CHOLERA: SOME REMAKES UPON \j n. v Ju JDi xi a. SOME RBMAEKS UPON ¦ ITS NATURE AND PATHOLOGY, WITH A REPORT OP TWENTY CASES, OUT OF A LARGE NUMBER SUCCESSFULLY TREATED UNDER A CERTAIN SYSTEM DURING THE LATE EPIDEMIC. €t*S X by rP k 0. LITTLE. F.R.C.5.1., L.M., &c, MEDALLIST OF PA^^RoGICAL SOCIETY, DUBLIN ; MEMBER OP BKITISH MEDICAL ASSOCIATION } MEMBER OF SURGICAL SOCIETY OF IRELAND, &C, &C. Read and discussed at the Thirty-fifth Annual Meeting of the British Medical A*»oc\ation t . held in the University of Dublin, 9th August, 1867. '"-'-'j^W&EA&k r#y LONDON : JOHN CHURCHILL & SONS. DUBLIN : JOHN FANNIN & CO. EDINBURGH: MACLACHLAN & STEWART. we Umac \QJ67 DUBLIN : riIINTED BY CHARLES COOPER, AT THE OFFICE OF THE MEDICAL PEESS AND CIBCULAB, CONTENTS Introduction Cholera, nature and pathology ow . .6 Principles of Treatment . . . .6 Case I. Symptoms, History, and Treatment of, ... 11. „ complicated with mitral valve disease ; opis'chotonos, 8 ... IV. „ cholera sicca, . . .9 ... V. „ convulsions, remarkable character of . 10 ... VII. „ convulsions, general ; opisthotonos, . 12 . . . VIII. „ cholera sicca, . . .13 . . . IX. „ contagious origin of ; teetotaller, . 13 .X.. „ ? . . .14 .... XII. ? contagion; collapse; stomach pump ; death, 15 ... XIII. ? contagion, . . .17 ... XIV. „ fear, cause of . . IS ... XVI. „ teetotaller; opisthotonos, . . 19 ... XVII. ? from neglected diarrhoea, . . 20 -... XVIII. ? . . . .21 .. XIX. „ opisthotonos, . . .21 ... XX. „ „ first appearance in '67 . 22 Rubeola cholerica . . .23 Table I. Patients' age, sex, health previously, &c, deductions, . 24 ... 11. Conditions, hygienic, assigned cause, contagious element 25 . . . 11l Invasion of disease, duration, results, &c. . . 26 . . . IV. Cramps, parts affected by . .27 ... V. Treatment, details of . .28 Causation — efficient and "predisposing, . . .29 Mountjoy Prison, outbreak of cholera in, . . . 30 Water, most usual medium, . . . .31 Rules, anticipatory, and regarding patients . . 32 Cerebro-spinal and sympathetic engagements, proofs of . 33 Post-mortem results of disease . . 34 Intestinal glands, absorption of poison by . . .34 Contagion by excreta, . . . .35 Treatment, general summary of . . .35 Mustard, characteristics, adulterations, concentrated tincture of . 36 Conclusion . . . . .37 INTRODUCTION Mr. President and Gentlemen, The subject upon which I am permitted to address this distinguished Association, is of such absorbing interest, and so surrounded by difficulties, as to inspire me profoundly with diffidence on approaching its consideration. This feeling is intensified by the reflection that, for a long time in our fraternity, minds the most gifted, laden with the spoils of culture and experience, animated by unceasing perseverance and noble philantrophy, have been explorers of the obscure domain which I purpose entering for a short period. Their labours were fruitful in scientific results, and tended to alleviate human suffering. They did not however, reach the goal of their cherished hopes — an accurate tiowledge of the nature of Cholera, which all admit, can one indicate the proper treatment. Theories innumerable ive been prppounded of this scourge of our race ; some apparently rational and conclusive; others "baseless as the fabric of a dream ;" all proved inadequate by practical application — their true test, as recently remarked by Sir Thomas Watson. In a suggestive spirit, and with the hope of eliciting the opinions of this learned assembly, I beg to quote from the Medical Press and Circular, August 1, 1866, my views as to the nature and pathology of this disease, upon which, during the late epidemic, I based my treatment, with gratifying results in a considerable number of cases, twenty of which PWITH A RECORD OF TWENTY CASES. I am disposed to consider Cholera as primarily affecting the nervous system, and am led by its many points of similarity to associate it with a large and obscure class of diseases, whose pathology may be found in a loss of balance between the cerebro-spinal and sympathetic systems, the former preserving a preponderating influence. It is most likely a contagion, but of what nature is yet a matter of speculation. It is probably an animal poison, introduced into the system through the media of water, food, and air; and there is every reason to believe, that, the development and diffusion of the morbific matter, are favoured by certain atmospheric, hygienic, and individual conditions. Whatever may be the modus operandi of this poison, its chief effects appear to be, a suspension of the sympathetic power over the capillaries, a consequent blocking up of those vessels, and a cessation of their functions. Generally, in the first stage of the disease, the capillaries seem to resist to the utmost the depressing effects of the toxic agent, which may explain the great increase and evolution of animal heat, the excretive efforts of the alimentary canal, and the high nervous phenomena which usher in the disease. The elimination of the poison through these vessels in some cases, is not as rapid as its development, owing to weakness of the sympathetic system in such individuals. Among the consequences are, an accumulation of the injurious matter in the system, the suppression of the secretions, and the establishing of the features indicative of the second stage of the malady. From observation and the results of my treatment, I conceived