the two cases is, that the impediment to the flow of blood through the lungs, which is occasioned by the poisoned blood of the cholera patient, would not exist in the case of an animal confined in an atmosphere of very diluted oxygen. There appears no reason to suppose that the blood, during the collapse of cholera, is in any degree less than usual susceptible of the process of oxidation ; for it is found that the blood, taken from the body, either during life or after death, assumes the usual red colour when exposed to the air ; the colour of the lungs is brightened by artificial respiration, and when the pulmonary circulation has been freed from impediment, either by venesection or by the saline injection or by the elimination 200 THE PATHOLOGY OF of morbid material through the intestinal canal — in each case the free admission of oxygen with the more copious stream of blood, is immediately followed by a rise of temperature, and the other signs of a more active combustion. The limited supply of oxygen during collapse is obviously a sufficient cause for the defective oxidation, and it would be unphilosophical to seek for another cause. One result of the limited supply of oxygen during collapse, must be an excess of unoxidized material in the blood ; and it is probable that this altered composition of the blood may be one amongst the secondary causes of its impeded passage through the lungs ; at the same time that it diminishes the fitness of the blood for undergoing the respiratory changes, so far as these depend on the interchange of the gases — carbonic acid and oxygen. As this condition of blood is one of the consequences of the limited supply of oxygen, so its removal can be effected only by a more liberal admission of that gas. Knowing what we now do of the immediate cause and the consequences of the defective supply of oxygen in cholera, we can ex23lain the partial benefit, but yet the unsatisfactory results, said to have been obtained by making patients in collapse inhale pure oxygen gas. Mr. Martin tried the experiment upon one of his patients, and he states that, ' the effect for half-an-hour was extraordinarily promising ;' but from want of a proper apparatus he was unable to continue the experiment (xi. P- 353)- Dr. Gull reports (vii. p. 2io) that Mr. Allen, of Oxford, administered oxygen gas in four instances. 'A mouth-piece, having an inspiratory and an expiratory valve, was attached to a mackintosh bag, containing four gallons of pure oxygen. After about six inspirations the countenance slightly improved, but no permanent benefit ensued.' EPIDEMIC DIARRHOEA AND CHOLERA. 201 The effect of the experiment would obviously be to introduce into the blood a larger supply of oxygen than would find entrance when atmospheric air is inhaled, and the result would be a greater oxidation of the blood-constituents, and a corresponding increase of temperature. This rise of temperature, and the altered composition of the blood, would perhaps, in some degree, assist the flow of blood through the lungs, and would thus far contribute to increase still more the supply of oxygen. But the benefit thus conferred would be limited by the fact that the morbid condition of blood which is the chief cause of the impeded circulation, is not influenced, so far as we know, by the oxygen. And it is possible that a more rapid combustion without a corresponding facility of eliminating its products through the lungs, Avould be attended with symptoms of narcotism, through the poisonous action of carbonic acid on the brain. We have seen no reason to believe that the cholera poison exerts any directly depressing influence on the heart, such as many pathologists have supposed, and by which they have made unsatisfactory attempts to explain the extreme smallness and feebleness of the pulse during collapse. The character of the pulse is fully and completely explained by the impeded flow of blood through the lungs. It is, however, by no means improbable, that amongst the consequences of the imperfect aeration of the blood may be included some diminution of the muscular power of the heart. It appears reasonable to suppose that the contractile vigour of the left ventricle is in some degree impaired by the circulation through its substance of insufficiently oxygenized blood ; and this enfeebled condition of the left ventricle may explain the occasional, though comparatively rare appearance of some accumulation of blood in its cavity after death — an appearance which would imply a want of power in the ventricle to expel its contents. 202 THE PATHOLOGY OF It is a fact admitted, as we have seen, by very experienced and competent observers, that actual syncope is a rare occurrence in cholera. The instances of sudden death during collapse, which have sometimes been thought to arise from syncope, are more probably explicable by the impediment to the passage of blood through the lungs having suddenly become so great as to be incompatible with life, on account of the insufficient supply of blood received by the left side of the heart and by the brain. It is, however, of practical importance to remember that the risk of this catastrophe, no less than that of ordinary syncope, is increased by muscular exertion or excitement; against which, therefore, the patient ought, as much as possible, to be warned and guarded. Sec. XII. Phenomena of reaction. The observations which we have hitherto made, have related chiefly to the stage of collapse. When reaction comes on, a different series of phenomena present themselves. One of the earliest indications that the blood is beginning to pass more freely through the lungs, is a less sunken appearance of the eyes, and this is always associated with a return of the pulse, which has perhaps for some hours been imperceptible ; or an increase in its power and volume, when it has previously been extremely feeble and small. Simultaneously with these signs of amendment the temperature rises, and the colour of the skin improves, the cheeks and lips often assuming a pink tinge, which forms a pleasant contrast to the cadaverous appearance which it displaces.* These signs of amend- * We have now no difficulty in understanding the rapid recoveries from the state of collapse which often occur, and we see that such recoveries bear a closer resemblance to the restoration of animation after submersion in water than Twining probably 203 EPIDEMIC DIARRHOEA AND CHOLERA. ment indicate that oxygen is again freely admitted with the fuller stream of blood through the lungs to the left side of the heart and the arteries, and that, in consequence, the process of combustion, with the evolution of heat, is resuming its usual activity. During the period of reaction, Twining found that the expired air contained from 3.5 to 4 per cent, of carbonic acid, and sometimes more than that amount (v. p. 15). When a patient dies during the stage of reaction, the lungs are often found of a dark colour, much congested, and containing a large quantity of blood and serum. In some cases this state of engorgement passes into one of complete hepatization. This condition of lung, after reaction, was first described by Mr. Jackson (xxxviii.). It was afterwards particularly referred to by Dr. Budd (xxxix. vol. 4, p. 116), who pointed out the necessity of careful auscultation to discover this form of pneumonia, which might otherwise escape detection during life. It will be seen that the condition of lung here referred to, forms a remarkable contrast to the pale, bloodless, and collapsed appearance which characterises the lung when death has occurred before the period of reaction. The probable explanation of the difference is the following : — The occurrence of reaction, which is marked by the symptoms just now described, is attended by this change in the circulation through the lung ; the morbid condition of blood which excited the contractility of the pulmonary arteries has ceased; and the blood, charged with one of the products of combustion — carbonic acid — passes freely into the pulmonary capillaries, but not freely through them, unless the carbonic acid is given off as rapidly as it is formed and conveyed to the lungs. When the elimination of the gas is slower than its formation, imagined when he made the comparison which I have before quoted (p. 105). 204 THE PATHOLOGY OF the vessels of the lung become more and more gorged, and the usual phenomena of asphyxia occur.* The circumstances which favour this engorgement of the lung during reaction, are probably — ist, A free administration of opium and alcohol in the previous stage, so that the blood becomes charged with combustible materials, which being rapidly oxidized during reaction, lead to the formation of more carbonic acid than the lungs can dispose of; 2nd, A previously morbid condition of lung (this occurred in Case 33, p. 107) ; and, 3rd, It is probable that great exhaustion and an enfeebled condition of the heart may help to produce pulmonary engorgement. It is practically of much importance to be on the watch for the signs of pulmonary engorgement during the period of reaction. It is during the first few hours after the returning warmth of the skin has indicated that the process of oxidation is becoming more active, and when the lungs are being, as it were, overworked, that this complication is likely to occur. One of the earliest signs of this condition is a slight return of the sinking of the eyes, with a diminution of the power and volume of the pulse, and occasionally a fall of temperature ; symptoms which are all indicative of the flow of blood through the lungs becoming again impeded. At the same time the breathing is hurried, or it is heavy and laborious, and there is usually more or less of drowsinesss. These symptoms were all present in Case No. 45 (p. 77), and some of them in Case No. %1 (p. 38). When symp- * The difference between the condition of the lung in collapse and during reaction, is, in some degree, illustrated by Dr. Davy's experiment on the two guinea-pigs (see p. 197). The animal placed in the air-pump receiver, from which the air was gradually withdrawn, had his lungs paler and more collapsed than the strangled animal. The degree of engorgement of the lungs corresponded with the relative quantities of carbonic acid in the blood of each animal. 205 EPIDEMIC DIARRH(EA AND CHOLERA. Toms of tins kind occur, the posterior and lower parts of the chest should be carefully examined for signs of condensation of the lung, or of secretion into the airtubes. lam now convinced that the coma which so^metimes occurs during reaction, when the bile and urine are being copiously secreted, is occasioned by the carbonic acid which accumulates in the blood in consequence of the engorgement of the lungs. I believe that this was the cause of the fatal coma in the two cases referred to above, and that the treatment should have been directed chiefly to the lungs. Sec. XIII. Cause of the suppression of bile and urine. That a certain amount of oxygen is as essential for the formation of bile and urine as it is for the generation of carbonic acid, is a well established and almost a selfevident fact. It therefore follows that in pointing out the conditions which, of necessity, involve a very scanty supply of oxygen during the period of collapse, we have indicated the source whence arises the suppression of bile and urine. The secretions are suppressed simply because the blood does not pass through the lungs in sufficient quantity to introduce the supply of oxygen necessary to form these products of combustion in any but the scantiest proportions. It is probable that minute quantities of bile and urine, as of carbonic acid, are continually being formed and even secreted during collapse, for traces of bile may occasionally be detected in the stools by careful testing, and small quantities of the urinary constituents may pass off by the same means,* and even through the kidneys, oftener * Dr. Garrod detected a trace of uric acid in the stools on 206 THE PATHOLOGY OP than is suspected ; but both these secretions are virtuallysuppressed during collapse. Yet they do not accumulate to any extent in the blood ; for we have seen (p. 134) that only a slight excess of urea, if any, can be found there during this stage, and it is only when the kidneys fail in the discharge of their functions after reaction sets in, when the constituents of bile and urine are being abundantly formed, that any considerable accumulation of urea occurs. Nor is there usually any evidence of an accumulation of bile in the blood. Simon, however, states (xlii. vol. 1. p. 326), that in one case he found the constituents of the bile (bilin and biliverdin) in the blood. The probable reason why there is any increase of urea in the blood during collapse is, that the morbid condition of blood impedes the circulation through the kidney as it does that of the lung,* and so retards the elimination of the small quantity of urinary excrement which is formed during this stage. We have conclusive evidence of a certain degree of renal congestion, in the fact that the urine passed during the first few hours after reaction is, in most cases, slightly albuminous. There are some striking abnormal appearances of the blood in cholera, the explanation of which will naturally lead us to attempt an interpretation of the connexion one occasion (see ante p. 139), and Dr. Henry Johnson, of Shrewsbury, appears to have found urea in the stools of one patient in collapse. {London Journal of Medicine, vol. i., p. 952.) There is the chance of urine from the bladder having been mixed with the stools in these cases. * It is very probable that the morbid blood of cholera passes with as great difficulty through the liver and kidneys, and perhaps through various other organs, as it does through the lungs ; but the impediment in the lungs is of far more serious import than that which occurs elsewhere, for the simple and obvious reason that all the blood in the body has to pass through the lungs, and, in so doing, to serve as the channel for the introduction of atmospheric air. EPIDEMIC DIARRHOEA AND CHOLERA. 207 between the physical characters of the blood; the suspended formation of carbonic acid, bile, and urine; and the limited supply of oxygen. Sec. XIV. Changes in the colour, coagulability, and density of the blood. The dark colour and the defective coagulability of the blood during collapse, are, in all probability, direct results of the deficient supply of oxygen. With respect to the colour there can scarcely be a doubt, for the dark blood is reddened by exposure to the air; and when, by any of the means before referred to, the freedom of the pulmonary circulation, and, with it, the supply of oxygen is restored, the blueness of the face and lips, which had been occasioned by the circulation of black blood, is immediately replaced by the pink hue which indicates the free circulation .of oxygenized blood. There are many facts which tend to prove that the coagulability of blood is greatly influenced by the supply of oxygen which it receives. Thus, arterial blood coagulates more rapidly and more firmly than blood taken from the veins of the same animal. Dr. Davy made careful observations on this point, (xiv. vol. 2, p. 13). He allowed the blood from the carotid artery and from the jugular vein of lambs to flow into similar vessels, and noted the rapidity and the firmness of coagulation. And the result invariably was that the arterial blood coagulated more rapidly and more firmly than that from the vein. Dr. Davy also observed that in the human subject when death has occurred in any of those modes which involve an imperfect aeration of the blood during the latter periods of life, the coagulability of the blood is often impaired. I give the results of his 208 THE PATHOLOGY OF observations in his own words (xiv. vol. 2, p. 192): — ' The instances in which the blood was found liquid, and not coagulable on exposure to the air, the fatal event in the majority of cases, was referrible to the respiratory organs, and was owing either to drowning, hanging, the fumes of charcoal, or the effusion of blood into the bronchi or air-cells. The former occurred in a case of pneumonia; the latter in two cases of sudden death from what Laennec has called pulmonary apoplexy. The blood's liquidity in these cases was not a postmortem effect resulting from putrefaction; this was clearly ascertained. It ivas oiving either to the loss of the natural fibrin or lymph, on which the property of coagulation depends, or such an alteration in it as to deprive the lymph of this quality.' The influence of oxygen upon the amount of fibrin in the blood, is shown in a very conclusive manner by some observations of Dr. Gairdner* (xli. p. 152). He first analyzed the blood from the heart and aorta of six healthy rabbits, and he found that the average amount of fibrin in 1000 parts was 1.65; globules, 82.35 ; albumen, 46.3. He then made three other rabbits breathe a highly oxygenated atmosphere, and the average result was, fibrin, 2.4; globules, 69.56; albumen, 40.23. It was evident, therefore, that under the influence of this excess of oxygen, the fibrin had increased, w r hile the globules and albumen had considerably diminished. Now, this result is strictly in accordance with the observation of Dr. Franz Simon, who says, (xlii., vol. 1, p. 157), 'It is a well known fact that the respiratory process not only increases the plasticity of fibrin in the blood, but also its quantity; and that, on the other hand, the amount of fibrin diminishes in blood * Dr. Gairdner's experiments are referred to by Dr. Carpenter, in his Principles of Human Physiology, p. t6o, fourth edition. EPIDEMIC DIARRHCEA AND CHOLERA. 209 which is not efficiently brought in contact with oxygen.' The condition of the fibrinous portion of the blood in cholera, affords a good illustration of this doctrine. Simon also states, and confirms his statement by the results of analysis, that, with very few exceptions, the amount of fibrin always varies inversely with the mass of the blood-corpuscles ; or, in other words, that the more corpuscles there are, the less in quantity is the fibrin, and vice versa. He explains this result by supposing that the oxygen quickens the metamorphosis of the corpuscles, and that the products of this metamorphosis are fibrin and at the same time urea, uric acid, and bilin. This statement is obviously, in some degree, conjectural ; but there is a fact which appears to confirm one part of the hypothesis, and that is the discovery of the very close relation which exists between the colouring matter of the blood and that of the bile. It has been found that crystals of hsematoidin may be obtained from bile as well as from blood; so that, as Lehmann remarks (xliii. vol. I, p. 29a), if bilifulvin and hsematoidin are not identical, they must be very closely related, since the former may readily be converted into the latter. Now, we shall presently find that these facts are of great interest in connexion with the pathology of the blood in cholera ; and the following extract from Simon (xlii. vol. I, p. 160) will be seen to have an immediate relation to the subject. He says, ' If the circulation be impeded in any part of the body, and it is prevented from receiving its due supply of oxygen, the metamorphosis of the corpuscles will likewise be impeded and rendered imperfect; the matured blood -corpuscles, which are approaching the stage of solution, will not be dissolved, and there will consequently be an accumulation of colouring matter, especially of heemapheein, which is the most abundant pigment in the matured corpuscles.' Now, we have seen from the analysis of the blood (ante, p. 133), that r 210 THE PATHOLOGY OF this accumulation of colouring matter occurs in cholera : and the condition of the cholera blood affords a remarkable confirmation of Simon's statement, that the metamorphosis of the corpuscles is hastened by an excess and retarded by a deficiency of oxygen. We find, too, that in cholera the albumen is in excess. In fact, the cholera blood is in a condition the exact opposite of that of the blood in Dr. Gairdner's highly-oxygenized rabbits (see p. 208) ; the fibrin is deficient, the corpuscles and the albumen are in excess. Now, it would be unreasonable to deny that this relative excess of solid matter, and the consequent high density of the blood in cholera, is, in part, occasioned by the loss of fluid through vomiting and purging. It can scarcely be supposed that any form of profuse diarrhoea does not, for the time, diminish the amount of liquid in the blood. But it would be not less unreasonable to doubt that the limited supply of oxygen, and the consequent more or less complete suspension of the normal metamorphoses, must have the effect of increasing the density of the blood, by arresting the oxidation of those of its constituents which, in health, are constantly eliminated in the form of bile, urine, and carbonic acid.* It is quite certain that, during the period of reaction, when oxygen is freely entering the circulation, the blood is, at every moment, losing a portion of its solids, which are passing off in combination with oxygen ; and that by this means, no less than by the absorption of liquid, the blood is diminishing in density. The reverse of this must be supposed — may, indeed, be said to have been proved by analysis — to occur during collapse. The close relation which has been found to exist between * The result of the incomplete oxidation of the blood and the tissues, which occurs during collapse, may be compared with the dense and smoky flame of a lamp which receives an insufficient supply of air. EPIDEMIC DIARRHOEA AND CHOLERA. 211 the colouring matter of blood and that of bile renders it in the highest degree probable that the copious bilious stools which occur during reaction are the products of the blood-corpuscles which, having accumulated during collapse, afterwards undergo a rapid metamorphosis under the influence of oxygen. That one result of this metamorphosis is the formation of carbonic acid is proved by the fact, that when blood is agitated with oxygen a portion of the gas is absorbed, carbonic acid is formed, and heat evolved.* There appears, therefore, little doubt that some of the constituents of the bile and carbonic acid result from the metamorphosis of the blood corpuscles ;f but there is no proof that either fibrin or urea is derived from the same source. Lehmann appears to be of opinion that fibrin is the result of the action of oxygen upon albumen. Fibrin, he says, may be considered to be intermediate between albumen and the organized tissues (vol. I, p. 343). If this be the source of fibrin, then the excess of albumen in cholera blood would be in part explained by the arrested formation of fibrin. Another possible explanation of this fact is, that some of the constituents of urine, and even of bile, may be derived from the oxidation of albumen. Thus Liebig shows (xl. p. 439) that one atom of albumen, 10 eqs. of water, and 56 eqs. of oxygen, contain the same * Dr. Davy found (Op. cit. vol. 2, p. 168), that when six ounces of venous blood were agitated in a bottle with one and a half cubic inch of oxygen gas, the temperature rose from 45 0 to 46.5, very nearly to 47 0 . f Professor Scherer, of Wurtzburg, is of opinion that the yellow colouring matter of urine is a direct result of the destructive assimilation of old blood-corpuscles. (See Dr. Golding Bird's Urinary Deposits, p. 104). Ihe fact that, in cases of jaundice, when bile accumulates in the blood, the constituents of that secretion are abundantly separated by the kidneys, is an additional evidence of the close relation which exists between these various forms of colouring matter, and increases the probability that they may have a common origin in the disintegrated blood-corpuscles. P2 212 THE PATHOLOGY OF elements as I eg. of choleic acid, two equivalents of cholic acid, 12 eqs. of urea, and 36 eqs. of carbonic acid. Now, this formula does not, of course, afford any proof that bile, urine, and carbonic acid are thus formed from albumen, but it does help us to perceive how essential a large supply of oxygen is for the formation of those excretory products from any of the protein compounds ; and it is this fact with which we are chiefly concerned. In the present state of organic chemistry, it is not possible to determine the exact sources of urea. We know that it must have more than one source, for we see that many dyspeptic patients pass it in large quantities after meals, and we conclude that it has been obtained directly from the imperfectly assimilated food. Then, too, we find that it is continually passed by animals who have been long fasting, and abundantly too, after muscular exercise, and we infer that it has been obtained through the blood, from the waste of muscular tissue. Another interesting fact connected with the metamorphosis of muscular tissue, is the discovery by Pettenkofer, of those two crystalline bodies, creatine and creatinine, in the urine, and the subsequent identification of them by Liebig with the body, which had long before been described by Chevreul as occurring in the juice of flesh (xlv. p. 95). The same substances have since been discovered in the blood of oxen, by operating on large quantities of that fluid.* Since then, to use the words of Dr. Carpenter (xiii. p. 63), creatine 'is found so constantly in the juice of flesh — more abundantly in that of wild and hunted animals than in that of tame and domesticated races, and most abundantly of all in that never-resting muscle, the heart, it may be fairly presumed to be a product of the disintegration of the * Carpenter's Principles of Human Physiology, p. 153 — note. EPIDEMIC DIARRH(EA AND CHOLERA. 213 muscular tissue ; and so far as we at present know it is the first product of that metamorphosis.' Now, although creatine and creatinine are both found in the urine, it is probable, as Dr. Golding Bird has suggested, that a considerable proportion of creatine is resolved into uric acid and urea, before its final elimination. And it seems not unlikely that, during the collapse of cholera, these and other allied products of disintegrated tissue may accumulate in the blood, in consequence of the defective supply of oxygen, and that the increased density of the blood may be in part occasioned by such accumulation. This view receives some confirmation from two analyses of urine passed during reaction, which are recorded by Dr. Letheby,* and in which he found the proportion both of urea and uric acid low, while that of extractive — creatine, creatinine, and other organic matters — was very high. One fact, confirmatory of the view that the very scanty formation of bile, urine, and carbonic acid during collapse is a result of the diminished supply of oxygen, is that the secretion of milk continues during the stage of collapse. Magendie states (vi. p. 27), that one of his female patients had been delivered of a child a few days before she was seized with cholera, and that the secretion of milk continued through a first and a second collapse, which ended fatally. So abundant was the accumulation of milk, that it was necessary to empty the breasts in order to relieve the pain which their distension occasioned. Now, it is evident that the chief constituents of milk — casein, sugar, and oil — may be obtained from the blood Avithout the addition of oxygen ; and it can scarcely be doubted that, in this fact we have the explanation of this secretion being continued during * Medical Gazette, December, 1849, and London Journal of Medicine, vol. 1, p. 143 — note. 214 THE PATHOLOGY OF collapse, when the oxygenized secretions are suspended. Magendie's explanation of the occurrence is, that the blood reaches the breasts, and supplies the materials for their secretion, on account of those glands being nearer to the heart than the liver and kidneys, which, being at a greater distance, do not receive the supply of blood necessary for the discharge of their functions ! Now, it is evident that those changes in the blood during the collapse of cholera, which are due to the limited supply of oxygen, ought to occur during the cold stage of an ague fit, exactly in proportion to the duration and the severity of the cold stage. And, so far as we have yet had the opportunity of seeing, such changes do actually occur. We find, for instance (see ante, p. IJ4), that the blood is described as being of dark colour, thick, and imperfectly coagulable; the secretion of urine, too, is either suspended or it is pale and limpid, from the deficiency of its solid constituents.* The state of the biliary secretion we cannot readily ascertain, for reasons before given (p. 172), but it is in the highest degree probable that it is affected simultaneously with that of the urine. Then, during the hot fit, the more active oxidation and disintegration of materials is shown by the deeply-coloured, turbid urine, as well as by the heat of skin and by the embarrassment of breathing, which is probably occasioned by the excess of * It is not without interest to remark that there are three forms of suppression of urine, unconnected with renal disease : First, the watery portion may be entirely absent or very scanty, in consequence of a drain of fluid from the bowels or from the skin ; this happens in choleraic diarrhoea without collapse, and in some diseases attended with profuse sweating. Second, the liquid portion of the urine may be secreted while the solids are defective, in consequence of a diminished oxidation of bloodconstituents ; this occurs during the cold stage of an ague fit. Third, during the collapse of cholera both the water and the solids are absent, in consequence of the simultaneous drain of fluid through the bowels, and the arrest of those disintegrative changes which result from the action of oxygen. 215 EPIDEMIC DIARRHCEA AND CHOLERA. carbonic acid then passing off by the lungs. The high temperature of the second stage, as well as the dense and turbid urine, are probably due to the rapid combustion of those materials which have been accumulating in the blood during the cold stage. And, if this be so, then the blood, at the end of the cold stage, will be found more dense and richer in colouring matter than either at the commencement of the fit or at the end of the hot stage. We will now consider for a moment some of the chief points of resemblance and of difference between an ague fit and the collapse of cholera, which have before been referred to (p. 169, &c). Sec. XV. Comparison of an Ague Fit with the Collapse of Cholera. The great factwhichiscommonto the two conditions is, the impeded flow of blood through the lungs, and the limited supply of oxygen which is consequent upon that impediment. There are considerable variations in the duration and the severity of the cold stage, or collapse, in either disease ; but, in general, the cold stage of ague is shorter and less intense in degree, than the collapse of cholera. Then, during the cold stage of ague, we must suppose that the morbid blood undergoes some change which at length allows of its free transmission through the lungs, and that the normal condition of blood is afterwards restored, through the agency of the various excretions during the hot and the sweating stages. We know as little of the nature of that mysterious change in the blood which puts an end to the cold stage by restoring the freedom of the pulmonary circulation as we do of that other equally mysterious change from the normal condition of the blood, which must be assumed to be in progress 216 THE PATHOLOGY OF when the symptoms of invasion commence, and which reaches its height simultaneously with the impeded pulmonary circulation which marks the intensity of the cold stage. In contrast with the phenomena of the successive stages of an ague fit we find that the morbid poison of cholera is gradually eliminated, by means of the vomiting and purging during the continuance of the collapse. So that, if these processes are uninterrupted, the elevation of temperature which accompanies reaction seldom exceeds a pleasant glow upon the surface, and rarely reaches a fever-heat. That this is the correct explanation of the hot stage of an ague fit and of the comparative infrequency of such a stage in cholera, is rendered in the highest degree probable by a consideration of the circumstances under which these conditions may be reversed. Thus, we learn from Twining and others, that when the cold stage of an ague fit is cut short by venesection at the commencement of the rigor — that is, before there has been time for any considerable accumulation of combustible material in the blood, — it is not usually followed by a hot or a sweating stage, while the same operation towards the end of the cold stage does not so. surely or so completely, if at all, diminish the duration or the severity of the succeeding stages. Then, with respect to cholera, it is an undoubted fact that the injudicious arrest of the intestinal discharges, by opiates and astringents, has, in a large proportion of cases, been followed by a febrile condition as formidable and as fatal as the stage of collapse. The loss of fluid by the intestinal canal, in cholera, while it doubtless adds to the density of the blood in that disease, cannot be considered to be the cause of the impeded flow of blood through the lungs, or of the other leading symptoms of collapse, since we find that an impediment to the pulmonary circulation, often equal in 217 EPIDEMIC DIAEEH(EA AND CHOLERA. degree to that which occurs in cholera, and susceptible of removal or of relief by the same means, viz., venesection, occurs during the cold stage of an ague fit, unaccompanied by any such loss of fluid. And it may be seen from the history of the cases recorded in the first part of this treatise, that the freedom of the pulmonary circulation is frequently restored, and the other symptoms of collapse diminish and disappear, while the loss of fluid by vomiting and purging continues with undiminished rapidity. What, then, is the pathological relation of the vomiting and purging to the other symptoms of cholera ? Sec. XVI. The pathological significance of vomiting and purging in cases of epidemic Diarrhoea and Cholera. When considering the evidence for and against the theory which attributes to the loss of fluid, by vomiting and purging, the chief symptoms of collapse, we saw that many well-authenticated facts in the history of cholera are quite at variance with the hypothesis in question. We found, for instance, that there is rather an inverse than a direct ratio between the amount of vomiting and purging and the degree of collapse, that the symptoms of collapse are not such as a mere loss of fluid would be expected to produce, nor is the effect of treatment, particularly of stimulants, venesection, and purgatives, such as can be reconciled with the theory in question. Then we have seen that there are numerous facts which tend to show that the symptoms of cholera are due to the influence of some morbid poison, which enters the blood and changes the vital properties of that fluid ; this is rendered probable by the striking resemblance between the symptoms of cholera and the recognised effects of other morbid poisons, and of noxious agents injected into the blood ; and the probability is increased by a 218 THE PATHOLOGY OF minute examination of the phenomena of collapse and of the share which the impeded pulmonary circulation and the scanty supply of oxygen have in the production of these phenomena. The entire history of cholera — its causes, its symptoms, and the influence of treatment, — lends support to the theory that the vomiting and purging which occur in epidemic diarrhoea and in cholera, are salutary and curative efforts of nature to separate from the blood and to cast out of the body the noxious materials which constitute the essential cause of the diseases in question. The proofs of this doctrine are to be found, as I have suggested, in the entire history of epidemic diarrhoea and cholera; but there are some facts relating to the transition from the symptoms of bilious diarrhoea into those of cholera with collapse, which perhaps afford the most striking confirmation of the doctrine in question. As to the precise nature of the morbific agent which produces diarrhoea and cholera, we are as ignorant as we are — and as it is probable that we ever shall be — of the exact nature of every morbid poison; but judging of these morbific agencies in the only manner permitted to us, namely, by their effects upon the living body, there appears good reason to believe that the morbid influence, of whatsoever kind it may be, which produces the symptoms of cholera with collapse, is very similar to, if not identical with, that which occasions what is commonly called ejiidemic, or choleraic, or bilious diarrhoea. One of the strongest arguments in favour of this identity of cause and origin is derived from the fact, that the two forms of disease invariably prevail at the same time in the same places, so that while some persons present the symptoms of bilious diarrhoea, others suffer from the more formidable symptoms of cholera with collapse. Then, too, it is. an admitted fact, that bilious diarrhoea often precedes and passes into cholera in the same individual; 219 EPIDEMIC DIARRHCEA AND CHOLERA. and it has been considered to be an object of great importance to detect and to arrest this premonitory diarrhoea before it passes into the fully developed disease. There cannot be a reasonable doubt as to the great practical importance of preventing the transition from diarrhoea into cholera ; and the question will presently arise, in what way this desirable object can most certainly, speedily, and safely be attained. Now, those who advocate the theory that the collapse of cholera is a result of the drain of fluid from the blood, believe, as a natural consequence of their pathological creed, that the great object of treatment is to arrest the drain of fluid; and they administer, for that purpose, such medicines as are considered most efficacious for checking vomiting and purging; opium being the drug which has been more universally used for this purpose than any other. The advocates of this practice assert, that if the diarrhoea can be arrested before the symptoms of collapse set in, it is to be supposed that, in some cases, at least, a patient who, without the aid of treatment, would have passed into a state of confirmed cholera, has been rescued from this more formidable disease ; and with respect to those cases — which are admitted to occur — in which symptoms of bilious diarrhoea continue, and pass into those of collapse, while persevering efforts are being made to arrest the discharges by opium and astringents, it is said that the disease unhappily made progress in spite of the bestdirected efforts to arrest it. But do not the facts admit of a different interpretation ? The question is one of immense importance, and requires a very careful consideration. Now, in estimating the influence of treatment upon the course and symptoms of disease, it is of essential importance to ascertain as accurately as possible what is the course of any particular disease when its progress is not interfered with by artificial means. Without strict 220 THE PATHOLOGY OF attention to this point of inquiry it is obvious that we may attribute to the influence of our remedies a cure which has been accomplished by the natural powers, not only independently, but in spite of our misdirected efforts. With respect, then, to the influence of opium and astringents in arresting diarrhoea, and thus preventing the full develojraient of cholera with collapse, is it not reasonable to enquire whether there is a possibility that many of the reputed cures of diarrhoea by these means might have been accomplished without their aid ; and, still further, whether some of the cases in which the transition from diarrhoea into full collapse has occurred, would have taken that course if the curative efforts of nature had not been interfered with by art ? If we are to judge numerically, and without any reference to pathological considerations, of the influence of any plan of treatment for the cure of diarrhoea, it is evident that we ought to have as a standard of comparison the results of a large number of cases of the disease, which have been permitted to run a natural course uninterfered with by art. Now, it is difficult to obtain such data ; for few persons suffering from this complaint, who come under the observation of medical practitioners, would be content without some kind of medication. I have been informed, however, that one practioner, during the recent epidemic, found that diarrhoea might be very safely and successfully treated by coloured water. And Mr. Wakefield stated, in a letter to the Times, in August last, that in a large number of cases of diarrhoea occurring amongst prisoners, the only medicines which he gave were carbonate of soda and mint tea, and not a single case passed into cholera. It can scarcely be supposed that this plan of treatment had any other effect than to dilute the contents of the bowel, and so to assist their speedy expulsion — a mode of operation entirely different from that by opium and astringents. Mr. French states, 221 EPIDEMIC DIARRHOEA AND CHOLERA. with reference to the treatment of diarrhoea (xlix. p. Js), ' I am satisfied, from much experience, that cases of epidemic diarrhoea generally speedily subside under the use of the simplest possible remedies, which are wholly free from astringent properties.' Now, it is evident from observations of this kind that opiates and astringents are not necessary for the cure of diarrhoea, and it appears very probable that the disease has a natural tendency to terminate in recovery. But the best opportunity for ascertaining the effects of opium presents itself in some of those cases in which it most speedily and effectually arrests the vomiting and purging. If the sudden cessation of these actions under the influence of opium were never, or only very rarely, followed by any unfavourable symptoms, it might, with some ground of probability, be inferred that the theory which looks upon the vomiting and purging as a salutary effort of nature for the elimination of a poison must be defective, if not entirely erroneous ; but the result in many cases is far otherwise. The first case which deeply impressed me with the conviction that the practice of treating epidemic diarrhoea by opium is dangerous, occurred during the epidemic of 1849. A woman, about 40 years of age, was seized with the usual symptoms of choleraic diarrhoea — vomiting, purging, and cramps ; she had not a symptom of collapse ; the countenance was natural, the skin warm, and the pulse good. I gave her five grains of Dover's powder, to be repeated every hour. When I saw her again, in about three hours, she had taken three of the powders ; the vomiting, purging, and cramps had ceased, and she was in full collapse, from which she never rallied. This case gave a terrible shock to my belief that collapse was a consequence of loss of fluid, and that it was to be prevented by arresting the vomiting and purging which usually precede and accompany the symptoms of collapse. I saw no way of escape 222 THE PATHOLOGY OP from the conviction that my patient's condition had been fearfully aggravated by my well-intended but mischievous interference. In short, that the symptoms of the disease had been changed from those which Scot describes (see antea p. 99) as characteristic of a mild attack, to those which denote the most serious form of malady. Since that time I have had frequent opportunities of ascertaining from the published reports of cases, and from what I have myself seen in the practice of others, that the arrest of the vomiting and purging by opium, and the immediate occurrence of profound collapse, were not the result of mere accident in the case of my patient, but that one was a direct consequence of the other. The salutary efforts of nature — the vomiting and purging — by which the morbid poison was being eliminated, were arrested, the poison then accumulated in the blood, the flow of blood through the lungs became obstructed, and the patient fell into collapse; — a result analogous to the occurrence of general dropsy, with albuminuria, in consequence of the cutaneous rash of scarlatina being suppressed by the continued . application of cold to the surface. It would be easy to extract from cases published by various authors, a considerable number of instances in which the opiate treatment of diarrhoea was attended with results in strict agreement with those above referred to ; but there are obvious reasons why an author should very sparingly and cautiously make use of evidence derived from what he considers the mal-practice of others. One case, published in the first part of this treatise (Case 51, p. 88), maybe referred to as illustrating the approach of collapse after the suppression of vomiting and purging by opium, and the speedy disappearance of all unfavourable symptoms when the vomiting and purging were re-excited by repeated closes of castor oil. MM. Briquet and Mignot have published some instructive EPIDEMIC DIARRHCEA AND CHOLERA. 