that one of B 6 the greatest impediments to the action of the vaso-motor nerves in cholera, is the presence in the prima via of the products of the disease* Such an impression appears reasonable, as we remark every day in this system of nerves, that great excitementmaybe created by simple causes. In one case, the eating of a stale egg brings on vomiting; in another, diarrhcea is induced by mutton-broth, or green vegetables. In both cases, the sympathetic nerves, as if by an inherent repulsive principle, strive to liberate themselves from the disturbing influence, and such seems to me to point out the first step in the rational treatment of cholera. In accordance with those views, I sought, firstly, to free the sympathetic nerves, especially those presiding over the gastrointestinal mucus tract, from contact with the deadly products of the disease ; and, secondly, to renew the tonicity of those nerves. Of the means which I selected for the attainment of these ends, I relied chiefly upon an humble drug, the mustard of commerce, which, by its well-known emetic, aperient, and neuro-tonic properties, suited admirably my two-fold purpose, as, I think, will appear from the following recorded cases. CASE I. At 8 P.M., 17th August, 1866, I attended P. R, aged 35, who appeared death-like. He was supine; his features were hollow, and of a leaden hue ; eyes glassy, and upturned ; pupils natural ; breath cold ; voice whispering ; respiration inaudible, 18 per minute ; the fingers were crooked and exsanguine ; skin shrivelled and cold ; pulse thready, weak, 68 ; abdomen tympanitic, not tender, its muscles tense, well-defined ; bladder empty ; consciousness perfect. The patient had been living freely for more than a week. The day previous to this attack, he suffered from vomiting and purging of watery light-coloured matters. Two hours 7 before my visit, those conditions had ceased, when cramps in the stomach and bowels set in, which he compared to, " a sword thrust through him, and turned several times." The paroxysms recurred about every ten minutes, during which he had hiccup and inclination to vomit, moaned pitiably, implored relief, and expressed his feeling of approaching dissolution. Every attack of the cramps left him weaker and more TREATMENT. I administered a tablespoonful of strong mustard, dissolved in a tumbler of tepid water, and in about two minutes afterwards induced him to drink nearly two quarts of very warm water. This was followed by vomiting of a large quantity of gruel-like fluid, and by copious stools of a very similar char- X expelled forcibly, and with immediate relief to the sr. I then had the stomach and abdomen enveloped in Dism. After half an hour this was removed, and a warm I binder substituted. Slight pains in the bowels, mussoreness, and general prostration, now only remained. ;, therefore, that all the dangerous symptoms had dised, I gave a stimulating anodyne of iEtheri Chlorici Tincura opii Spiritus ammonise aromatici, s.s. 3 s.s. in a half-glass of warm brandy punch. I allowed ice in small bits to allay thirst, and beef-tea frequently. Next day he was pretty well, but very weak. On the following day he was up and cheerful. Ec disbelieved in the contagiousness of cholera ; and my cc as to disinfecting the excreta from him, and regarding bad sanitary state of the house, was not attended to. I informed that in or about a month afterwards, his son, . 14, living in the same house, took cholera and died. 8 CASE 11. I) p.m., Sunday, 26th August, I visited Miss X, aged 23, ramps in the stomach and legs; She was lying diaj in bed, violently tossing herself about, and screaming, cad was strongly curved backwards ; the features were congested, and quivering ; breath cold ; eyes firmly pupils slightly dilated ; pulse feeble and remitting ; 001, and perspiring, warm during the spasms; bowels ng, tympanitic ; respiration difficult ; heart's action ig, irregular, and with mitral valve murmur. I was informed that the patient had been long affected with heart disease. On Friday she dined upon fish, and drank col( water, since which time she has been unwell. Last nigh sickness of stomach and purging of opaline stools attacked her rather suddenly. Early this morning, those distressing conditions gave place to cramps in a mild form, but becoming more severe and frequent until the present, when they are intense and recur every five minutes. Spirits of camphor, chalk anc laudnum mixture, brandy in large doses, and other interna remedies had been tried. Frictions, hot applications, jars turpentine stupes, mustard, &c, had been applied externally all to no purpose, unless, as the patient said afterwards, to augment her misery. TREATMENT. Notwithstanding the heart disease, I was obliged to adopt the same active treatment here as in the preceding case, supplementing it, moreover, with a large enema of oil, turpentine, common salt, and warm gruel. The results were all I could desire. The patient was convalescent next day, though very weak, and made a good recovery. CASE 111. Kp.M., 16th September, I was called hastily to Mrs. sd 47, suffering since yesterday evening from sickif 9 stomach and rice-water purging, with cramps in wels superadded within the last two hours. She lay r hack, with limbs extended. Her features lookec r , hollow, and hopeless ; eyes glassy, and rolling up; pupils dilated ; pulse slow and weak ; skin and breath respiration