223 particulars of the results obtained by them in the treatment of diarrhoea by opium (xxx. p. 514). Their practice was to prescribe rest, rice diet, and from fifteen to thirty drops of 'laudanum of Sydenham,' the dose to be repeated in an hour, and to be followed by opiate enemata if necessary. In obstinate cases they gave altogether as much as from 80 to 100 drops of laudanum. The result of this practice was, that out of 200 patients who came under treatment at the commencement of the attack ('des le debut dcs 'premiers accidents'), twenty-six — rather more than one in eight — passed into the stage of collapse. Now, it must be borne in mind that ihe.-e patients were placed in the most favourable circumstances for the trial of any plan of treatment. They were, from the first, inmates of a well-ordered hospital ; rest, and a judiciously restricted diet, were combined with the administration of medicines ; yet, so large a proportion as one in eight passed into a state of collapse. Surely such a result affords very conclusive evidence that the effect of the opiate treatment was injurious. In the course of the recent epidemic I had under my treatment about twenty cases of choleraic diarrhoea, of so great severity that most of the patients appeared to be on the very verge of collapse. They were all treated by castor oil without any opiate, and in every case the improvement was speedy and the cure complete, as may be seen by a reference to the cases, all of which, with two or three exceptions, are recorded in the first part of this volume. But it may be asked how it happens, if it be so dangerous to arrest the vomiting and purging by opium, that so large a proportion as nearly seven-eighths of MM. Briquet and Mignot's patients escaped without more serious consequences? To this it may be replied, that, in a large proportion of cases, the diarrhoea continues, in spite of repeated doses of opium, for a period varying from a 224 THE PATHOLOGY OF few hours to several clays, and in such cases it is reasonable to suppose that the curative efforts of nature succeed in eliminating the morbid poison, notwithstanding the opposing influence of the drug. During the recent epidemic several cases came under my observation in which a diarrhoea had for several days been unchecked by large and repeated doses of opium and astringents. In all these cases one or two doses of castor oil sufficed for the cure. And, it is evident that the experience of MM. Briquet and Mignot was in perfect agreement with this; for they state that if, in spite of the energetic employment of opium, the diarrhoea continues for a period of two days, opium is then of no avail; and they have found, in such cases, that an emetic of ipecacuanha has immediately put a stop to the disease. It is probable that the diarrhoea which thus continues for several days while opiates are being given, and which is so speedily arrested by an emetic or a purgative, is due not so much to the continued presence of a morbid poison in the blood, as to the local irritation of the mucous membrane of the digestive canal by the morbid secretion which has been poured into it, and the complete escape of which has been prevented by the opium. Such a form of diarrhoea is very similar to that which is often excited by an accumulation of the fseculent contents of the bowel, and which, although it may for a time be restrained by opiates and astringents, can be effectually relieved only by removing the offending cause. But the injurious effects of opiates and astringents in the treatment of bilious diarrhoea, are shown not only in the sudden occurrence of collapse, or in the comparatively harmless result of a persistence of the diarrhoea, but also in the supervention of feverish symptoms, which are probably occasioned either by the retention of morbid materials in the blood, or by their reabsorption from the intestinal canal. This very common result of the opiate EPIDEMIC DIARRHCEA AND CHOLERA. 225 treatment may occur either simultaneously with the continuance of the diarrhoea, or after the cessation of that symptom. The usual symptoms are a thickly-coated tongue, thirst, headache, drowsiness, heat of skin, a quick pulse ; and if the same treatment is persisted in, the patient becomes delirious, and finally comatose. One author reports several fatal cases of this kind as cases of consecutive fever without collapse. They were, in fact, cases of bilious diarrhoea, treated by large and repeated doses of opium and alcoholic stimulants, and with the most unequivocally disastrous results. This result of arresting the intestinal discharges, appears to have been fully appreciated by Sydenham, who says (xlvi., vol. I, p. 163): 'By checking the disease at its onset, I should wear out the patient by an intestine war, since I should just confine the enemy to his seat in the bowels, should impede the natural evacuations, and detain those humours which were seeking for an outlet.' And again, with reference to the use of astringents, he says (p. 164): ' They keep the enemy to his quarters, arfd they change him from a visitor to a denizen. Besides this, the disease is prolonged, and there is danger in the delay. Vicious humours creep into the blood ; ill-conditioned fever is excited, and the patient suffers not only a severe disease, but a long one also.' Annesley's testimony is to the same effect, although his language is indicative of a somewhat different pathology. He says, with reference to the treatment of what he calls diarrhoea and bilious cholera (xlviii., vol. 2, p. 398) : ' It would be unsafe to restrain the evacuations by means of astringents and anodynes, for by so doing the increased secretion of bile might be converted into inflammation of the liver, or the simple accumulation of this fluid in the ducts and gall bladder, which would necessarily result from astringent and anodyne remedies, would be followed by serious disorder, if it even failed of y 226 THE PATHOLOGY OP inducing inflammatory action of the biliary apparatus. Nor would the bad effects of astringents in such cases be confined to these organs : the bowels would also be liable to suffer, and the sudden arrest of the increased secretion from their mucous surface, and the consequent retention of the morbid secretions collected in them, might be followed by acute inflammation, or a dysenteric attack. The objects which we should chiefly propose to ourselves in the treatment of these disorders, should be, first, to carry off the morbid secretions and accumulations ; secondly, to prevent the supervention of inflammatory action in the liver or intestinal canal ; and, thirdly, to restore the healthy functions of the digestive tube and assistant chylopoietic viscera.' We find, then, that the influence of treatment upon epidemic diarrhoea affords much confirmation of the doctrine which is suggested by the general history of the disease, that the intestinal discharges, together with the vomiting and purging, are the results of a salutary effort to eliminate noxious materials from the body. And with respect to the discharges which are characteristic of the stage of collapse, the evidence is still more conclusive. A large majority of those practitioners who advocate the use of opium in the treatment of bilious diarrhoea, appear to be fully aware that this medicine cannot be beneficially, or even safely, continued when symptoms of collapse supervene. This conviction, however, appears to have been arrived at from the results of experience, rather than from pathological theory ; for the theory, that collapse is occasioned by the drain of fluid, would suggest the necessity for the continued use of opium so long as the drain of fluid persists ; and accordingly opium has frequently been given in large doses during the stage of collapse, but with results so unmistakably injurious as have sufficed to prove, to the satisfaction of most men, if not the unsoundness of the EPIDEMIC DIARRHCEA AND CHOLERA. 227 pathological theory, yet at least the error of the practice which appeared to be suggested by it. The great degree of influence which a pathological theory may exert upon practice, can scarcely receive a more striking illustration, than in the attempt to restrain the intestinal discharges in cholera, and so to shut up within the bowel that peculiarly offensive rice-water fluid, the very smell of which often excites nausea in those who come within its influence. The earlier Indian writers on cholera, whose minds were much influenced by the idea that the nervous system was the chief seat of the disease, and who accordingly gave opium to relieve spasm, were yet so convinced of the necessity for removing the offensive secretions from the bowel, that they almost invariably gave purgatives to effect this object. Annesley particularly insists upon the importance of clearing away the peculiar whitish, viscid secretion, which constitutes, in fact, the solid portion of the rice-water stool, and which is often found in the intestines in great quantities after death; and he expresses his conviction, that a relapse has frequently been occasioned by its continuance in the bowel (x. p. 169). The use of purgatives appears to have suggested itself to Annesley and others, from a consideration of the offensive character of the secretions, and the probable ill effects of their retention in the bowel, rather than from any definite theory that these secretions are the means of removing a materies moi'bi from the blood. It can scarcely, however, be doubted, that this is the true pathological interpretation of the intestinal discharges, and that they are the result of a very active secretory, eliminative effort. This doctrine receives much confirmation from the very interesting observation of Boehm (xlviii), that the secretions in question, both those which are discharged during life, and those which are found in the bowel after death, contain a large quantity of epithelium from the Q2 228 THE PATHOLOGY OF mucous membrane of the small intestine. The flocculi in the rice-water stools consist almost entirely of perfectly organized epithelial cells, most of them of large size. Of this I have satisfied myself, by repeated examinations of the discharges from different patients. But I have seldom been more surprised than to find that the peculiar creamy, viscid secretion, which sometimes nearly fills the small intestine after death, is also almost entirely made up of the same fully formed epithelium. This viscid secretion was abundant in Case No. 31 (p. 52), and I placed it under the microscope, with the expectation of findiug the appearances usually seen in coagulable lymph, when, to my astonishment, I found it composed of large epithelial cells. Now, it is quite obvious that this large quantity ef epithelium could not be derived from the mere peeling away of one or two layers of cells from the surface of the mucous membrane — the result of a local irritation or of maceration by the fluid contents of the bowel after death. The abundant cellformation in such circumstances could only result from an active vital effort at organization. And if the object of that effort be not to withdraw from the blood some morbid products, it is difficult to suggest any explanation of the phenomena. The desquamation of the skin after scarlatina, and of the kidney tubes in some forms of renal disease, especially in cases of renal dropsy connected with scarlatina, may be referred to as instances of morbid phenomena strictly analogous to the intestinal desquamation in cholera (see xxv., p. 104). The very peculiar odour of the cholera stools — so entirely unlike the odour of any other product of the human body, that it alone would suffice for the diagnosis of the disease — affords conclusive evidence that the discharges contain either some new and peculiar material, or that some constituent of the body has undergone a peculiar form of putrefactive change. In either case it can scarcely 229 EPIDEMIC DIARRHOEA AND CHOLERA. be doubted that elimination is the most important means of cure. So far as I have been able to ascertain, the peculiar flocculi which are characteristic of the rice-water stools, do not occur until the secretion of the liver has been suspended — they occur simultaneously with the other symptoms of collapse : the pale and watery stools which precede this stage of the disease being bilious, but much diluted. But after the secretion of bile has been restored, the stools continue to present the flocculent appearance for some hours, while they are deeply tinged with bile — the flocculi at this stage being probably composed of the epithelium which has been thrown off during collapse. It is probable that some desquamation of epithelium occurs in cases of bilious diarrhoea, but it is certainly more constant and much more active during collapse, when the secretions of the liver and kidneys are suppresse — in fact, the whole secretory effort appears then to be directed towards the mucous membrane of the stomach and small intestines : a large quantity of blood is conveyed to those parts, and their vessels are found minutely injected after death. I have before suggested that the rose tint of the small intestines is probably occasioned by the action of the contents of the bowel on the blood in the vessels. There can be little doubt that the sense of burning heat in the epigastric region is caused by the large accumulation of blood in the stomach and intestines, and by the active vital and chemical processes of which these organs are the seat. It is probable, too, that the insatiable thirst, and especially the craving for cold liquids, are in great measure occasioned by the local heat and uneasiness, although they must be partly attributed to the drain of fluid from the blood. Before passing on to the consideration of the treatment of diarrhoea and cholera , there are some points 230 THE PATHOLOGY OF respecting the relation between choleraic diarrhoea and choleraic collapse, which may claim a brief notice. We have found reason to conclude that the morbid poison, the essential cause of cholera with collapse, is identical with that which gives rise to the epidemic bilious diarrhoea; and that the striking phenomena of collapse are occasioned by the interruption of the respiratory functions, which results either from a greater susceptibility on the part of the individual patient, from a greater virulence or a larger dose of the poison, or from the influence of a mode of treatment which retards the escape of the poison through the stomach and intestines. The difference between the phenomena of cholera* with full collapse, and those of bilious diarrhoea, are very obvious, but the two conditions pass into each other by almost imperceptible gradations. The sense of oppression at the chest and the embarrassed respiration which occasionally occur at the commencement of a severe attack of choleraic diarrhoea, are indications of some degree of impediment to the flow of blood through the lungs : an impediment, too, which, in all probability, is prevented from increasing by the continual escape of the morbid poison through the stomach and intestines. The depression of temperature * The application of the term cholera (ko\i) bile, and pta to flow) to the stage of collapse, which, is now usually considered to be cholera par excellence, is a curious instance of the perversion of a word from its primary use, and from its etymological meaning. The term was originally used to express a bilious flux, and the earlier Indian writers considered it to be strictly applicable to the malignant cholera, which they supposed to be associated with ' putrid bile.' At the present time, while it is an acknowledged fact that the absence of the biliary secretion is one of the most characteristic features of the stage of collapse, the term cholera is not only retained, but it is applied almost exclusively to this form of disease ; while the term ' choleraic diarrhoea,' or ' bilious diarrhoea,' or the pleonastic term ' bilious cholera,' is used to designate the disease which is characterized by bilious stools. EPIDEMIC DIARRHCEA AND CHOLERA. 231 and the enfeebled pulse, which often co -exist with bilious diarrhoea, are doubtless, in part, occasioned by the exhausting effects of the vomiting and purging ; but they may also be supposed to result, in some measure, from a degree of impediment to the flow of blood through the lungs, which sensibly diminishes the supply of oxygen, although it does not give rise to the symptoms of full collapse. Another symptom which marks the gradual transition from choleraic diarrhoea to collapse, is the diminution of the quantity of bile in the stools. It is obvious that the bile may be much diluted by the mixture of a copious liquid secretion from the mucous membrane, and the quantity of bile in a watery stool of this kind often appears to be scanty; but when a patient is passing into collapse, the stools will gradually lose their bilious character in proportion to the degree of impediment to the flow of blood through the lungs, and to the scantiness of the supply of oxygen which is occasioned by that impediment. According to my experience, the suppression of bile is not complete, nor do the stools assume the true rice-water character, until the pulmonary circulation has become so much impeded as to occasion a decided sinking of the eyeballs. The sinking of the eyeballs, which is so constant and so characteristic a symptom of collapse, is almost invariably associated with the rice-water stools. In other words, a degree of impediment to the pulmonary circulation which suffices to occasion a decided sinking of the eyeballs, is usually sufficient to arrest the biliary secretion, by a process which has already been fully explained. The transition from the rice-water stools to the bilious stools during reaction, is obviously an indication that the pulmonary circulation is regaining its freedom, and that a larger supply of oxygen is entering the blood. Another symptom which is common to choleraic 232 THE PATHOLOGY OF EPIDEMIC DIAKKHCEA, ETC. diarrhoea, and to cholera with collapse, is cramp of the muscles. The result of my own observation is, that cramp is more frequently present in cases of severe choleraic diarrhoea than in the stage of collapse, and that it is rarely complained of during reaction. There can be little doubt that a morbid poison in the blood is the cause of the cramps, and this explanation is confirmed by the rare occurrence of cramp after reaction, when the poison is supposed to have been eliminated. The fact that cramps are less constant during collapse than during the stage of bilious diarrhoea, is probably explained by the not unfrequent occurrence of that torpid condition during collapse which appears to be incompatible with cramp or acute pain; and I have observed that the cramps during collapse are usually most severe in the case of those patients who are at the same time the coldest and the most conscious. — (See ante, p. 196.) PAET 111. TREATMENT OF EPIDEMIC DIARRHCEA AND CHOLERA. Sec. I. Treatment of Epidemic Diarrhoea. NO one can have undertaken to give general directions for the treatment of any important class of diseases, without feeling the great difficulty of the task. The circumstances which may influence the course of a disease, and which may therefore render necessary some modification of the treatment, are so numerous, that even if they could all he foreseen, the labour of including them in a general description would he out of all proportion greater than the benefit which would result from so tedious a detail. It is scarcely possible to over-estimate the importance of attention to minutise in the study of disease and in the practice of medicine ; but how is this necessary knowledge of details to be acquired and imparted to others? The task becomes easy exactly in proportion as we succeed in acquiring a knowledge of general principles. We can speak with confidence as to the treatment of a disease only after we have studied successfully its natural history — by which I mean the origin and the sequence of its symptoms, their relation to each other and to the remote cause of the disease, and, lastly, the mode in which the disease tends to terminate, either in death or in more or less complete recovery. Without such knowledge we can say very little that is worth hearing, of the effect of treatment; for we are in 234 TREATMENT OF continual danger of attributing to the influence of our remedies the beneficial results which are simply due to the vis medicatrix naturce; and which this curative power — this great friend of erring physicians — may have accomplished, in spite of our mischievous interference. The practice of medicine has, within the last few years, received important aid from the science of pathology, and from the same source much more help is to be expected. What is required is, that the sciences of pathology and therapeutics be brought into more intimate relationship with each other, so that each may receive aid from the other, and that both may advance together. An accurate pathological interpretation of the intestinal discharges in cholera, might have shown the danger of any attempt to arrest them; but since pathology did not give that warning in time, it may learn from therapeutics the lesson which has been conveyed by the mischievous effects of opium and astringents. It can scarcely be doubted, that while such a knowledge of the pathology of a disease as will suffice to indicate some general principles for its treatment, is a far safer practical guide than the most particular rules which cannot be shown to be referable to any general principle; so, an erroneous pathological theory is doubly mischievous, inasmuch as it often suggests an injurious practice, and prevents the ready recognition of its ill consequences. The history of the various theories which have prevailed with respect to the nature and treatment of cholera, affords abundant illustration of these remarks. And it would be neither uninteresting nor uninstructive to pass in review the chief of those theories which have at different times been advocated, and to examine the results which have attended their application to practice. Such a survey, however, would lead us too far from our present object, which is, to point out such rules for the prevention and cure of epidemic 235 EPIDEMIC DIARRHCEA. diarrhoea and cholera as appear to be most in accordance with the present state of our pathological and therapeutical knowledge. It is probable that there are few persons living in a district where cholera is prevailing, who do not experience, in some degree, the effects of the epidemic influence. These effects are various, often trifling in degree, and sometimes, perhaps, rather the result of mental emotion than of any merely physical influence. I have before referred to the symptoms of disordered innervation, such as slight pains and twitchings in the muscles. Several persons complained to me of these unpleasant sensations during the recent epidemic, particularly one of my medical friends, who had been anxious about some of his patients, and who had been indulging in doses of grey powder, &c, which I advised him to discontinue, and in place of them to take a tonic mixture and an occasional drive to Hampstead. He came to me again in a few days, and told me that he had acted upon my advice, and that he had lost the unpleasant sensations of which he before complained. Another very common disturbance is referable to the intestinal canal, and consists in a rumbling noise, and an unpleasant sense of commotion and insecurity. The digestive powers are obviously impaired, so that a very trifling error in diet is attended with an unusual amount of disturbance, and not unfrequently with diarrhoea. These signs of derangement often occasion much anxiety both to the patient and his friends, and it is of considerable importance that they should be met by a judicious plan of treatment. Now it is obvious, that as the digestive organs are those which are chiefly concerned, the patient should be instructed to avoid over-taxing these organs, either by a large quantity of food, or by food which is difficult of digestion. He should take his meals at regular hours, avoid long fasting and over-fatigue ; he may take a moderate quantity of cooked vegetables, but he must 236 TREATMENT OF not indulge in salads, raw fruit, and other luxuries, which, in a healthy season, he might enjoy with impunity. It is particularly important to caution patients, and especially the lower classes, as to the ahuse of alcoholic stimulants. Those who have heen in the habit of taking moderate quantities of such stimulants may, in general, continue their use without disadvantage, and probably with benefit; but it can rarely be desirable to exceed the usual quantity. It is unreasonable to suppose that a man can be so well able to resist an epidemic influence while he keeps his tongue in a state of feverish dryness, and at the same time lessens his appetite and impairs his digestive powers, by the frequent introduction of a fiery dram into his stomach. In short, the prevalence of cholera should be a warning to every man to be temperate in all things. Amongst other means of improving the tone of the digestive organs, daily exercise in the open air, and cold or tepid sponging, or the shower-bath, are useful auxiliaries. Then, as to medicine, the first and most important advice to a patient is not to be his own doctor at any time, and least of all at a time when cholera is prevailing. It is unquestionably for the advantage of all patients that those who can afford it should at once go to their usual medical attendants, and take no medicine without their advice, and that the poor should apply to some of the many charitable institutions which offer advice and medicines gratuitously. If patients could be induced to act upon this advice, there would then be no occasion for warning them against the use, or rather the abuse, of particular drugs, whether opiates and astringents, or purgatives. I believe that the unpleasant sensations in the stomach and bowels to which I just now referred, are most effectually and permanently relieved by a light tonic : one which I have frequently prescribed with benefit in such cases is the following : — $, Tinct. ferri sesquichl. uixv, tinct. calumbse sj, syrupi zingiberis sss, aqua Biss. To be EPIDEMIC DIARRH(EA. 237 taken twice or three times a day, after meals. This maybe continued for several weeks, in fact, daring the whole period of the epidemic, if it is found to agree. It will often give tone to the stomach, increase the appetite and the digestive powers, and improve the general health. When the derangement of the digestive organs amounts to diarrhoea, the treatment required will be somewhat different, according to the severity of the symptom, and its probable exciting cause. A diarrhoea, during the prevalence of an epidemic, should never be neglected. So long as it continues, the patient is insecure ; his digestive powers are necessarily impaired, in a greater or less degree ; and if he is not very cautious as to his diet, some ill-digested, fermenting materials may pass into his blood, and excite the most serious symptoms. It is probable that one of the most frequent causes of a mild attack of epidemic diarrhoea becoming chronic or severe, is the patient continuing his usual mode of living, and exercising no care as to the quantity or the quality of his food. This is not leaving the disease to nature, but it is putting an artificial impediment in the way of a natural cure. A patient who has a diarrhoea of any severity, should be restricted to a milk and farinaceous diet during the few hours that the disease, when judiciously treated, usually continues. In a considerable number of cases, it will be found that there has been more or less of constipation previous to the commencement of the diarrhoea. Every practitioner of any experience must have met with numerous instances of diarrhoea like the following. A patient, most frequently a female, but not uncommonly a man, after suffering more or less inconvenience from constipation, is seized with a sharp attack of diarrhoea; the motions being slimy and sometimes bloody, and accompanied by a severe pain at the bottom of the back, which women, who have borne children, often compare to the pains of 238 TREATMENT OF labour. The earlier attacks of this kind usually terminate after a few hours without help from medicine. The patient may then go on, suffering only from habitual costiveness, for a period varying from a few weeks to several months, before the occurrence of another attack, which may end in the same way. But a patient who has once had an attack of this kind, is very liable to a recurrence of the malady, unless the state of the bowels be judiciously regulated; and after a considerable number of attacks, the diarrhoea usually continues longer — for several days or even weeks — and sometimes it becomes a permanent chronic disease, seriously interfering with the comfort and impairing the health of the sufferer. A careful inquiry will seldom fail to elicit the true nature of these cases. The chief diagnostic marks are the previous history of constipation, (though it is to be remembered that a gradual accumulation in the bowel is quite consistent with the occurrence of a daily but scanty evacuation,) the slimy, and often bloody evacuations, with an abundance of hardened faeces after the operation of a purgative, and, in most cases, the severe pain at the lower part of the back. Now, if a case of this kind is treated by opiates and astringents, the pain and purging may often be allayed for the time, to return with increased violence as soon as the influence of the medicine has ceased. There is but one safe and certain cure for this form of diarrhoea, and that is the removal of the irritating contents of the large intestine. A tablespoonful of castor oil usually accomplishes this very speedily and effectually. I have often known this dose arrest a diarrhoea which had continued for many days. The great superiority of castor oil over other purgatives in cases of this kind, consists in its speedy yet unirritating mode of action. After the immediate action of the oil has ceased, some astringent, such as logwood or catechu, may sometimes be given with advantage. The return EPIDEMIC DIARRHCEA. 239 of these painful and exhausting attacks is to be prevented by the careful regulation of the bowels; by a judicious diet ; daily walking exercise, short of great fatigue, which is a frequent exciting cause of an attack ; and, in some cases, by a course of tonic medicine, especially steel, with an occasional, or, if necessary, a daily small dose of compound rhubarb pill, or the watery extract of aloes. The cases here described are not identical with the ordinary cases of epidemic diarrhoea, but I have referred to them now for two reasons : first, as acknowledged instances of a form of diarrhoea which can be certainly and effectually cured only by purgatives ; and second, because constipation appears, in many instances, to be a predisposing cause of epidemic diarrhoea. At the commencement of the last epidemic, while I was prescribing for the out-patients at the hospital, I found, on careful inquiry, that a very large proportion of those who were suffering from the epidemic diarrhoea had just previously had decidedly constipated bowels. The proportion of previously constipated patients suffering from diarrhoea appeared to be much greater than could be accounted for, except by supposing that constipation was either a predisposing or an exciting cause of this epidemic diarrhoea. The same observation has been made by others. Thus Dr. Paine says, with reference to epidemic diarrhoea (ix., p. 18), ' This condition, in many instances, is preceded by constipation, which, however, is not so uniform as has been imagined, but which, if neglected, is very liable to result in diarrhoea.' Now, that constipation should be an exciting or a predisposing cause of diarrhoea during an epidemic period, is in perfect accordance with other acknowledged facts. For instance, it is well known that the functions of the stomach and intestines are more than usually susceptible of disturbance at such times. Some articles of diet, which may usually be digested with ease, will create disorder 240 TREATMENT OF and act as purgatives, and aperient medicines often appear to act with more than ordinary violence. What, then, can be more probable than that a feeeulent accumulation in the bowel, which has a tendency at all times to act as an irritating purgative, should manifest that tendency in an especial degree when the sensibility of the intestinal canal is increased by the epidemic influence ? There is yet another way in which these feeculent accumulations in the bowel may excite an attack of diarrhoea, and that is, by actually poisoning the blood. The breath of persons who are habitually costive often has a foetid, indeed, it may almost be said, a fseculent odour ; which can be explained only by supposing that the gases which enter the blood from the intestinal canal are exhaled through the lungs. In fact, these unhappy patients have a cesspool in their large intestines ; and if such a nuisance be dangerous in proportion to its nearness, then, to have it within the bowels must be perilous indeed. Now, the treatment of a diarrhoea having such an origin, by the indiscriminate administration of chalk and opium, would be very unlikely to produce any but a mischievous effect. The chalk would, probably, have little influence either for good or evil ; but the opium, in proportion to the number and magnitude of the doses, would check the escape of the irritating contents of the bowel, and, in the same degree, would aggravate and prolong the attack; whereas, a single dose of castor oil, in some aromatic water — cinnamon, or peppermint, or caraway — will often suffice for the cure. If any tendency to looseness remains after the action of the oil, this may be readily removed by some gentle astringent, such as logwood or catechu. If the patient has a strong objection to castor oil, a few grains of rhubarb, in a draught with aromatic spirit of ammonia, will be equally efficacious. In every case the patient should be 241 EPIDEMIC DIARRHOEA. cautious as to his diet until the disorder has quite ceased. After the operation of the aperient, a basin of arrow-root or sago, with a dessert-spoonful of brandy, will often prove a pleasant cordial dose. Suppose, however, that we have to deal with an attack of epidemic diarrhoea, occurring in a person whose bowels have not previously been constipated, is there less reason than in the other class of cases to believe that a mild aperient may still be a more efficacious remedy than opium and astringents? If we carefully examine the abdomen of a patient who is suffering from acute diarrhoea, we may often ascertain that his small intestines contain a considerable quantity of fluid; and that this fluid is of an irritating quality we infer from the pain and discomfort of which the patient complains. Now, putting out of consideration the question of poisoned blood, and looking at the diarrhoea as a merely local affection of the intestines, does it appear reasonable to prevent the escape of this offending fluid from the bowels ? If opium had the effect of merely preventing the further secretion of fluid into the bowel, while it offered no impediment to the escape of that which has already been secreted, it might indirectly contribute to the evacuation of the intestines ; but since it notoriously lessens the irritability and movements of the bowel, and so checks the evacuations, it appears unreasonable to give this medicine when the contents of the bowels are quite as irritating and offensive as the accumulated faecal contents in those cases of diarrhoea after constipation to which I have before referred. But, in questions of this kind, experience must decide between conflicting opinions and theories, and the practical question is, by what means can epidemic diarrhoea be most speedily and safely cured? I have already referred to some facts which tell much against the effect of opium in these cases (see p. 22 1 et seq.). Then there is some- it 242 TREATMENT OF thing very significant in the fact that, whereas, according to the returns of the Registrar- General, the deaths from cholera in London during the recent epidemic, from August 1853 to November 1854, were 1 1,495; tne deaths from diarrhoea during the same period amounted to 4267 ; so that diarrhoea occasioned a mortality more than a third as great as cholera. Now, it is evident from these returns that diarrhoea is a very fatal disease, and that the treatment of it is not so invariably successful as to call for no improvement; and, although I have no means of ascertaining that in any one of those four thousand and more fatal cases, opiate and astringent remedies were given, yet it is not unreasonable to suppose that such had been the treatment in the greater number of instances. This is rendered probable, not only by the acknowledged prevalence of that mode of treatment, but also by a fact, which came under our notice at the hospital, that a large proportion of the patients with diarrhoea and cholera had been treated by chalk and opium before they were admitted. Then, it may be observed, that if the mortality from diarrhoea amongst our patients had been as great in proportion to the deaths from cholera, as that which occurred throughout London during the recent epidemic, we should have had at least four deaths from diarrhoea, whereas we had not one. But the influence of treatment may generally be gathered with more certainty from the careful observation of a few cases, than from the comparison of a great number, of which the particulars can be but imperfectly known. In the course of my Hospital and Dispensary practice, I have prescribed some thousands of bottles of chalk mixture with opium, but I never felt quite satisfied that the practice was either rational or successful. I gradually and cautiously adopted a different course, and I have now no doubt that my former practice was worse than useless, and that the effect of it was, in many instances, 243 EPIDEMIC DIARRHOEA. to prolong an attack of diarrhoea which would have terminated much sooner if I had not interfered. The two following cases may he taken as a fair illustration of the results of two different plans of treating diarrhoea : — A physician in attendance upon cholera patients was seized with diarrhoea at one o'clock in the morning ; he had much pain and commotion in the bowels, and two copious liquid stools in quick succession. After the second stool he took a table-spoonful of castor oil in a glass of cold water ; the dose acted twice before breakfast-time ; he went to his work as usual, during the day, and had no further evacuation of the bowels for two days. A surgeon, in large practice, was seized with diarrhoea immediately after his return to town, at the end of September. As his time was valuable, he did not wish to waste it in the water-closet, and he thought to cut short the attack by opium. He first took ten drops of laudanum ; the diarrhoea continued, and he repeated the dose, but without benefit. He then administered an opiate injection, but the purging continuing, he afterwards took a compound soap-pill. In the meantime, he had been so discomposed by the opiates that he passed two restless nights; his face was pale, his tongue coated, and he had severe griping pains in the bowels, for which he was induced to take a dose of castor oil, which he afterwards repeated, with much benefit. The result of this attempt to cut short a diarrhoea by opium, was a serious derangement of health, extending over a period of nearly a week. A considerable number of cases similar to this came under my observation during the recent epidemic (see, for instance, Cases 6, p. 8; 21, p. 37; and 47, p. 81). One case was that of a medical practitioner, who consulted me respecting a diarrhoea which had continued e2 244 TREATMENT OF for a week, in spite of opiates and every variety of astringent ; he was becoming very nervous about himself, and he had a dread of going near a case of cholera lest he should take the disease. I advised him to take a table-spoonful of castor oil. He took the dose, which acted twice, and the diarrhoea was cured. It is needless to multiply instances or arguments. Any one who once makes trial of the plan will soon find better reasons for continuing it than any with which I can furnish him.* It is not necessary to give a large dose of oil, nor, in most cases of simple diarrhoea, to repeat the dose. I heard of one physician who, having a sharp attack of diarrhoea, took a full ounce of castor oil, and complained that he felt exhausted after its action. And one nonprofessional gentleman told me that he had taken castor oil for diarrhoea, and I gathered from his account that, before the first dose had ceased to operate, he took a second and a third in quick succession. He, too, complained that he felt exhausted. In both these cases an unnecessarily large quantity of oil was taken. It is sometimes asserted, that an attack of cholera has been excited by a dose of purgative medicine. I doubt, however, whether this has been strictly true in any case. When describing the symptoms which mark the invasion of cholera, I gave an extract from Twining (see p. 125), which appears to me to contain the true explanation of the reported cases of cholera excited by a purgative dose. A patient whose system is already under the influence of the cholera poison, and who considers himself ' bilious,' takes an aperient pill or draught, the symptoms of cholera develop themselves, and the disease is thought, * Some practitioners are in the habit of treating diarrhoea by an opiate at the commencement, to check the purging, and subsequently by a purgative, to carry off the morbid secretions. It appears to me that the opiate is an unnecessary risk and hindrance, without any compensating advantage. 245 EPIDEMIC DIARRHCEA. by a superficial observer, to have been occasioned by the purgative (see Case 16 — Remarks, p. 28); a conclusion which is, perhaps, as inaccurate as it would be to attribute an ague-fit to a dose of quinine taken when the languor and other disordered sensations mark the approach of the paroxysm. Twining states (v. p. 13), that he has 'known more than one case in which persons, feeling some slight indisposition, have taken a dose of rhubarb and magnesia, with a small quantity of ginger, early in the morning ; after which distinct cholera symptoms have appeared with the first purgative effects of the medicine.' He adds — 'It is evident that in most such cases an insidious attack of cholera was going on before the medicine was taken.'* But, although I do not believe that the homoeopathic dogma has any such strong fact in its favour as would be the actual causation of cholera by a purgative, I can conceive that the injudicious use or abuse of purgatives * With regard to this point, I may refer to a very interesting letter by Dr. Ogle, in the Medical Times and Gazette (October 7th, 1854, p. 378), on Purgatives in relation to Cholera. The letter is apparently intended as the correction of a statement which had appeared in one of the journals, to the effect, that in two or three cases at St. George's Hospital, cholera had been excited by the operation of a purgative. Dr. Ogle found that twelve patients had become the subjects of cholera while they were in the hospital, besides six night-nurses, one assistant night-nurse, and a night-porter. He says : 'Out of these twelve patients there were only two who had been taking anything like an aperient for some time previous to death. Now, it seems that one of these two had not had the bowels open for three days ; and, consequently, took half- an -ounce of castor oil on, I believe, the same day he was attacked with cholera. The other one, ordinarily subject to constipation, had been for seven or eight weeks, while a patient in the hospital, obliged to take either castor oil or colocynth. regularly every day ; and it so happened that he was affected with cholera.' Dr. Ogle adds : 'It would be a bold thing to say, that cholera in these two was caused by the purgatives, and, probably, quite as correct or logical to assume, that in the others it had been produced by any ordinary salines, &c, which they might have been taking.' 246 TREATMENT OF might render a person prone to be affected by the cholera poison; just as great fatigue, or long fasting, or haemorrhage, or any other depressing influence, may predispose to an attack of the disease. It is better to avoid saline purgatives during the time of a cholera epidemic, on account of their tendency to become absorbed, and so, by entering the blood, to effect changes in that fluid which, at such times, may be injurious; while castor oil, which, probably, never becomes absorbed, is, of all purgatives, the safest. Perhaps, too, it is well to adopt the advice which is given by more than one of the Indian practitioners ; namely, when an aperient is rendered necessary by constipation, to give it early in the morning rather than late at night, so that its operation may not occur during the night, when, as is well known, attacks of cholera most frequently happen. We have hitherto considered the treatment of simple diarrhoea, uncomplicated with vomiting or cramps. The addition of these two symptoms constitutes what is commonly called choleraic diarrhoea. This more severe form of disease requires essentially the same treatment as simple diarrhoea, only with some modification as to details. In general, when a patient has been seized with a severe attack of this kind, confinement to the bed is desirable ; this being the readiest means of insuring warmth and rest in the horizontal posture. When vomiting occurs spontaneously, it is on no account whatever to be checked, but on the contrary encouraged by directing the patient to drink freely of warm water ; and if the patient has only a feeling of oppression at the chest, and nausea, without free vomiting, he will experience considerable relief from the operation of an emetic. He may take one or two tea-spoonfuls of mustard, or a dessertspoonful of salt, or a scruple of powdered ipecacuanha, or the same quantity of sulphate of zinc, in warm water. 