feeble, at times hurried; urine scanty; ab al muscles in tonic spasm ; bowels distended with flatus 3 every ten minutes, with increasing severity. Ec patient does not know by what cause this illness may been created. She thinks that green vegetables and cold , which she took at dinner on yesterday, may have brought TREATMENT. X emetic and enema, as in last case. The evacuations Dpious, fluid, and wheyey. In about two hours all pain tier distressing symptoms had ceased. Next day she was ut very weak. — CASE IV. At 10 P.M., September 20th, I found J. C, aged 54, lying upon his back, with his mouth open, as if awaiting an approach ing calamity. "He had the fades cholerica, pearly upturne( eye, slightly dilated pupil; cold breath and skin; low feeble voice; pulse almost impalpable, 48; respiration inaudible, un less at intervals of about every five minutes, when inspiration became hurried and gasping, on the advent of fearful cramp in the stomach, which constituted the great misery of the patient. This symptom was accompanied with an inclination to vomit, but inability to do so. The bowels were rumbling and tympanitic; urine very scanty. Every recurrence of the paroxysms left the patient weaker, and threatened in a shor time to terminate his life. B patient had been in good health up to two or three days ten he became generally ill, from cold he believes. The 10 bowels have been confined. The cramps have continued for five or six hours, despite many remedies. Within the past two hours they have become intense. I administered two ounces of mustard as an emetic, which produced an abundant discharge of whitish matter, like soup, with shreds of muscle-fibre through it. I then advised an enema of oil, turpentine, common salt, and gruel, which brought away a large quantity of fluid, light-coloured stools. After having given the usual anodyne, I left him comfortable. The next day he was well. CASE V. At midnight, 27th September, I attended J. N., aged 39, with fearful cramps in his legs and stomach. He was lying on his back in an iron bedstead; had opisthotonos of head and neck; facies cholerica; half-closed and imploring eyes, pupils moderately dilated; breath and skin cold; pulse weak, but natural; voice faint and whispering, except during a paroxysm, when his cries were heartrending. Then, also, the flexor muscles of the lower limbs could be felt contracting wave-like from their distal extremities, until they formed in the thighs and calves of the legs large firm tumours, which continued to increase until the attack began to subside, when, pari passu, they also disappeared. At the same time, the diaphragm was spasmodically contracted, and conveyed a ball-like feeling beneath the ensiform cartilage, and an impression that, at one moment the right leaflet of the muscle was principally affected, and the next moment the left, the globular contraction being felt, now on one side of the zyphoid appendix, then The following is the history of the case : — ¦yesterday, at the Skerry Islands, the patient partook of ispberry cordial, and cold water, at dinner. Soon afterpurging and vomiting set in, and about nightfall cramps 11 Ehim, and have since continued. The evacuations any, and ceased this morning. He has just been car. The paroxysms returned every two or three minutes, rich I discovered that it was dangerous to be within i as he thought nothing of twisting the iron bars of After each fit of pain, he sank more and more into nd despondency. TREATMENT. I was obliged to repeat the emetic three or four times, from a difficulty at first of exciting vomiting, and at a later period, from a return of the cramps with a tendency to relapse. A mustard foot-bath, sinapisms, and the anodyne, contributed towards the fortunate result. After three hours of attendance I left him convalescent. I the next day, he had secondary fever. The pulse was 98, and sharp ; tongue furred in centre, red around the cheeks flushed ; nervous anxiety ; trembling of hands ; i confined, tympanitic; tenderness over the ilio-cecal ; abdominal pains and stitches. Saline effervescing mixtures, with a draught at bed-time, occasionally, of castor-oil and tincture of opium, were my remedies. I ordered ice, beef-tea, and a little wine frequently. At the end of a week he was quite restored to health. Since that time he has had a disagreeable creeping sensation in his legs, and occasionally large tumours form in the calves, with painful cramps. CASE VI. At 4 P.M., Ist October, I was called to J. J., aged 29, with cramps in the legs and stomach. He was extended on the bed pulseless, and almost speechless. His countenance was dusky and thin ; eyes sunken and pearly ; pupils dilated and covered by upper lid ; breath and skin of very low temperature ; respiration feeble, almost inaudible ; abdominal muscles 12 Kd stiff ; no tympanites ; bladder empty ; about every minutes cramps in legs and stomach attack him, and m almost lifeless. He caught cold in the country by sleeping in a damp room about a week ago. For the past three days he had had bowe complaint, and vomiting of whey-like matters. At noon to day, cramps took the place of those conditions. TREATMENT. The same in principle as in previous cases. Reaction was well-established in about two hours, and he made a satisfactory recovery, but remained weak for more than a fortnight after. CASE VII. At mid-day, 2nd October, I was summoned to W. L., age< 29, with