247 EPIDEMIC DIARRHCEA. In general, I should give the preference to ipecacuanha, when it can be obtained without delay. The patient's friends, and the patient himself, often have a dread of vomiting in these cases. It is unpleasant to witness the straining efforts which it involves, and it often indicates a severe attack of disease ; but let both the patient and his attendants be assured that the process of vomiting is most certainly beneficial, and quite unattended with risk, and that to suppress it by opium, or by any other means, would be in the highest degree dangerous. (In illustration of these remarks see Cases 19, p. 34; 51, p. 88 ; and 53, p. 9[ ; also the case referred to at p. 221). It is evident that by the act of vomiting, the morbid secretions of the stomach, and those of the upper part of the intestine, are ejected much more speedily than they can be by the slower operation of a purgative ; and this explains the great and immediate relief which is often afforded by that means. When the stomach has been thoroughly emptied, and when the straining efforts have ceased, a table-spoonful of castor oil may be given. Now, it frequently happens that the oil itself acts as an emetic, and if it does so the dose must be repeated. No mischief results from its emetic action ; but when dose after dose is rejected, it may not be easy to ensure the passage of the oil into the intestine, so as to obtain its purgative effect. In these circumstances I have generally succeeded best by giving it floated on a little cold water, and then directing the patient to lie still and to drink no liquid for half an hour, by which time the oil will generally have passed into the intestine. In some cases, even of severe choleraic diarrhoea, a single dose of castor oil will suffice for the cure. But in most instances, when there is severe pain and cramp, and when there is much fulness and dulness on percussion over the small intestines, from an abundant secretion of liquid, it will be necessary to repeat the dose 248 TREATMENT OF once or oftener, with an interval of one or two hours between each dose. The object is to remove the irritating contents of the bowel ; and when that has been fully accomplished, the distressing symptoms disappear, and the patient requires no further medical treatment. During the recent epidemic, eighteen cases of choleraic diarrhoea, so severe as to require admission into the hospital, and most of them on the verge of collapse, came under my care ; fifteen of these will be found recorded in the first part of this volume, besides two cases which occurred out of the hospital.* It will be seen that, while some of these were cured by two or three doses of castor oil, others took a much larger quantity. I am now quite convinced that some of these patients had much more oil than was necessary or desirable ; and I refer to this fact particularly, because, since all these patients recovered very speedily, we may infer that no serious consequences result from even an excessive dose of castor oil in cases of choleraic diarrhoea; the action of the medicine being in no degree proportioned to the magnitude of the dose. Yet I by no means advise the exhibition of frequent or large doses ; on the contrary lam of opinion that, while many cases of choleraic diarrhoea may be cured by a single half-ounce dose of castor oil, there are few cases which can require more than three or four such doses. Of course it is understood that a dose which has been rejected immediately by vomiting, counts for nothing as a purgative. I am thoroughly convinced by pathological considerations and by the results of experience — experience as well of the fatally mischievous effects of opium and astringents, as of the uniformly beneficial action of emetics and mild purgatives — that the eliminative method of treatment is safer and more successful than any other ; * No account is here taken of the numerous out-patients who were successfully treated on this plan. 249 EPIDEMIC DIARRH(EA. and I believe it will very rarely happen that a case of choleraic diarrhoea, which has come fairly and fully under the influence of this plan of treatment, will pass on into the stage of collapse. If any tendency to watery diarrhoea, with irritability of the bowels, remains, after the violence of the attack has subsided, a few doses of decoction of logwood, with tincture of catechu, will suffice to remove these symptoms ; but scarcely one in ten of the cases which have come under my observation has required any medicine of this kind after the discontinuance of the oil. With respect to the mode of giving the castor oil, I have already stated that cold water appears to be the best vehicle, when the stomach is irritable and disposed to reject the medicine ; but this is a point respecting which the patient's taste may be consulted. Some persons think castor oil with hot milk almost a luxury, while others look upon it as the greatest of abominations. It may be given with peppermint or cinnamon, or any such carminatives, if the patient approves and the stomach tolerates the dose. In other cases tincture of orange forms a pleasant cover for the oil; and when made into an emulsion with gum and syrup, I have seen it taken and retained by a child who had made unsuccessful attempts to swallow it when floated on water. In no case let it be given with opium, for the purpose of ' keeping down' the oil. It is far better to have a whole bottle of oil rejected by vomiting than to check the sickness by a narcotic. Castor oil is no specific for diarrhoea, and if the patient has an insuperable objection to it he may take rhubarb, which is, perhaps, the next best aperient in these cases. I know several practitioners who are in the habit of treating all cases of diarrhoea with rhubarb, and, as I have been assured, with very satisfactory results. There are some who believe that no case of choleraic diarrhoea can be satisfactorily treated without a few 250 TREATMENT OF grains of calomel. There is nothing in the pathology of the disease which appears to require the aid of mercury. It cannot be necessary in order to promote the secretion of bile, which is already in excess ; and whatever good results from its use is, doubtless, attributable to its purgative action. I believe that mercury is an unnecessary remedy, and, therefore, I do not recommend its use in the treatment of this disease. The fact that a very large proportion of attacks of diarrhoea will subside under the use of repeated small doses of calomel, as shown in the report of Dr. Ayre to the College of Physicians (vii. p. 176), is an additional proof, if it were required, that neither opium nor astringents are necessary for the cure of this disease. Within the last two or three years sulphuric acid has been strongly recommended as a remedy for choleraic diarrhoea. The few trials which I have myself made of it, did not encourage me to continue the use of the remedy, and I have heard and read conflicting reports of its efficacy from others who have used it more extensively. The different results are, probably, in a great degree explained by the different doses and modes in which the medicine has been given. By some, it has been given in doses of a drachm every twenty minutes, until four doses have been taken, without any other addition than cold water ; while others have given it in smaller doses, and have combined it with opium and aromatics. It would be easy to foresee that these different doses and modes of exhibition would be attended with different, if not with opposite results. Small doses of sulphuric acid are well known to have an astringent action, but such as would exert little control over an acute attack of diarrhoea. The addition of opium, however, to a feebly acid mixture would approximate the action of the dose very closely to that of the favourite chalk-and-opium compound. The opium is the powerful ingredient in each 251 EPIDEMIC DIARRHOEA. mixture, while the acid and the chalk are comparatively inert. But when dilute sulphuric acid is given in drachm doses, with the simple addition of cold water, it must surely act as an irritant, and so assist the evacuation of the intestines ; in other words, it acts as a purgative. If any one douhts the irritant action of dilute sulphuric acid in large closes, let him, when he is not suffering from diarrhoea, take half-an-ounce of the medicine, divided into four doses, within a period of less than two hours : he will soon find, unless he has a peculiarlyconstructed mucous membrane, that he is suffering from what the French pathologists call g astro -entente, with mucous diarrhoea.* The medicine when given in these large doses for the cure of diarrhoea, runs off rapidly with the other contents of the bowel, and, therefore, remains but a short time in contact with any one portion of the mucous membrane. Sometimes, however, it does not pass off so speedily or so entirely, and the mucous membrane suffers in consequence. I have heard from several distinct sources that patients not unfrequently complain of a severe griping pain for some days after the cessation of a diarrhoea which has been treated by sulphuric acid. Since, therefore, it appears in the highest degree probable that the action of sulphuric acid, in large doses, is that of an irritating purgative, and since its use is often followed by unpleasant results, which do not attend the employment of other means, of at least equal efficacy, for * Dr. Watson says, with reference to the notion, once prevalent, that the diarrhoea and the perspiration in phthisis bear an inverse ratio to each other — ' One reason, perhaps, for this error, may be found in the circumstance, that acids, which have the effect, often, of checking the perspiration, tend also, as is well hnown, to produce diarrhoea' (xxxv. vol. 2, p. 195). The same author states, that sulphuric acid may be freely given to relieve the night-sweats in phthisis 'if the bowels are costive,' but 'tvhen the bowels are irritable, and will not hear it, we must have recourse to other means ' (vol. 2, p. 214). 252 TREATMENT OF the cure of diarrhoea, I have determined not to employ that remedy for the treatment of this disease in future, and, for the same reasons, not to recommend its employment hy others. Those practitioners whose experience has convinced them that sulphuric acid is a safe and successful remedy for diarrhoea will, of course, continue its use ; and it is, perhaps, well that they should do so ; for they might meet with less success from any other plan of treatment, to which they have not heen accustomed, and in the employment of which they have not acquired the necessary degree of tact and experience. It is scarcely necessary to repeat what I have hefore said with reference to simple diarrhoea, namely, that the patient must he restricted to a farinaceous diet until the violence of the attack is over. When much exhaustion follows the cessation of the purging, a little hrandy in arrow-root or sago may he allowed. But I would not permit brandy to be taken to relieve pain or any other symptom, at the commencement of the attack ; its effect at that period being to narcotize the patient, and subsequently to excite fever and head-ache. The thirst which usually accompanies a severe attack of diarrhoea may be allayed by taking cold water almost ad libitum. The return to the ordinary diet must be made gradually and with care. Let me add, by way of caution, that there are forms of diarrhoea which are not to be cured by the method which I have described. I may mention, as exceptional cases, the diarrhoea of phthisis and of typhoid fever which results from ulceration of the intestine. There is, also, a form of diarrhoea characterized by loose stools soon after each meal, and occasioned by the passage of imperfectly digested food from the stomach into the intestines. The cure of this form of diarrhoea can be effected only by treatment directed to the restoration of the impaired digestive powers. The means of accomplishing this 253 CHOLERA WITH COLLAPSE. object it is not now my intention to dwell upon ; I have referred to the subject here only in illustration of the important principle, that, for the successful treatment of diarrhoea no less than for the successful treatment of every other form of disease, an accurate diagnosis and a correct pathology are essential conditions. Sec. 11. Treatment of Cholera with Collapse. If the account which I have given of the pathology of collapse be correct, then it not only affords a satisfactory explanation of the confused and contradictory reports which have been made as to the results of various plans of treatment which have at different times been recommended and practised, but it furnishes us with the only safe guide in the choice and use of remedies. We have no specific cure for cholera, nor is it probable that a specific will ever be discovered. The disease is to be prevented, in the fullest and widest sense of the term, by a judicious employment of those sanatory means the efficacy of which is indisputable; and woe to us all, both rich and poor, if we fail to receive and to act upon the teaching which each visitation of cholera is intended to convey to us! When the disease has seized its victim, and is fully developed, we must deal with it as best we can, with the help of such pathological light as we can obtain. Of the means by which an attack of choleraic diarrhoea may be arrested, before it has passed into the stage of collapse, I have already treated; we have now to consider the treatment of that more formidable condition — collapse. It surely does not require very lengthened arguments to prove that any plan of treatment, to be successful in the stage of collapse, must be one which has for its object to favour and assist the escape of those secretions from the stomach and intestines, by means of which, as 254 TREATMENT OF we have learnt from our pathological inquiries, the morbid poison of cholera is eliminated from the blood. There are some pathologists, however, who, although they look upon the intestinal discharges as having, on the whole, a beneficial effect, yet do not admit that any advantage is to be derived from artificial attempts to aid them. Thus, Mr. French says, with respect to the treatment of cholera (xlix. p. 74) — ' It is clear that if a secretion take place to eliminate a poison or relieve a congestion, there can be no wisdom in immediate efforts to stop it. But is the opposite course wiser — namely, to assist uature in those efforts by the use of purgatives ? Certainly not; that process is best accomplished by nature's own efforts.' It has been thought by others that the analogy of small-pox and its treatment, affords an argument against the use of purgatives in cholera. Thus, it is admitted that the eruption of smallpox is a means by which a noxious poison is eliminated from the system ;' but it is said that when, in former times, the treatment of smallpox was conducted on the principle of assisting the development of the pustules, by keeping the patient in a close and heated atmosphere, the mortality of the disease was much increased. It would have been strange, indeed, if the mortality had not been increased by such a mode of treatment ; but it must be shallow reasoning which supposes any analogy between that method of treating smallpox and the use of purgatives in cholera. The unhappy small-pox patient, who was covered with heaps of bedclothes and confined in a close and artificially heated atmosphere, was not only deprived of the refreshing influence of cool and pure air — not only was he made to breathe air deficient in oxygen and charged with an excess of carbonic acid — but, in addition, he was compelled to inhale through his lungs the morbid poison which had been eliminated from the skin; so that he was CHOLERA WITH COLLAPSE. 255 poisoned by an atmosphere, the impurities of which were continually accumulating and increasing in virulence. So far, therefore, from there being an analogy between this ancient, irrational, and destructive mode of treating small-pox and the treatment of cholera by purgatives, the analogy would be much more exact with an opposite mode of treating cholera — one by which a patient should be made to swallow his own evacuations, or one which approaches nearest to this in its results, namely, that which has for its object to restrain the evacuations by opium and astringents. Indeed, between this mode of treating cholera and the old heating plan of treating small-pox there is a very close resemblance ; they are alike contrary to the principles of pathology and to the dictates of common sense, and they have been attended with equally destructive results. If we carefully consider the phenomena of cholera, we find that the complete elimination of the morbid products is accomplished by a process which consists of two distinct stages : there is, first, the secretion of fluid from the blood into the gastro-intestinal canal, and, secondly, there is the discharge of this fluid by vomiting and by stool. Now, the elimination of the morbid poison of cholera may be arrested either by the cessation of secretion into the intestine, or by the stomach and intestines failing to expel their contents. The arrest of the secretory process is a comparatively rare occurrence ; but an instance of it may be seen in Case 23 (p. 40). An accumulation of the contents of the stomach and intestine, in consequence of a torpid or enfeebled condition of the muscular coats of the canal, is much more frequent, as may be seen in the cases recorded in the first part of this treatise. In a very large proportion of cases of collapse a careful examination of the abdomen, by palpation and percussion, will detect more or less fulness of the small intestines ; and occasionally this portion of the 256 TREATMENT OF intestinal canal actually becomes paralysed by overdistension, so that the expulsion of the contents is rendered impossible (see Case 31, p. 52)5 2 )- I n other cases the stomach becomes distended in a similar manner, partly by the morbid secretions, and partly by fluids which have been swallowed (see Case p. 55). The intestinal discharges in cholera consist, as we have already seen, of a liquid and a solid portion, the latter forming the flocculi of the rice-water stools, and being chiefly composed of epithelium. It not unfrequently happens that the watery portion of the stools is freely discharged, while the more solid parts are retained and accumulate in the bowel. This fact has been noticed by several authors. Dr. Parkes alludes to it in the following terms (i. p. no) :—: — ' A proteine constituent is found in large quantities in the intestinal canal, but is not discharged by stool. Sometimes, when there are only two or three w r aiery stools, the intestines after death are found to contain a large quantity of this thick whitish or yellow substance.' I have before (p. 227) referred to Annesley's opinion, that relapse has frequently been occasioned by the retention of this foetid material in the bowel. And in Cases 36 (p. 63) and 40 (p. 70), it will be seen that the gelatinous material in question was brought away during life by the action of castor oil. Now the two facts to which I have referred — the frequent accumulation of the liquid contents of the stomach and intestines in cholera, and the occasional retention of the more solid portions of the secretion, even when the watery parts have escaped — appear to indicate the necessity for emetics and purgatives. The first stage of the eliminative process in cholera — the secretion of fluid into the intestinal canal — has its analogy in the cutaneous eruption of small-pox, measles, and scarlatina ; the second stage of the process — the evacuation of the stomach and intestines — has no counterpart WITH COLLAPSE. 257 amongst the phenomena of the eruptive diseases, and it is for the performance of this part of the process that the unaided powers of nature are often found to be insufficient. It would, perhaps, be difficult to prove that any purgative medicine has the power of directly assisting the escape of the cholera poison, or the products of that poison, from the blood into the intestine ; but it cannot be doubted that, by removing the contents of the bowel, and so obviating the impediment to the secretory process which would result from their accumulation, an indirect aid is given to the elimination of the poison from the blood. The speedily fatal consequences of over-distension of the bowel, when the attempts to remove that condition have been unsuccessful, may be seen in Case 31 (p. 52). At the commencement of the recent epidemic of cholera, I determined to treat the patients who came under my care by repeated doses of castor oil ; believing, as I do, that no purgative is so well adapted as this to fulfil the indications for the rational treatment of cholera — namely, to prevent the accumulation of morbid secretions in the stomach and intestine ; to effect their evacuation as speedily as is practicable, yet to do this with the least possible irritation of the mucous membrane, and without increasing, in any unnecessary or injurious degree, the amount of secretion from the blood into the digestive canal. There is no purgative at once so mild, so certain, and so speedy in its action, as castor oil; while its oleaginous properties, and its bulkiness, render it peculiarly fit to dislodge the viscid secretions which cling to the mucous membrane in cholera. The results of the treatment by castor oil may be seen in the history of the cases recorded in the first part of this treatise. At the close of the history of each case, I have made what may be considered clinical remarks upon the symptoms and treatment, and in several s 258 TREATMENT OF CHOLERA instances I have pointed out what I now believe to have been errors in the management of the disease ; errors which, at that time, it was scarcely possible to avoid, but which may readily be avoided in future. I purpose now to pass in review the chief points which require attention in conducting the treatment of cholera during the stage of collapse, and afterwards during the period of reaction. My remarks will have direct reference to hospital practice, but they will be applicable, with very slight modification, to the treatment of cholera in private houses. It is a point of the first importance for the physician to secure the co-operation of zealous and intelligent assistants and nurses. By assistants, I mean resident medical officers and clinical clerks, whose duty it will be to watch the cases, to superintend and direct the nurses, and to record the symptoms during the absence of the physician. Amongst the pupils of a medical school, there will seldom be wanting a sufficient number of able assistants who will cheerfully do whatever is required of them.