cramps in his limbs, bowels, and stomach. On nr visiting him, he was in a paroxysm, the most agonising have ever witnessed. He was lying on his side, his hea( thrown far back, his hands firmly clutching the bed post. He writhed his whole body, gnashed his teeth splintered some of them, and screamed loudly during the spasms, which lasted for about two minutes. He then sank into an apparently dying state, his mind clear throughout His features became of the hollow ghastly character so indica tive of cholera. The respiration and voice were very feeble breath and skin cold, a greasy perspiration adhered to the lattery pulse slender and very weak ; urine suppressed ; abdo men tumid and tympanitic ; spirits wretched. The patient dined late last evening on cold meat and vegetables, and drank cold water, soon after which purging and vomiting assailed him, and persisted up to three hours ago, when cramps affecting the legs, arms, bowels, and stomach came on, in the order stated. They recurred about every five minutes. The character of the stools, I observed, was similar 13 TREATMENT. As usual, but more active. At the end of two hours, he seemed safe, when I left him. At 3 p.m. the cramps returned with great severity. They, however, soon disappeared by repeating the first remedies. He recovered his strength slowly, and has very often since suffered from disturbance of the CASE VIII At 3 A.M., October 11, I saw S. F., aged 26, lying supine in paroxysms bf cramps in the stomach and bowels. I observec the facies cholerica here ; eyes closed, balls rolling, pupils covered by upper lid, and dilated ; breath cold ; pulse regular skin perspiring, and of very low temperature ; bladder empty bowels tympanitic; mind intelligent, but disposed to rest The cramps recur every five minutes, and are attended with nausea, but not vomiting. • * tie conditions set in about midnight, after supper, a the patient had used melons and cold drinks. Man; had been employed to remove the pains, and, amongs brandy to excess ; all to no purpose. He was nearly ted. TREATMENT. Em former cases, and with similar effects. He ejected quantities of gruel-like matters from his stomach, and mvalescent in two hours. Next day he was at business, in his usual health. CASE IX. It A.M., October 11, I got a sudden call to J. C, a teetoaged 51, with cramps in the stomach and bowels. He bended in bed ; had the features characteristic of cholera ; taring, rolling in their sockets, and inclined upwards ; id breath cold ; pulse and respiration feeble ; voice sub- 14 Eand mournful; abdomen tender, tympanitic ; bowels ling, with now and then rice water purging and vomiting, spirits were low, almost without hope. I patient could not trace the attack to any exciting unless to the use of cold water. Sickness of stomach wel complaint, ushered in the illness on yesterday, and still i. This morning the cramps assailed him, and although has been done to benefit him, he is growing worse. The 3 return about every five minutes. He had frequently . a cholera patient (Case V.) within the past fortnight. TREATMENT. lie as in former cases, and with like effects. Nextfday he slight renewal of cramps in the abdomen, which, however athinate stupes, and a draught of oil, with turpentine )ium, overcame. He regained his strength very slowly. CASE X. At 9 a.m., 12th October, I visited Miss C, aged 25, with cramps in the stomach, purging and vomiting of rice-water liquids. She was in the supine position ; her neck was rigid her features were cadaverous ; cheek bones prominent ; eyes pearly, and rolling upwards, pupils dilated ; breath and surface cold; voice faint, and whispering; pulse excitable anc attenuated ; abdomen enlarged, tympanitic, its muscles rigid respiration short and feeble ; urine suppressed ; vomiting more frequent, and followed by cramps about every fifteen minutes inducing great prostration and lowness of spirits. 13 patient, usually delicate, was attacked by sickness of stoand bowel complaint on yesterday, and by cramps at mid- She thought that her present illness was brought on by and sweet cake, of which she had partaken several nights lusly. She had been, three weeks ago, in close attendupon one of her relatives, two miles distant, who was :ed by cholera, and whose case (IV.) is mentioned above. 15 TREATMENT. The same in principle, and with like good consequences, as CASE XL Fit 8 p.m., October 15, I visited H. Gr., aged 41, with cramps legs and bowels. He was supine. His face looked dark and haggard ; eyes glassy, rolling, and upturned, pupils 111 ; breath and skin cold ; fingers crooked and blanched ; and respiration extremely feeble, sighing expiration ; i tympanitic ; abdominal muscles hard ; bladder empty ; clear, but fearful on the approach, every ten minutes, of amps, which begin at the extremities and run rapidly is the bowels, in which they form tumours, and a large at the pit of the stomach. At 4 A.M., on yesterday morning, sickness of stomach and purging of rice-water stools came on, and returned eight or nine times in the next three hours. They then became less frequent, until 4 p.m. this day, when they were superseded by cramps-, accompanied with a fainting feeliDg. These paroxysms begin, (in the words of the patient), with " a dreadful darting sensation in the toes and fingers, and end in the stomach and belly," as I have described. He has passed no water since morning, and very little yesterday. Previous to this attack he had been exposed to colds at night on duty. TREATMENT. Same as in former cases. On Wednesday the cramps returned, but the usual treatment overcame them. For more than a week afterwards, he felt sore all over, and slowly regained strength. He has suffered from disordered bowels since, CASE XII. ¦ p.m., 15th October, having visited Mrs. S., aged 68, d her extended in bed, apparently in a dying state, 16 I less and speechless. Her features were dark, hollow, and ded ; tongue viscid, and protruding to the left side ; eyes closed and glassy ; pupils dilated, fixed, and insensible to lations of light ; skin cold, and moist with greasy sweat; •ation scarcely observable ; breath chilling; heart's sounds tnely feeble, the first sound at times inaudible ; urine essed all day; cramps recur every ten minutes, when ecomes more conscious, turns her head, and moans. The ninal muscles feel dry and rigid ; bowels tympanitic. For the past two years the patient had been hemiplegic on the right side, and for fourteen years previously, was afflicted with rheumatic disease of the joints. During the last two or three days she had been nursing a relative in cholera, whose case (X.) I have here detailed. Early last night purging and vomiting of light coloured fluids began, and continued throughout the night, until about 8 o'clock this morning, when cramps in the stomach and bowels took the place of the first distressing symptoms. After very few paroxysms, which appeared to exercise a rapid and deadly effect, she sank into the state of collapse, in which I first saw her. The prognosis was most unfavourable on account of the patient's age, paralytic, and rheumatic conditions, and her prolonged algid state. Notwithstanding, I resolved upon applying, as well as the circumstances would permit, the usual remedies. TREATMENT. Er having had her supported in the bed, her head reclining irds, and her mouth held open, I poured in the stimuemetic, a good portion of which and some warm water, sceeded in gulping down. I waited for a sufficient time c desired effect, but it was only by irritation of larynx with my finger that vomiting was excited. She about a quart of gruel-like fluid, and felt better, she Reaction seemed about to set in. The temperature 17 arose ; the voice and pulse returned ; spirits became more cheerful. I then directed, as in former cases, the warm enema to be given, which removed a good deal of liquid stools, anc apparently gave her much ease. A sinapism was then applied to the stomach, and after having given directions as to her getting beef-tea, wine, and ice, I prescribed the stimulating anodyne with only gtt. xv. tr. opii, and left her for a few hours. At 8 p.m. I saw her again. She was evidently sinking fast. The reaction had not been progressive. I had sinapisms applied over the heart, abdomen, lower extremities, and hot jars to the feet. The features were now covered with clammy perspiration ; the pulse gone at the wrist, faintly felt in humeral and larger arteries ; voice and consciousness gone ; mucus rales were developed in the trachea and bronchi during my visit, and life, as it were, imperceptibly flickered out. After death, no post-mortem examination being possible, I merely examined her limbs and muscles, which were dry, rigid, and almost fleshless. This case suggested to me the propriety, under similar circumstances, of giving the stimulating emetic, and of afterwards washing out the stomach with the pump. I have not been able to test the effects of such a line of treatment, but it appears to me to be deserving of a trial in cases like the present. CASE XIII. At midnight, 16th October, S. L., aged 32, was taken suddenly ill with purging, vomiting, and cramps in the stomach and legs. His face was haggard and dark ; eyes glassy, pupils dilated ; breath and surface of body cold ; skin dry ; respiration and pulse feeble ; inspiration gasping ; bowels rumbling and tympanitic ; urine not secreted, scanty all day. The vomiting was the most distressing symptom, and was quickly followed every ten minutes by the cramps. The excreta were like pea-soup in colour and consistence. 18 room with a person in cholera; and had been recently much exposed to cold, hardship, and night duties. He blamed con- TBEATMENT. The same as in other instances, and with the same happy termination. He continued very prostrate for some days afterwards, and for many months subsequently, he was troubled with irritability of stomach and bowels. CASE XIV. At 6 A.M., 22nd October, I was called to J. C, aged 37, with cramps in the stomach, bowels, and extremities. His position in bed was supine ; his head and neck were strongly inclined backwards; face bluish and emaciated; eyes glaring, rolling upwards, pupils dilated ; breath and skin cold, the latter covered with clammy perspiration ; pulse and respiration weak ; abdomen gurgling and tympanitic, its muscles tense ; urine suppressed ; mind clear ; spirits extremely bad. The patient had been troubled for the past fortnight with diarrhoea. On yesterday evening, at 6 o'clock, vomiting and purging of creamy matters set in. About three hours before my visit, cramps seized him in the bowels, stomach, arms, and legs. They occur about every five minutes, and have become unbearable. The bowels are now quiet, but nausea continues. He says that he is sinking fast, and knows not how the illness