* It is, however, not always so easy to obtain the services of good and trustworthy nurses for cholera patients. Many nurses have a dread of the disease, and cannot readily be induced to undertake the painful and anxious task of dealing with it; the consequence is, that a class of patients requiring more judicious and incessant watching than any others, are often left to the care of reckless women who, at a time of less pressing * My experience during the recent epidemic has taught me that no patient in extreme collapse can safely be left to the exclusive care of nurses, however able and trustworthy they may be, for a period of more than two hours at any time, either of the day or night. I would never undertake the charge of cholera patients in a hospital if I could not ensure some supervision of the nurses during the night. With respect to this important point of practice, Annesley says (x. 159)—' The patient ought never to be left a moment without an attendant who is capable of acting according to circumstances, and who may take advantage of every change.' 259 WITH COLLAPSE. demand for nurses of all kinds, would probably find no occupation. This was the case in King's College Hospital during the earlier part of the recent epidemic. Before I took the charge of the cholera wards, there had been four cases of the disease, three of which had occurred amongst patients in one of the surgical wards, and every case had ended fatally. The consequence was a panic amongst the nurses, and night nurses especially could with difficulty be obtained ; those whom we did get were not trustworthy, and two patients were lost through the criminal neglect of nurses during the night. I then made an appeal to some of the better class of nurses ; I assured them, as I felt that I could conscientiously do, that if they would pay strict attention to the ventilation and cleanliness of their wards, and if they were careful and temperate in food and drink, they would incur very little risk in nursing cholera patients. I further promised a pecuniary reward to such of them as discharged their duties well and faithfully. From that time we had no trouble or anxiety as to the nursing of our patients ; several of the nurses earned and received the promised reward ; and although some of them suffered occasionally from nausea and diarrhoea, for which they generally took, of their own accord, a dose of castor oil, not one of them had cholera ; nor, I am happy to say, did we lose any servant or officer of the hospital during the recent epidemic. When cholera patients are admitted into a general hospital, it is on several accounts desirable that separate wards should be appropriated to them. One great objection to placing them in a ward with other patients is, that most persons, even in good health, are more or less terrified at the sight of one who is suffering from cholera, and the sick are still more likely to be thus affected. And again, a patient with cholera requires such incessant attention, that there can be no quiet, either by day or s 2 260 TREATMENT OF CHOLERA by night, in a ward where such cases are received. Therefore, if other patients are mingled with them, all must be disturbed and restless I think, too, that it is a matter of some importance to have a convalescent ward for the cholera patients, so that those who have passed through the worst stage of the disease should not be disturbed and distressed by the painful scenes which must be constantly witnessed amongst those sufferers who have been recently admitted. It is scarcely necessary to insist upon the importance of good ventilation and cleanliness in a cholera ward. Any morbid discharges which are set aside for the inspection of the medical attendants should be kept in close vessels, and removed from the wards as soon as possible. When a patient is admitted in collapse, he should be carried up stairs, undressed, placed in bed, and prevented, as much as possible, from making any muscular exertion, so long as the symptoms of collapse continue. On no account should he be placed in a warm bath. I learn from others that the warm bath has often had a very depressing effect upon patients in collapse : thus, Dr. Parkes says (i. p. 210), ' I have seen a man walk firmly to the bath, with a pulse of tolerable volume, and a cool but not cold surface, and in five or ten minutes have seen the same man carried from the bath, with a pulse almost imperceptible, and a cold and clammy skin. I cannot find in my notes a single case in which the warm bath appeared beneficial.' It is probable that the depressing effect of the bath is chiefly occasioned by the suspension, for the time, of the cutaneous respiration. We breathe through our skins as through our lungs ; and the cutaneous respiration and exhalation cannot be entirely suspended for a length of time without destroying life. 'It was found by MM.Becquerel and Breschet, that when the hair of rabbits was shaved off, and a composition of glue, suet, and resin (forming a coating impermeable to WITH COLLAPSE. 261 the air), was applied to the whole surface, the temperature rapidly fell, notwithstanding the obstacle thus afforded to the evaporation of the sweat, whereby, it might be supposed, the temperature of the body would be considerably elevated. In the first rabbit, which had a temperature of ioo° before being shaved and plastered, it had fallen to 89^° by the time the material spread over him was dry. An hour after, the thermometer, placed in the same parts, had descended to 76 0 . In another rabbit, prepared with more care, by the time that the plaster was dry, the temperature of the body was not more than s^° above that of the surrounding medium, which was at that time 69^°; and in an hour after this the animal died.'* Now, it is not difficult to understand the depressing effect of the warm bath upon a patient in collapse, if we consider that he is suffering from a form of asphyxia ; that the supply of oxygen to his blood is already greatly reduced, and therefore that the suspension of the cutaneous respiration, by immersion in a bath, even for a few minutes, must be attended with much inconvenience and .distress. The same observations apply to the hot-air and vapour baths. I have frequently seen cholera-patients placed in the hot-air bath, and the result of my observation is, that while the warmth appears to be beneficial, by relieving the cramps, and sometimes even improving the pulse, yet that, on the whole, the patient is rather distressed than comforted by the hot and stagnant atmosphere in which his body is placed. And I attribute this result to the impediment which the cutaneous respiration must of necessity suffer in such circumstances. There are other objections to the use of the air or vapour bath, arising from the frequent passage of the intestinal discharges ; but these are of less weight than that to which I have before alluded. * Dr. Carpenter's Principles of Human Physiology (p. 645), 262 TREATMENT OF CHOLERA When a patient is admitted with such a coating of dirt on his body as would seriously interfere with the functions of the skin, I would have him sponged, while in bed, with warm water and soap, until the surface is cleansed. He should then be covered with a moderate amount of bed-clothes, and hot bottles or cans may be applied to his feet and stomach. I have seen no ill effect from warmth applied in this way. The distressing jactitation, and the tossing away of the bed-clothes, which we so frequently witness, are, as I think, simple indications of want of breath ; a want which is not sensibly increased by dry heat applied to the surface, while it can scarcely be doubted that it is desirable to prevent, as much as possible, the depression of the patient's temperature. (See the explanation of the effects of hot saline injection into the veins, p. 187). The cramp of the muscles may be relieved by vigorous friction with the hands, or with a coarse flannel, or better still, with a flesh-brush. The pain and burning sensation in the epigastric region require the frequent application of mustard poultices to the skin. If the patient vomits freely at the time of his admission, it will be sufficient to encourage the vomiting by letting him drink copiously of warm water ; but if sickness does not occur spontaneously, it is desirable to commence the treatment with an emetic ; for which purpose a scruple of powdered ipecacuanha may be given in warm water, and followed by copious draughts of the same liquid. The object of the emetic at this period is, not only to assist the stomach in ejecting any morbid secretions which it may contain, but also to ensure the removal of any opiate or other noxious drug which may have been administered before the patient's admission. When the stomach has been emptied, a table-spoonful of castor oil may be given in cold water (I am supposing the patient to be an adult), and the effect of the medicine WITH COLLAPSE. 263 must be carefully watched by the medical attendants, more especially during the first two or three hours — in other words, until it becomes apparent to what extent the emetic and purgative action of the oil is likely to proceed. The object for which the castor oil is given is, to produce vomiting and purging sufficient to ensure, from time to time, the evacuation of the stomach and intestines, and to prevent the accumulation of morbid secretions. The quantity of oil which will be required for the purpose will vary considerably in different cases, so that the number of doses and the frequency of their repetition must be determined in each case by the judgment of the medical attendants ; — general directions only can here be given. The nurse should be supplied with a slate, upon which the name of each patient is written, and opposite each name are three ruled columns, at the head of one of which is written, 'oil, 1 of another, 'vomit,' and of the third, 'stool;' and she is required to note in these columns the hour and minute when each dose of oil is given, as well as the exact time of each act of vomiting, and of each stool. It is well, too, that the quantity of liquid passed by stool should be noted, when this can be conveniently measured or approximately estimated. These tables, or an abstract of them, are copied by the clerks into their case-books, and a glance at them enables the medical attendant to see the quantity of medicine which each patient has taken, as well as its emetic and purgative action. Now, it will be found that the effect of the oil is very various in different cases : sometimes nearly every dose is rejected within a few minutes after it is taken, while in other cases every dose is retained. These differences are attended with other variable results, and require corresponding modifications of treatment. When a patient vomits very frequently, the case, if carefully watched and 264 TREATMENT OP CHOLERA judiciously managed, will, in general, prove favourable. Two points of treatment will require care in such a case. One is, not to exhaust the patient by exciting vomiting with too great frequency ; and the other, to ensure the passage into the bowels of a sufficient quantity of oil to prevent a great accumulation of morbid fluid in the intestines. If the patient does not vomit more than once or twice in an hour, during the first twelve hours, it is probable that he will receive only benefit from the vomiting — benefit, too, of which he is, in general, quite conscious. In such a case, as a general rule, the half-ounce dose of oil may be given every hour during the first twelve hours, and afterwards perhaps every two hours ; but this will depend on the progress and the circumstances of the case. At this rate nine ounces of oil will have been taken during the first twenty-four hours, and of this quantity probably at least two-thirds, or even more, will have been rejected by vomiting. In the meantime, we have to attend to the condition of the bowels. Now, it is evident that very frequent vomiting, although it may evacuate the stomach and the upper part of the small intestines, can scarcely pump the fluid from the lower part of the ileum ; and it is equally evident, that if the greater part of the oil is rejected as soon as it has been swallowed, its purgative action cannot be expected to occur. In such circumstances we shall often find that there is considerable fulness, and dulness on percussion over the small intestines, indicating an accumulation of fluid in their cavity. This accumulation must not be allowed to continue ; and its removal may usually be effected by the conjoint action of copious enemata of salt and water, with one or two doses of oil, so administered by the stomach as to ensure its passing on into the bowel. The latter object may generally be attained by giving the oil with a small quantity of cold water — for this purpose iced water may 265 WITH COLLAPSE. be used, — and then directing the patient to lie still, and to drink no liquid for at least half-an-hour, by which time it is probable that the oil will have passed out of the stomach. The dose must be repeated in the same manner until the fulness of the bowels has been removed. I have said that there are some cases in which every dose or nearly every dose of the oil is retained. Now, in genera], these cases occasion the medical attendant much more anxiety than those in which vomiting occurs with great frequency. But amongst these cases there is a considerable variety. In some, the oil quickly acts as a purgative, and the patient soon experiences great relief. An illustration of this may be seen in Case $, (p. 73)7 3 ) in which the patient was cured by five ounces of castor oil. In other cases, when every dose of the oil is retained, its purgative action becomes excessive, unless the patient is carefully watched, and the frequency of the dose is diminished in proportion to its action on the bowels. In other cases, the vomiting, which was frequent at first, becomes less frequent, or ceases entirely after a time, apparently in consequence of the patient becoming exhausted. In these cases again, the greatest care and watchfulness are required, so to regulate the dose of the oil that its purgative action may not become excessive. A quantity of oil which may be given, not only with safety but with obvious benefit, to a patient who vomits frequently, could not be given without risk of exciting dangerous and even fatal purging to some patients who reject none of it, or only a small proportion, by vomiting. But excessive purging is by no means a constant result of every dose of oil being retained by the stomach ; on the contrary, there are some cases, and these are amongst the most serious with which we have to deal, in which the oil excites neither vomiting nor purging. The small intestines are full of fluid, but the whole 266 TREATMENT OF CHOLERA gastrointestinal canal shares in the general torpor which often accompanies the state of collapse, so that the stomach does not respond to the sharpest emetics, nor can the intestines be moved to discharge their contents by purgatives or by enemata. An example of this state of things, and of the fruitless efforts to overcome it, may be seen in Case 31 (p. 52). Now, a consideration of this variety in the cases and in the effects of treatment, will show the impossibility of prescribing any general rule either as to the quantity of castor oil, or as to other remedial measures which shall be applicable to all cases of the disease. The safest and the only sure guide in the treatment of cholera is a full and clear understanding of the pathology of the disease. Without such a knowledge, the practitioner, however well armed with directions received from others, can scarcely avoid falling into some of the many errors which have affected the treatment of cholera, and which have led to the neutralization of the good effects of one remedy by the simultaneous application of some other means, which were intended to aid the treatment, but which a better pathology would have shown were calculated to have an injurious influence. Illustrations of these remarks will be found in the Appendix, and especially with respect to the combination of 'an abundant supply of iced water' with the treatment of cholera by castor oil. Reverting now to the cases in which, with little or no vomiting, there is frequent purging, it is evident that this condition wall require either an entire discontinuance of the oil, or what will, in general, be preferable, its continuance at longer intervals. If the purging becomes excessive when the oil has been given in half-ounce doses every hour, let it be repeated only every two or three hours, and let the effect be carefully watched. In most cases, as soon as bile appears in the vomited WITH COLLAPSE. 267 matters and in the stools — an appearance which, as we know, is almost of necessity attended with other signs of amendment, — the interval between the doses of oil may be doubled, and after a few hours the oil may be discontinued, except that perhaps one dose daily will be required during the next two or three days. With respect to those cases in which the stomach and intestines are torpid, and with difficulty excited to action, it is well to bear in mind that the probability of success in our endeavours to overcome this difficulty, is greater in proportion as the treatment is applied early. Hence the importance of watching the effect of the castor oil during the first two or three hours after the patient's admission, so that if we find that it does not act either as an emetic or a purgative in the usual half-ounce doses, we may double the dose, or combine each dose, as I have done in several cases, with two grains of calomel, at the same time injecting copious enemata of salt and warm water into the bowel. I have never given more than four doses of calomel to one patient, and it probably will not often be necessary to exceed that quantity. It sometimes happens that when the bowels have been very torpid, perhaps from over-distension, at the commencement, they continue to act very freely when once they have begun to discharge their contents ; care, therefore, is required not to continue the large and frequent doses of purgatives beyond the point of necessity. ' But,' I have been asked, ' is it desirable to recommend a plan of treatment for cholera which requires such incessant care and watchfulness ?' To which query I can only reply that if there be any successful mode of treating either this or any other serious disease which does not require, on the part of the medical attendants, great care and watchfulness, such a plan would, for many obvious reasons, deserve the preference ; but until 268 TREATMENT OF CHOLERA such a plan of treatment is discovered, I shall continue to practice and to recommend that which I have so far described. As to the quantity of oil which may be required for the treatment of any one case, it is obvious that this must vary considerably. Perhaps with the usual amount of vomiting, the average quantity of oil for an adult may be about ten or twelve ounces ; in some cases half the quantity will suffice, while in others half as much more may be necessary. The dose for children must be reduced in proj)ortion to their age. Amongst my patients there was one child aged three (Case 28, p. 47), and another aged five (Case 49, p. 85) : both were in great collapse when admitted, and both recovered. I have already said that unless the patient vomits spontaneously at the time of his admission, it is desirable to commence the treatment with an emetic. When, during the progress of the case, vomiting is occasionally excited by the oil, there will be no further necessity for giving a special emetic dose ; but the beneficial effects of vomiting are so decided, that some means should be resorted to for exciting the effort at least once in two hours during the stage of collapse. There are various modes of doing this : one plan which I have sometimes found to succeed very well, is to give the oil in water, with a moderate quantity of ammonia — either the sesquicarbonate or the aromatic spirit. The stimulus of the ammonia often excites vomiting, and when this is the case it may be given either with the oil or without it as often as it appears desirable to obtain its emetic action. In other cases, I have given, from time to time, an emetic of salt and mustard — a dessert-spoonful of salt and a teaspoonful of mustard, — with a copious draught of warm water. When the collapse is very great, a stimulating emetic, such as ammonia or mustard, is more likely to succeed than one of ipecacuanha. The good effects of WITH COLLAPSE. 269 vomiting are generally apparent in the relief from a sense of oppression, and often, too, in an improvement of the pulse. Several of my patients expressed a great desire for a repetition of the emetics, in consequence of the relief which they had before experienced from their action. The beneficial effects of vomiting are probably in part due to the mechanical impulse which the straining efforts give to the circulation, but there is reason to believe that the removal of the morbid secretions is also of great service. In some cases the stomach becomes so much distended by its contents, as to interfere mechanically with the movements of the diaphragm (this occurred in Case 33, p. 55)- It is obvious that the removal of such an impediment must be most desirable and very beneficial. When a patient is drinking copiously and seldom vomiting, the condition of the stomach should be carefully examined by percussion, with a view to prevent a great accumulation of liquid in its cavity by the timely exhibition of an emetic. The relief which follows the action of an emetic is sometimes very great and striking. A remarkable instance of this, as reported by Dr. Hawkins, is communicated in Dr. Gull's Report (p. 199). 