originated, unless from fear on seeing a cholera patient carried through the streets on yesterday. TREATMENT. Here, three tablespoonfuls of the mustard were required to produce the desired effect, and an almost incredible quantity of very warm water. Reaction was tardy, but in about two hours it was well established. In the evening he had slight 19 cramps in the abdomen, which, soon yielded to previous remedies. Next day he waa very feverish. By the application of the means used in the first recorded case of consecutive fever, this attack subsided, and his recovery was complete in CASE XV. At 6 p.m., 29th Oct., I was in attendance upon Mrs. 0., aged 51, with cramps in the stomach. She was lying in the extended posture; her face was cadaverous, listless; eyes closed, pupils moderately dilated, and insensible to a lit candle placed close to them ; pulse and respiration faint, at times imperceptible ; breath cold ; surface dry, rough, and of very low temperature ; abdominal muscles in tonic spasm ; bowels tympanitic ; urine scanty ; voice feeble, whispering ; spirits depressed ; mind rational; occasionally between the paroxysms, which occur every five minutes, unconsciousness and inability to be aroused No cause can be discovered for this illness, which began on yesj^jjiay with a feeling of general discomfort of body, anc lowness of spirits, with sickness of stomach. These conditions prevailed until this morning, wheii she vomited a smal quantity of wheyey matter, after which the cramps attackec her, and have been increasing in severity. Her strength has gradually failed her since their advent. TREATMENT. Eie usual remedies had the effect of evacuating the stomach bowels, of a large quantity of rather thick cream-coloured ;ers. She made an excellent recovery. CASE XVI. r.t 8 p.m., 14th November, I saw P. 08., a teetotaller, aged who was in great suffering with cramps in the abdomen. The decubitus was supine ; head and neck curved backwards ; 18 room with a person in cholera; and had been recently much exposed to cold, hardship, and night duties. He blamed con- TREATMENT. The same as in other instances, and with the same happy termination. He continued very prostrate for some day 3 afterwards, and for many months subsequently, he was troubled with irritability of stomach and bowels. CASE XIV. At 6 A.M., 22nd October, I was called to J. C, aged 37, with cramps in the stomach, bowels, and extremities. His position in bed was supine ; his head and neck were strongly inclined backwards ; fece bluish and emaciated ; eyes glaring, rolling upwards, pupils dilated ; breath and skin cold, the latter covered with clammy perspiration ; pulse and respiration weak ; abdomen gurgling and tympanitic, its muscles tense ; urine suppressed ; mind clear ; spirits extremely bad. The patient had been troubled for the past fortnight with diarrhoea. On yesterday evening, at 6 o'clock, vomiting and purging of creamy matters set in. About three hours before my visit, cramps seized him in the bowels, stomach, arms, and legs. They occur about every five minutes, and have become unbearable. The bowels are now quiet, but nausea continues. He says that he is sinking fast, and knows not how the illness originated, unless from fear on seeing a cholera patient carried through the streets on yesterday. TREATMENT. Here, three tablespoonfuls of the mustard were required to produce the desired effect, and an almost incredible quantity of very warm water. .Reaction was tardy, but in about two hours it was well established. In the evening he had slight 19 cramps in the abdomen, which soon yielded to previous remedies. Next day he was very feverish. By the application of the means used in the first recorded case of consecutive fever, this attack subsided, and his recovery was complete in about a week. CASE XV. At 6 p.m., 29th Oct., I was in attendance upon Mrs. 0., aged 51, with cramps in the stomach. She was lying in the extended posture; her face was cadaverous, listless; eyes closed, pupils moderately dilated, and insensible to a lit candle placed close to them ; pulse and respiration faint, at times imperceptible ; breath cold ; surface dry, rough, and of very low temperature ; abdominal muscles in tonic spasm ; bowels tympanitic ; urine scanty; voice feeble, whispering; spirits depressed; mind rational; occasionally between the paroxysms, which occur every five minutes, unconsciousness and inability to be aroused No cause can be discovered for this illness, which began on yesterday with a feeling of general discomfort of body, and lowness of spirits, with sickness of stomach. These conditions prevailed until this morning, when she vomited a small quantity of wheyey matter, after which the cramps attacked her, and have been increasing in severity. Her strength has gradually failed her since their advent. TREATMENT. Eie usual remedies had the effect of evacuating the stomach bowels, of a large quantity of rather thick cream-coloured ;ers. She made an excellent recovery. CASE XVI. Kp.M., 14th November, I saw P. OB., a teetotaller, aged was in great suffering with cramps in the abdomen, όbitus was supine ; head and neck curved backwards ; 20 Sitenance dark and sunken; eyes rolling, pearly, pupils ral ; pulse and respiration feeble ; breath and skin cold, latter bathed in greasy perspiration ; voice weak, whislg; abdomen tender, tympanitic, and rumbling, its muscles i ; urine suppressed ; mind clear, anxious and highly senb ; cramps return about every ten minutes, when the tembure rises ; the pulse and breathing grow strong, the latter mes hurried. The patient had had bowel complaint for a fortnight. Two days ago, purging and vomiting of fluid, " like tea slops," attacked him, and ceased only this morning on the setting in of cramps. The latter were mild at first, but by degrees grew more severe until the present time. He blames his habit of drinking cold water for his illness. TREATMENT. Same as in preceding cases, and with like good effects. He has been subject occasionally to diarrhoea since that illness. CASE XVII. At 11 A.M., 14th November, T. D., aged 47, sent for me to treat him for violent cramps in the stomach and bowels. He rested on his back ; his countenance was dark and shrunken ; eyes half closed, glassy, and very free in their sockets, pupils dilated; breath and skin cold; pulse and respiration weak; abdomen swollen and tympanitic ; the muscles of it feel hard and well defined ; the urine scanty ; stools liquid, milky ; mind calm, clear, but dejected. Ear the past fortnight he had had nausea and bowel comlt, with watery evacuations. On yesterday, purging and iting of opaline shreddy matters ensued, and continue. This morning cramps attacked him in the abdomen, and have left him very feeble. They recur every quarter of an hour, or thereabouts. 21 TEBATMENT. ¦usual, and with same good results. } patient was slow in regaining strength. CASE XVIII. At 11 A.M., 27th November, I visited W. M., aged 28, with cramps in the stomach, neck, and shoulders. His features were hollow, dark, and gloomy ; eyes glaring, pupils dilated ; voice feeble ; pulse and respiration weak and irregular ; inspiration difficult, and gasping ; breath cold ; extremities icy ; abdomen distended, and tympanitic; bladder empty, no water passed to-day ; position supine. On yesterday he dined upon cold meat and parsnips, and afterwards drank milk and cold water. At four o'clock this morning, bowel complaint, with light-coloured watery stools, came on. Between that time and eight o'clock he had five large liquid motions, accompanied with straining. About daylight he felt slight cramps in the stomach, and nausea. He went out to his business about eight o'clock, but soon got such a severe attack of purging, vomiting, and cramps, that he had to be carried home. The cramps recur about every five TREATMENT. E previous cases. For some weeks afterwards, he suffered ins in the shoulders, irritability of bowels, and general is. CASE XIX. I) P.M., November 27th, I visited Mrs. F., aged 30, with 3in the bowels and stomach. She reclined on her back; her nd neck were strongly curved backwards; features dusky, ted, and expressive of great anguish ; voice whispering, when the cramps assail her, every second or third minute, when her cries are pitiable ; eyes are semi-closed, rolling up- c 22 wards, pupils natural ; breath and extremities cold; respiration feeble and irregular ; abdomen enlarged, tender, and tympanitic; urine not secreted ; great anxiety and lowness of spirits. I he can only attribute her present sickness to cold-water .king, of which she is in the habit. She has had purging vomiting of greyish fluids frequently since last night, and been unwell since yesterday morning. This evening the ips took the place of the previous distressing conditions, and seems exhausted nearly from their force and frequency. TREATMENT. I usual : a large enema, as before prescribed, was of great t here, after the evacuation of the stomach. In two she was convalescent. Her recovery afterwards was ,ctory. CASE XX, At midnight, 16th June, 1867, I was called in attendance upon A. R, a female, aged 32, seized rather suddenly with cramps in the stomach, bowels, and limbs. On my visiting her she was in a paroxysm, lying diagonally in bed, her head and neck were strongly bent backwards, and four persons were in vain trying to control her violent motions. Her screams were frightful, and, as if she were undergoing torture, at intervals intensified. Her features were blue and congested ; skin and breath warm ; respiration and pulse quick, weak, and irregular. After three or four minutes the attack passed off, and left her helpless and drowsy. Her countenance then looked dark and wasted ; eyes closed and rolling, pupils under upper lid; temperature of breath and surface had fallen very low ; respiration and pulse feeble ; urine scanty ; nausea and vomiting of milky fluid precede the cramps, which recur every five or six minutes. She has hitherto enjoyed very fair health. Ten years ago sne naa naa cholera, one cannot assign any cause for her 23 i i. '11 *11 1 present illness. All day she was quite well, dmed upon corned meat and yegetables, and drank cold water after dinner, which she thinks may have induced the disease. Ite in the evening she went out to take a short walk with md, but was obliged to hasten home, having become sud• ill with the cramps. Stimulants, counter irritants, and had proved useless. I directed the following TREATMENT. As in the other cases, with the enema. Two ounces of mustard were required to produce a good emetic effect. In about two hours all alarming symptoms had subsided. The matters ejected from the stomach and bowels were abundant, watery, and of the colour of mutton-broth. I ordered beef-tea and ice to be freely given to her. Next day a rather sharp