'It occurred in the case of a male patient, aged thirty. He was perfectly blue and pulseless, with great restlessness and dyspnoea. Death seemed impending. With the forlorn hope of relieving the oppression complained of at the epigastrium, I directed a salt and water emetic to be given, which, as soon as it operated, gave great relief, and from that time the patient began steadily to recover.' I have mentioned ammonia as an emetic, but there is reason to believe that this medicine may be useful as a general stimulant during the state of extreme collapse. It certainly appeared to act beneficially in the two or three cases in which I gave it. The liquor ammonia? is strongly recommended by Twining (v. p. 46-7), as a 270 TREATMENT OF CHOLERA safe and efficient stimulant, and he states that it has been used with singular success by Mr. Steart, an account of whose successful practice is contained in the 6th volume of the Transactions of the Medical and Physical Society of Calcutta. My present determination is to make further trial of the liquor ammonise as a stimulant in cases of extreme collapse. For this purpose it may be given in doses of twenty or thirty drops sufficiently diluted with water. After the evidence which has been adduced as to the injurious effects of alcoholic stimulants in collapse, it scarcely need be said that they ought never to be given to a patient in that condition. While the collapse continues, their effect is, by adding to the amount of unoxidized materials in the blood, to increase the embarrassment of the pulmonary circulation, and so to lessen the volume and the power of the pulse, and to lower the temperature of the body. And after reaction occurs, the alcohol serves only to increase the febrile heat which results from the rapid oxidation of the accumulated combustible materials. There are some persons who believe that alcohol, during collapse, can do neither good nor harm, and their belief is based on the notion that absorption is absolutely suspended during collapse. M'agendie, however, has demonstrated the continuance of absorption from the intestinal canal during collapse, although with less rapidity than in health. He injected camphor into the rectum of a patient in the cold stage, and in five minutes he detected the odour of the drug in the patient's breath. In health, he says, it may be detected in one minute after the injection. He also detected the smell of ether in the breath a few minutes after its injection into the bowels (vi. p. 97). We may, therefore, conclude that the acknowledged inefficacy of alcoholic liquids as stimulants, during the stage of collapse, cannot be explained by the 271 WITH COLLAPSE. erroneous assumption of a complete suspension of absorption. And that their influence is positively injurious I am convinced, not only from my own observation of their bad effects, and from what the experience of others has taught me, but also from the physiological considerations to which I have before referred. The almost universally admitted fact, that opium aggravates the symptoms of collapse, renders it scarcely necessary to protest against the use of that drug in such circumstances. It is probable that opium does harm, not only by preventing the escape of the morbid poison from the blood, and of the secretions from the digestive canal, but that it also has a direct effect in adding to the embarrassment of the pulmonary circulation. It is difficult to conceive any form of asphyxia in which the effect of opium can be other than injurious. It scarcely admits of a doubt, that no advantage whatsoever is gained by giving any kind of nourishment during the stage of collapse. The blood is too rich in solid constituents, and therefore cannot require an addition of albuminous or other nitrogenous materials. The digestive powers are suspended ; in most cases the patient has an absolute abhorrence of any mixture with the water which he craves in abundance ; and the distressing sense of oppression occasioned by a small quantity of milk or beef tea is another clear indication that these liquids are a useless and an injurious burden to the patient's stomach. lam satisfied that, as a general rule, pure water should be the only drink of a patient in the stage of collapse. An important question then arises : What should be the temperature of the water ? Should it be warm, or cold, or iced ? The sense of burning heat at the epigastrium is an almost constant symptom, and it is said to be more effectually relieved by iced water than by any other means; but it does not necessarily follow that it is expedient, or even safe, to relieve that symptom by 272 TREATMENT OF CHOLERA such means. I have before suggested that the sensation of heat is dependent on the intense congestion of the gastro-intestinal mucous membrane, and the large accumulation of blood in its vessels ; and this large supply of blood is obviously inseparable from the active excretory function of those structures during the collapse of cholera. In short, the elimination of the morbid poison by the stomach and intestines, the abundant supply of blood, and the burning sensation, are so inseparably connected, that one cannot be removed or lessened without a corresponding influence upon the others. Hence it follows that when iced water relieves the burning sensation in the stomach, it must lessen the supply of blood, and diminish the secretion from the mucous membrane. And the testimony of those who have given ice and iced water largely, is to the effect that it checks the discharges and diminishes the irritability of the stomacli — in other words, it checks vomiting. Now, if we have rightly interpreted the pathological phenomena of cholera, ice will be injurious exactly in proportion to the degree in which it checks gnstric excretion and vomiting; its injurious influence being somewhat similar to that of opium, though perhaps less in degree — very analogous, too, to the effect which a continual cold draught, or cold lotions on the skin, would have in suppressing the eruption of scarlatina. In the latter case the burning and tingling heat of the skin would be relieved, and the patient would be highly gratified, until he found himself suffering with the symptoms of inflamed kidneys and dropsy. Then, since it is an admitted physiological fact, that warm fluids are absorbed more rapidly than those which are cold, it is evident that there is less probability of supplying to the blood its defective fluid constituents by means of iced water than by water of a higher temperature. Besides, the introduction of a large quantity of iced water into the stomach must certainly lower the WITH COLLAPSE. 273 temperature of the body, and in the same degree retard the general circulation, thus counteracting the beneficial effects of heat applied to the surface of the body. The indiscriminate use of iced water, during the collapse of cholera, affords, as I think, a remarkable example of a practice apparently beneficial but actually injurious, based upon a superficial and erroneous pathology. I have given iced water occasionally, when the vomiting has appeared unnecessarily frequent ; and it appears to me that this is the only purpose for which it can safely or usefully be given. In most cases, when vomiting occurs readily and with the usual frequency, I have allowed an unlimited quantity of cold water, i. c., water of the temperature of the room occupied by the patient. But there are circumstances in which I believe that the patient should be induced to drink warm, rather than even moderately cold liquids, namely, when with an extreme degree of collapse there is difficulty in exciting vomiting. There is yet one remedy which may, in certain cases, be resorted to with advantage, and that is venesection. Now, I beg to state distinctly, that I have never bled a patient with cholera, nor have I ever seen one bled ; my knowledge of the effects of this remedy is derived entirely from others ; but I have carefully read the history of a considerable number of cases, particularly those contained in Scot's Report, and it is evident that the most striking relief from venesection has been obtained when urgent difficulty of breathing was the chief symptom during collapse. I have already suggested an explanation of the mode in which it is probable that the abstraction of blood operates (see p. 178). When the breathing during collapse, is very rapid and laborious, while the vomiting and purging become less frequent, or cease entirely, there is no ground for hope that the patient will survive the attack, unless some effectual relief can speedily be afforded ; and venesection appears to be the T 274 TREATMENT OF CHOLERA only means capable of giving such relief.* I now think it very probable that in Case 23 (p. 40), the child might have been saved by venesection within the first few hours after her admission. Without such aid, and with such rapid breathing, the case was evidently hopeless from the time that the vomiting and purging ceased. It seems by no means improbable that the cessation of the purging in that and similar cases may be a result of the small quantity of blood which reaches the intestines, in consequence of the great degree of impediment in the lungs. If this be the case, venesection might indirectly restore the intestinal secretions. It is important to bear in mind that the object of venesection in cholera is not to produce syncope, but to relieve the distension of the right side of the heart, and of the large veins. The operation, therefore, should be performed while the patient is recumbent, and it is perhaps better to give a dose of ammonia as a stimulant before opening the vein. Those who have practised the operation in these circumstances, and who have the greatest confidence in its efficacy, admit that it is often difficult to procure a sufficient quantity of blood. With respect to this point, Scot makes the following remarks (ii. p. lx.) : 'It is acknowledged, even by the most zealous of its advocates, that this difficulty (of obtaining blood) has often occurred, and proved insuperable. When, however, the operation is performed with the moral conviction that, if successful in obtaining blood, the life of the patient will most probably be saved, the operator will persevere, undiscouraged, in his efforts ; he will call in every suitable aid, such as frictions, bathing the arm in hot water, re-opening the orifices of the vessels, administering stimu- * The saline injection into the veins might give temporary relief, but with my present knowledge of the mode in which it operates, I consider the repetition of this experiment unjustifiable. 275 DURING REACTION. lants, and external warmth. He is not deterred and induced to desist by any intermediate accession of debility or collapse, nor is lie tempted to rest satisfied with any temporary melioration of pulse ; his object goes beyond the present moment, and he feels satisfied that if he can fully unload the internal vessels, he will save his patient, and if he fails that he will most probably lose him.' It appears scarcely necessary to say that the blood should be taken from the veins, and that no possible good, but almost certain mischief, would result from the abstraction of blood from an artery. The object, in fact, is to relieve the overfulness of the venous system, and so to procure the passage of more blood through the lungs into the arteries. I have references to several published oases of cholera in which, with a singular disregard of the laws of physiology and pathology, arteriotomy was performed, and the result of this operation, together with the copious administration of alcohol and opium, appears to have produced a conviction in the mind of the operator, that previous writers had over-estimated the beneficial effects of bleeding during collapse. Finally, with respect to venesection, I have to say that, if I ever practise it, I shall do so with extreme caution for the relief of urgent dyspnoea, when that symptom obviously arises from obstruction in the lungs, and not from exhaustion, and when no other means appear likely to afford relief. Sec. 111. Treatment during reaction. It will be unnecessary to say much, in addition to the remarks appended to the various cases, respecting the treatment during reaction. When reaction has fairly set in, as indicated by the countenance, the pulse, and the T 2 276 TEEATMENT OF CHOLERA temperature, and subsequently by the reappearance of the bile and urine, the castor oil should be given at longer intervals, so as to avoid an unnecessary amount of purging, but yet to favour the escape of the morbid secretions which have been poured into the bowels during collapse, as well as those which are often formed in considerable quantity during reaction. For this purpose, an occasional dose of oil will generally be necessary during the first two or three days after reaction commences. One of the earliest and one of the greatest dangers during reaction, is that which arises from capillary engorgement of the lungs. I have already explained the pathology and mentioned the chief symptoms of this condition of lung. It may prove rapidly fatal by asphyxia (see Case 33), or more slowly by coma (see Cases 22 and 45. In future I shall endeavour to remedy this condition of lung by the application of leeches or cuppingglasses over the congested lower lobes, and by free counterirritation over the chest ; and when drowsiness threatens to pass into coma, it will be well to shave the head, apply cold lotions or ice, and a few leeches to the temples, according to the age of the patient. The tendency to congestion of the lung during reaction requires that, while the room is well ventilated, the patient be carefully protected from cold draughts of air. If any stimulant appears to be necessary while the signs of pulmonary engorgement continue, my belief is that small doses of liquor ammoniee or of chloric ether are safer than wine or brandy. If the term 'consecutive fever' be synonymous with ' ursemia,' then I can with truth affirm that consecutive fever has not occurred in one of my cases; for in every case the secretion of urine has been fully restored after reaction was established. I believe that ursemia will rarely occur after cholera when the practice of giving opium and brandy has been discontinued. The 277 DURING REACTION. only case of suppression of urine after reaction which I saw during the recent epidemic, was that of a tradesman, ahout whom my opinion was asked at this stage of the case. I learnt that he had been in extreme collapse, that he was treated by castor oil, and that he had appeared to be going on well until it was found that, up to the 3rd and 4th day, no urine had been passed. The suppression continued ; he became delirious, and died. Now, the probable cause of this fatal suppression was the too early exhibition of alcoholic stimulants. I was told that he had taken considerable quantities of wine and brandy, if not while he was in collapse, yet very quickly after. It seems not unlikely that the alcohol may in such circumstances take much of the oxygen which is necessary to render the refuse blood- constituents fit to be discharged through the kidneys. It is, at any rate, quite certain that alcoholic stimulants are injurious in every case of threatened suppression of urine, and they ought not to be given to a cholera patient until the secretion of urine has been completely restored. The condition of the kidneys in cases of uraemia after cholera is very similar to that which exists in cases of dropsy after scarlatina. The kidneys are congested, and the tubes contain desquamated epithelium, fibrinous coagula, and sometimes blood. The treatment required in the two classes of cases is also similar: the warm bath, dry cupping, or a moderate abstraction of blood by leeches or cupping over the loins; a scanty diet, purgatives, and the careful avoidance of stimulating diuretics, which will certainly do no good, and in all likelihood will do much harm.* * It has been suggested to me, that the acknowledged inefficacy of diuretic medicines in cases of suppression of urine after scarlatina, affords an argument from analogy against the use of purgatives in the collapse of cholera. The argument would have some weight if purgatives were as inoperative in cholera as diuretics in the other cases. Diuretics do not increase, but rather tend to diminish, the secretion of urine in the cases in question ; 278 TREATMENT OF CHOLERA DURING REACTION. It is a point of considerable importance to keep the patient on a scanty diet during the first few days after reaction. As soon as bile appears in the motions, milk and water, or barley-water, or thin arrowroot, with an occasional cup of warm tea, may be given. For about eight-and-forty hours after reaction sets in, the tongue is almost invariably covered by a peculiar brownish, but moist coat ; when this has disappeared, beef tea or broth may be given. And so, by degrees, and very cautiously, the patient may return to his usual diet. The too early indulgence in a hearty meal is often followed by diarrhoea, which is most easily removed by a small dose of castor oil. Except an occasional dose of this kind, the only medicine which I have usually given after reaction has been the common effervescing mixture, which allays thirst, and apparently helps to clean the tongue. In some cases there is a complaint of pain in the region of the stomach during the convalescence. This may be relieved by the application of a few leeches over the seat of pain. If the stomach remains irritable after reaction, and if vomiting continues to be troublesome, I know of no objection to the use of iced water for the purpose of removing these symptoms at that period of the disease. whereas, castor oil does actually increase the intestinal discharges in cholera. I think, too, that a writer in one of the medical journals suggested that it could not be right to give purgatives in cholera, because we cannot cure phthisis by expectorants ! Surely the author of that ingenious objection might accomplish almost anything. APPENDIX. Home observations on various points connected with the treatment of cholera, which could not well find a place elsewhere, I have thought best to append to what has already been said on that subject. And, in the first place, I have to make a few remarks respecting statements which have appeared in various publications, to the effect that the treatment of cholera by castor oil has been unsuccessful in the hands of some practitioners who have tried the plan. Now, there are various ways in which cases of cholera may be mismanaged, and a fatal result brought about, in spite of castor oil or the best possible remedy, supposing it to have been discovered ; but unless the particulars of the cases and their treatment are given, it is, of course, impossible for any one who has not seen them to form an opinion as to the cause of failure. The publication of results without a detailed history of the cases and of the treatment, is therefore entirely useless for any scientific purpose. I know that some practitioners have been very successful in the treatment of diarrhoea and cholera with castor oil ; and I trust that they will publish the particulars of their cases at some future time, when, perhaps, they will be less liable than at present to be accused of having pursued a dangerous and unscientific practice ; and when, possibly, it may be less difficult than it has hitherto been to obtain publicity for cases of cholera successfully treated by castor oil. My opinion is, that no one ought to give castor oil, or 280 APPENDIX. any other purgative, in cases of cholera, so long as he entertains the conviction that collapse is a consequence of the drain of fluid from the hlood. I believe that no one having that opinion will succeed with the use of castor oil, because he will not adopt the collateral means which are necessary to ensure success. He will give the oil with tincture of capsicum, as did one of the gentlemen whose ill-success was advertised by the Board of Health ; or he will suspect, as another of those anonymous gentlemen did, that the medicine interferes with the good effect of other remedies, and he will discontinue it ; or he will narcotise his patients with repeated doses of brandy, and attribute to the oil whatever bad results attend this mode of treatment, as more than one practitioner has done. But that which has appeared to me the most surprising fact, is the excessive quantity of castor oil which has been given by practitioners who yet appear to consider it, even in moderate doses, a most dangerous medicine in cholera ; and, so far as I can ascertain, this strange error has been a more frequent cause of failure than any other. In a letter which I addressed to the editor of the Medical Times and Gazette, in September of last year, and in which I gave a sketch of the treatment which I was pursuing, and its results, I said — ' Our plan has been to give the oil in doses of half-an-ounce every half-hour until the bowels are very freely acted on ; when we give it at longer intervals, and discontinue it altogether as soon as reaction is fairly established.' I also stated that 'more than one patient (out of fifteen) has had as much as a pint in fortyeight hours.' Now, I find, to my surprise, that several practitioners, who have professed to follow my directions, have greatly exceeded the quantity which I mentioned as the extreme amount that T had ventured to give. A writer in the Glasgow Medical Journal (October 1845) confesses to APPENDIX. 281 having given no less than 54 ounces (108 tablespoonfuls) to one patient ! It is a very interesting fact, that a patient with cholera should have lived sufficiently long to swallow so large a quantity of oil, and it may encourage a timid practitioner to give it in moderate doses. One very able and estimable physician told me that he had treated three cases of cholera by castor oil ; that two recovered ; that the one who died had lived sufficiently long to take thirty ounces of oil ; and that he had been deterred, as, probably, many others were, by the advertisement of the Board of Health, from giving the medicine any further trial. Now, it is true that I have given more than thirty ounces of oil to patients who have recovered ; but the fact was not known to this gentleman, nor could it have been to the Glasgow physician, who had only my letter in the Medical Times and Gazette to guide him. I am now convinced, as I have stated in other parts of this treatise, that ten or twelve ounces of oil is about the average quantity required for the treatment of cholera, and that, in general, two- thirds of this will be vomited. It is not only the excessive quantity of oil, but the collateral treatment which has occasioned the want of success in the hands of some practitioners. In the Medical Times and Gazette of October 7th, 1854 (p. 371), and in the Lancet of the same date, there is a report of nineteen cases of cholera which were treated by castor oil, in the ' Dreadnought' Hospital. Twelve of these cases were fatal ; and Mr. Complin, who reports the cases, remarks — ' Judging from the results, I think we are not justified in giving any credit to castor oil in Asiatic cholera.' It is stated, amongst other particulars of the treatment, that ' an abundant supply of iced water was given to all of them.' Would it not then be reasonable to inquire whether the unfavourable result is in any degree attributable to the iced water ? 282 APPENDIX. I have already given various reasons for believing that the indiscriminate use of iced water during collapse is injurious, especially on account of its checking gastric execretion and vomiting. It appears from a report of the cases in the ' Dreadnought,' that in six of the cases there was no vomiting, that one patient vomited only one dose of the oil, that three vomited six doses, while others vomited from ten to twenty-seven doses of the oil. A comparison of this report with those of my own cases, will show how much less frequently vomiting occurred, in the ' Dreadnought,' and it can scarcely be doubted that the iced water was the cause of the difference. So that the ice must have done harm exactly in proportion as vomiting is beneficial. Another result of the absence, or the rare occurrence of vomiting is, that all, or nearly all the oil is retained by the stomach, and so passes into the bowel, and exerts its purgative influence.* Now, most of these patients had very large quantities of oil. Thus, one man took seventy -six half- ounce doses, another seventy-two, another seventy, another sixty-seven ; and as very little of the oil was rejected by vomiting, it is not surprising that several of the patients were ' very much' purged. It is, however, not without interest, to observe that the patient who took the largest dose of oil, and who was very much purged, recovered without any consecutive fever, while several of the cases in which there was but little purging, were fatal ; no attempt having been made — so far as appears from the report — to assist the pur- * From a comparison of my cases with the report of those in the 'Dreadnought,' I infer that if equal quantities of oil were given to two sets of patients, while one set of cases were supplied with iced water, and the others with water at the temperature of the sick room, — the patients with the iced stomachs would retain at least three times as much of the oil as the others, and would therefore be liable to a correspondingly excessive degree of purging. APPENDIX. 283 gative action of the oil by enemata, or other means. Consecutive fever was fatal in four of the twelve cases, a result which may very probably be due to the influence of the ice in checking secretion from the stomach. There is no mention of the diet of the patients during reaction — an important omission. But if every one who has failed of success with castor oil would publish as full particulars as Mr. Complin has communicated respecting his cases, it probably would not be difficult to explain the variable results which have been obtained by different practitioners from a plan of treatment nominally the same, but essentially different in respect of some most important and influential particulars. In contrast with the results of the treatment by castor oil and ice in the ' Dreadnought' Hospital, I beg to submit the following report of cases which occurred at Greenwich, in the immediate neighbourhood of the ' Dreadnought.' Mr. Bradley, who communicated to me the particulars, treated the first seven cases of cholera which came under his care, with opium and stimulants. The result was, six deaths and one recovery. My letter in the Medical Times and Gazette, induced him to change his treatment. He substituted cold water for the stimulants, and salt emetics, castor oil, and calomel, for the opium. The result was, that of twenty-four patients in collapse, who were thus treated, seventeen recovered and seven died. Now, the great difference between this gentleman's practice and that reported from the 'Dreadnought,' is the substitution of salt emetics for iced water. In the one set of cases, vomiting was encouraged, while in the others it was suppressed, and this was probably the chief cause of the striking difference in the results. I have recently received a copy of a Report on the cholera patients admitted into the Middlesex Hospital during the late epidemic, and I find that in 23 1 cases of 284 APPENDIX. cholera, twelve different modes of treatment were tried, and that 123 of the cases were fatal. ' Sixteen cases were treated on the castor oil plan,' of these, eight recovered and eight died. In nine of the sixteen cases brandy* was given with the castor oil, and six of these cases were fatal ; whereas, out of the seven cases in which castor oil was given without brandy, only two were fatal. The author of the Report says, — ' On a careful review of the cases, the following conclusions were arrived at : — ' I. That in the worst class of cases death took place quite as soon, or even sooner, under the castor oil than under other modes of treatment. '2. In the most favourable group recovery was quite as rapid, perhaps more so, than in cases under other remedies. '3. In several cases of the medium group it was believed that the oil did serious injury ; and two cases which, on admission, had appeared as almost belonging to the most favourable group, proved fatal.' Now, although, apparently in both' these fatal cases, brandy was given, it does not appear to have occurred to the author of the report that this could have had any share in producing the unfavourable result. In spite of all the accumulated evidence to the contrary, it is assumed that brandy, when given to patients with cholera, has either no influence or a beneficial one. Nine cases treated by brandy and castor oil, are classed with seven cases treated by castor oil alone — the results being very different in the two sets of cases — and the whole are reported to have been treated 'on the castor oil plan.' One of the most mischievous consequences of the trust in specifics for cholera has been the adoption of means * • In cases where brandy was administered, it was given to an adult in doses of half an ounce every half hour.' — Report, p. 17. APPENDIX. 285 for preventing the rejection of the supposed specific byvomiting. Thus, the practice of giving frequent small doses of calomel has been usually associated with the use of laudanum, to prevent sickness. The opiate, it is true, has generally been given in small doses ; but if its effect has been no other than that of preventing or diminishing the frequency of vomiting, it must surely have been very injurious. If there were any proof that mercury possesses a specific curative influence over cholera, there would, of course, be less reason to dread the ill effects of any means which prevent its rejection from the stomach. But it cannot, with any ground of reason or probability, be maintained that mercury has any other influence upon cholera than that which it owes to its emetic and purgative action when given in large quantities. After the explanation which has been given of the suppression of bile during the stage of collapse, it can scarcely 'be supposed that for the restoration of that secretion it is necessary to act upon the liver by mercury. Scot, in describing the effects of calomel, says (ii. p. lvii.) : ' With respect to the supposed quality of quieting the irritability of the stomach, there seems abundant proof that, in cholera at least, calomel does not possess it ; but, on the contrary, it was, when judiciously observed, very often found to have quite an opposite tendency. It is now pretty generally admitted, indeed, that mere irritability of the stomach is not, in itself, a symptom of dangerous import ; and that, if the medicines given to check it have no other concomitant effect, the result is by no means advantageous to the patient.' He says, too, 'The stomach having often lost its power of rejection, this substance has often been found coating its internal surface ; and, when given in boluses, lying imbedded in greenish mucus, marks of inflammation being visible on the spot.' And Christie states (liii. p. 61), that spots 286 APPENDIX. of inflammation have frequently been found in those parts of the mucous membrane of the stomach to which the calomel adhered. Here, at least, is sufficient proof of the irritant action of calomel on the mucous membrane. Dr. Joseph Ayre, of Hull, who has been the great advocate of calomel in frequent small doses, denies that it acts as a purgative, but his own published cases appear to prove that it does (li.). And Dr. Gull describes the effect of the medicine as reported to the College of Physicians in these words : ' For the most part, it was quickly evacuated by vomiting or purging, or, when retained for a longer period, was afterwards passed from the bowels unchanged.' It is generally admitted that salivation is an uncommon result of this practice ; and this fact is confirmatory of the idea that the mercury must act as a purgative ; for although it would not readily become absorbed during collapse, yet, unless it escaped from the bowels by purging before reaction came on, it would then enter the system and produce ptyalism, as it does in some cases ; indeed this unpleasant result occurs quite often enough to constitute a great objection to the use of mercury in large quantities for the cure of cholera. It may often appear that the purging diminishes after the use of calomel, for the reason that the earlier stools in cholera are almost invariably more copious than the subsequent ones. This is usually the case even when castor oil is given ; and the probable explanation is to be found partly in the diminished supply of water from the blood in the later stages, but chiefly in the gradual escape of the cholera poison, which is, in most instances, a sharper cathartic than either calomel or castor oil. One gentleman who had been treating cholera with calomel, admitted to me that the purging continued while the calomel was taken ; but he attributed this entirely to the APPENDIX. 287 action of the cholera poison, and he supposed the calomel to exert some curative influence which he could not explain. I believe, however, that there is no proof of any such influence, nor any that calomel loses its usual purgative action when given in large quantities during the collapse of cholera. Some individuals give mercury, not so much on account of its supposed specific action in cholera as for the purpose of bringing away those peculiar ash-grey-coloured stools, which they say, with truth, do not occur when castor oil, or any other purgative, is given uncombined with mercury. Now, these dark-coloured stools are a result of the calomel being reduced to a state of black oxide by mixture with the alkaline contents of the bowel. Annesley proved this fact by mixing calomel with the viscid secretions from the intestines ; and the result was that it ' formed a dark-greenish grey, precisely similar to the dark-grey dejections already mentioned' (x. p. 174). After this explanation of the dark-coloured stools, it may be asked whether it is desirable to mix calomel with the secretions, during the collapse of cholera, in order to obtain such a result ? There are some practitioners who maintain that no medicine administered by the stomach can be of any service, during the collapse of cholera, because absorption is suspended or much lessened. Now, this objection appears to be based upon a misapprehension of the pathology of cholera, and of the mode in which nature and art may conspire to effect a cure. If the vomiting and purging are the means by which a poison is eliminated from the system, then there are many medicines which may assist these curative efforts without becoming absorbed. Castor oil, for instance, has been given, not with the expectation that it will be absorbed, which, in all probability, it never is, but simply that it may be 288 APPENDIX. ejected by vomiting or purging, and that it may thus con tribute to the expulsion of those morbid secretions which, without such aid, would be less speedily and completely eliminated. A recent writer on cholera, states that ' brandy, ether, ammonia, turpentine, and even champagne, were given to rouse the flagging energies of life, but to little purpose ; they were generally thrown from the stomach as soon as swallowed, and draughts containing creasote, chloroform, and camphor, shared the same fate. The stomach had, as it were, lost the power of ministering to the wants of the system.' Now, it may be asked whether in such circumstances the stomach could better ' minister to the wants of the system' than by the expulsion of its morbid secretions, together with such drugs as could not be retained and absorbed without adding to the perilous oppression of the vital powers ? Some persons appear to suffer from the apprehension of being thought to practise on the so-called homoeopathic principle, if they adopt the treatment of cholera by purgatives. The homoeopathic dogma, similia similibus curantur, as I understand it, implies that a disease is to be cured by those means which would excite the same or a similar disease in a previously healthy person. After all that I have written on the pathology of cholera, it seems scarcely necessary to repeat that neither castor oil nor any other purgative will produce the essential symptoms of cholera in a person previously healthy. It would excite in such a person merely those symptoms — viz., vomiting and purging — which so far from constituting the essence of cholera, are in fact the efforts by which nature endeavours to effect a cure of the disease. Now, to aid the curative efforts of nature was recognised as one of the chief duties of a truly scientific physician before the propounder 289 APPENDIX. of the homoeopathic dogma came into existence, and it probably will continue to be so when he and his infinitesimal system are no longer remembered. Perhaps it may not be out of place to remark, that castor oil is far from being a new remedy for diarrhoea and cholera. I find in Scot's Report (ii. p. 239), that it was used with great success by Mr. Duffin, an Indian surgeon, so long ago as the year 1787. The following extract from a letter in which he describes his plan of treatment, is not without interest : ' I have found no medicine equal to the castor oil, as it carries off the putrid colluvies without irritating the intestinal canal, which even the mildest purgatives in some measure do ; whereas the oil sheathes the internal coats, and blunts the irritating matter. I have always observed the spasms to abate when the oil has operated ; but frequently it is necessary to repeat the dose two or three times in a day when the spasms return. Opiates, in most cases when the nervous system is affected, are found useful ; but in the cholera they ought to be used with great caution, and never whilst there is the least apprehension of putridity. As long as the spasms continue there is a certainty of offending matter in the primae vice, which, if locked up by the opiates, even for one hour, too often a fatal mortification ensues.' In my first letter to the Medical Times and Gazette, I stated my belief that while the greatest mortality from cholera had occurred in the practice of those who have given freely either opium or alcoholic stimulants, those methods of treatment which had been attended with the largest amount of success were essentially eliminative in their tendency; and I mentioned particularly the treatment by emetics, by small and repeated doses of calomel, and the saline treatment of Dr. Stevens. In confirmation of this statement as regards the saline v 290 APPENDIX. treatment, T have condensed from Dr. Stevens's recent work (L), the following account of his theory and his practice. • The first effort towards a cure should be directed to assist nature in throwing off the poison from the blood, •per vias naturales, and, at the same time, supplying the necessary saline stimuli on which the action of the heart and its vessels depends. In accordance with this view, patients presenting merely the first stage of premonitory symptoms, diarrhoea and vomiting, took, on their admission, a seidlitz powder ; and if sinking was felt, but without bowel complaint, more active purgatives were then employed; or three or four teaspoonfuls of Epsom salts were added to the seidlitz powder. On the bowels being moved, plenty of thin beef-tea, well seasoned with salt, was given ; if much irritability of the stomach prevailed, a sinapism was applied to the gastric region, and thirst was relieved with either soda or pure water ad libitum. This simple treatment was so successful that a great number of patients had no further complaint, and were generally dismissed cured in a few days. 'If cramps, coldness, or sinking of the pulse were present, the patients were considered as cholera cases in the second stage. The 'non-purgative* salts were administered every half-hour, or more or less frequently, according to the symptoms, and in the following dose :—: — Muriate of soda, 3j.; carbonate of soda, sss. ; chlorate of potash, gr. vij. When the patient complained of heat or burning at the stomach, an additional , quantity of carbonate of soda was given with the saline powder. When life seemed rapidly ebbing, the collapse stage having been reached, a strong solution of the same salts, at a temperature of ioo°, was thrown into the bowel. The saline mixture was administered halfhourly; and in severe cases the muriate of soda was increased to a drachm, or even more, as circumstances APPENDIX. 291 seemed to require. In some cases an enema, composed of a large tablespoonful of common salt in water, at as high a temperature as the patient could bear, was administered every two or three hours..' Dr. Stevens says, respecting other modes of treatment which have been too often practised, ' Under the stimulating system the mortality was the highest, with the exception, perhaps, of the combinations of calomel, opium, and stimulants, when the mortality was literally murderous.' LIST OF AUTHORS REFERRED TO. Parhes. Researches into the Pathology and Treatment of the Asiatic or Algide Cholera — 1847. i Scot. Report on the Epidemic Cholera— Madras, 1824. IT 11l IV, Bell. Treatise on Cholera Asphyxia, or Epidemic Cholera— 1 83 1. Orton. An Essay on the Epidemic Cholera of India — second edition — 1832. V Twining. Clinical Illustrations of the more Important Diseases of Bengal — second edition — 1835. VI Magendie. Lecons sur le Cholera Morbus — 1832. VII Gull. Report on the Morbid Anatomy and Pathology of Cholera— lBs3. VIII Harwell. Asiatic Cholera ; its Symptoms, Pathology, and Treatment — 1853. IX Paine. Letters on the Cholera Asphyxia, as it has appeared in the City of New York — 1832. X Annesley. Sketches of the most prevalent Diseases of India — 1829. XI. Johnson James, M.D.,andJ. It. Martin. The Influence of Tropical Climates onEuropean Constitutions — sixth edition — 1841. XII Mackintosh, John, M.D. Principles of Pathology and Practice of Physic — fourth edition — 1846. XIII XIV Carpenter. Principles of Human Physiology — 1853. Davy, John, M.D. Researches, Physiological and Anatomical — 1 839 . Gar rod, A. B. On the Pathological Condition of the Blood in Cholera — London Journal of Medicine, vol. i. XV p. 409. XVI Schmidt. Characterestik dcs Epidemischen Cholera — Leipsic — 1 850. XVII o' Shaughnessy. Report on the Chemical Pathology of the Malignant Cholera — 1832. XVIII. Parhes. On the Intestinal Discharges in Cholera — London Journal of Medicine, vol. i. p. 134. 293 LIST OF AUTHORS REFERRED TO. XIX. Magendie. Lecons sur les Phenomenes Physiques dela Vie — 1842. XX Sailer. A Dissertation on the Motion of the Blood —iitf- XXI. Reid John. Physiological, Anatomical, and Pathological Researches — 1848. XXII. Draper. A Treatise on the Forces which produce the Organisation of Plants. — 1844. XXIII Jones, Wharton. British and Foreign Medical Review, vol. xiv. XXIV XXV Bowman. Philosophical Transactions — 1842. Johnson, George. On the Diseases of the Kidney — 1852. XXVI Erichsen. Edinburgh Medical and Surgical Journal. XXVII XXVIII XXIX XXX XXXI XXXII XXXIII XXXIV XXXV XXXVI XXXVII. XXXVIII. XXXIX. XL. XLI. XLII. XLIII. Paget, J. Lectures on Surgical Pathology. Jones, Wharton. Guy's Hospital Reports. Sales. Statical Essays — 1769. Briquet et Mignot. Traite Pratique et Analytique dv Cholera-Morbus — 1850. Blake, James. Edinburgh Medical and Surgical Journal. Grainger, R.D. Report on the Epidemic Cholera in 1848 and 1849. Christison. A Treatise on Poisons, 4th edit., 1845. Lee, Henry. Pathological and Surgical Observation — 1854. Watson. Lectures on the Principles and Practice of Physic — third edition. Harvey. Works, translated by Dr. Willis — Sydenham Society. Simon, John. Lectures on General Pathology — 1850. Jackson. Cases of Cholera collected at Paris, in 1832. Budd, George. Library of Practical Medicine, vol. iv. Liebig. Familiar Letters on Chemistry — 1851. Gairdner. On Gout — 1851. Simon, Franz. Animal Chemistry — Sydenham Society. Lehmann. Lehrbuch der Physiologischen Chemie — 1853- 294 LIST OF AUTHOES EEFEEEED TO. Brodie. Lectures illustrative of various subjects in Pathology and Surgery— lB46. XLIV XLV Bird, Golding. Urinary Deposits— lBs3. Sydenham. Works, translated by Dr. Greenhill— XLVI Sydenham Society. Annesley. Researches into the Causes, Nature, and Treatment of the more prevalent Diseases of India — 1828. XLVII B'dhm. Die Kranke Darmschleimhaut in der Asiatischen Cholera — 1838. XL VIII French, J. G. The Nature of Cholera Investigated, second edition — 1854. XLIX L. Stevens. Observations on the Nature and the Treatment of the Asiatic Cholera — 1853. LI. LII. Ayre, Joseph. A Eeport of the Method and Eesults of the Treatment for the Malignant Cholera— lB33. Snow. On the Mode of Communication of Cholera, second edit. — 1855. Christie. Observations on the Nature and Treatment of Cholera, and on the Pathology of the Mucous Membranes — 1828. Mil. LIV. BicJcson. On the Epidemic Cholera and other prevalent Diseases of India — 1832. LV. Paget, J. Medico-Chirurgical Transactions. THE END. BY THE SAME AUTHOR. Octavo, with Illustrations, price 14a. On the Diseases of the Kidney : THEIE PATHOLOGY, DIAGNOSIS, AND TKEATMENT. With a Chapter on the Anatomy and Physiology of the Kidney.