attack of fever, with rubeola cholerica followed, and continued for a week. Subsequently, some painful but small circumscribed abscesses, resembling anthrax, attacked her. One, the size of a penny, on her stomach, was very troublesome until I lanced it, which gave exit to more than half an ounce of thick grumous pus. She finally regained her strength under the treatment. Two children, who had been much about her during the early part of her sickness, were taken very ill with purging, vomiting, and inward pains. The motions of the bowels and stomach were encouraged with counter-irritation and suitable stimulants, and the children recovered. The water used was out of a pump long idle. There was no sewage to the premises. I shall now lay before you, in a tabulated form, the more important details of these cases, hoping they may be found of some use in the study of the nature and treatment of this y bicuuUb disease. 24 TABLE I. INDICATES THE NUMBER OF THE CASE, THE TIME OF MY FIRST SEEING IT, THE SEX, AGE, PREVIOUS HEALTH, HABITS, AND OCCUPATION —IN OR OUT-DOOR, OF THE PATIENT, AS FOLLOWS :—: — NUMBER DAY AND HOUR PREVIOUS „._„,, OCCUPAOP CASE. FIRST SEEN. SEX< AOE * HEALTH. "ABITS. TIOK# Male. Female. I. Aug. 17,66. 8 p.m. „ 85. Indiffere nt Irregular. Sedentary. 11. „ 26, 6p.m ? 23. Verybad. Regular. In-door. ni. Sept. 16, 9p.m „ 47. Pretty Regular. „ good. IV. ? 20, 10p.m. „ 64. Good. ? Out, active V. „ 27, Midnight. „ 39. Generally Irregular. Out-door. good. VT. Oct. 1, 4 p.m. „ 29. Excellent. Regular. Open air. _*H. „ 2, noon. „ 29. Verygood. „ „ VIII. „ 11, 3 a.m. „ 26. Goodgene- Irregular. In-door, rally. active. *X- » Uf 4a.m. „ 61. Good Teetotaller Out-door. _ health. X. „ 12, 9a.m „ 25. Delicate. Regular. In-door. XL .. 15i la.m „ 68. Bad for „ „ __ „ many years XIJ. »> 15, 8 p.m. „ 41. Robust. ? Open air. XUL „ 16, Midnight. ? 32. Good. „ Inandoutdoor. X*V- „ 22, 6a.m. „ 37. Excellent. Irregular. Sedentary. •Jyj. 1 -kt" 29 > 6pM » 51- Delicate. Regular. In-door. .XVI- Nov. 14, 11 a.m. „ 47. Good. Irregular. Active, out. XVII. „ 14, 8 p.m. „ 42. Hearty. Teetotaller Out-door. Xvm. „ 27, 11 a.m. „ 28. Excellent. Regular. Active, out. XJX. , » 27» 9pm n 30. Good. „ Sedentary. XX. Junel6,»67Mnight ? 32. Indifferent „ Indoor. It appears, therefore, that of those twenty eases, two occurred between the middle and end of August; three in the last fortnight of September; ten in October; four between the middle and end of November; and one about the middle of June last, the first case of the disease in Dublin this year. Between six in the evening and six in the morning, three-fourths, or J6 cases happened. There were 13; males, and 7 females. The previous health of fourteen was good; that of six indifferent or bad. Ponly were teetotallers; the others used more or less of fermented liquors, numbers of in and out-door occupation, were nearly the same. These facts lead to the following conclusions:— 1. The disease reached its climax in October. 2. It was more generally developed after sunset. 8. The average age was 38. 4. Good previous habits and health did not exempt from the discase,-some evidence of its contagious character. 25 TABLE 11. STATES THE NUMBER OF EACH CASE, THE HYGIENIC CONDITIONS ASSIGNED CAUSE, AND PROBABILITY OF COMMUNICATION BY CONTAGION, THUS :—: — in"™* HYGIENIC CONDITIONS. ASSIGNED CAUSE. PROBABJ^ ™**A Hospital, it appears that on the 18th December, five days previously, a fatal case had happened in that tution, which is close to the prison. The pre-disposing causes, — which I considered as individual, 31 atmospheric, and hygienic mal-conditions — were, in a greater or a lesser degree, present in every case. 1. As regards the individual proclivity, I may state that many of my patients were accustomed to use fermented liquors in moderation. Some upon whom the disease pressed most heavily, were free drinkers ; whilst only two teetotallers were attacked — not very severely, and soon recovered. PAge seemed to be an element in the susceptibility. The young, and those far advanced in years, were generally xempt. Persons in the middle and active periods of life, with much mental or bodily labour, loss of rest, exposure to cold nd irregularity of meals, were most subject. My oldes' )atient was 68, my youngest 23. The average age of twenty ases was 38, as before stated. Most of them were in the algic tage of the disease when first I saw them. Some were in ollapse. 3. Preceding the outbreak, the atmospheric conditions were pidemic, judging from the prevalence amongst us of measles, 'evers, meningitis, and " black death," (likely a modification f cholera) ; and, in the lower animals, of rinderpest. I may emark that, for the most part, fevers of a bad type, some of which I attended, had broken out in the localities subsequently isited by cholera, and which were generally objectionable n some hygienic aspects. In most cases, carelessness f sanitary] precautions prevailed in the vicinity ; whilst the water supply was impure. I fully concur with my friend Dr. Mapother in the opinion, that, water is most generally the medium of communicating the malady. Dr. More Madden has recorded a very remarkable circumstance in proof of this view. The first case of cholera in Kingstown occurred in a house on an acclivity, and spread to the next house below it, and thence to others on the descent. Chemical examination was made into the water supply at No. 2 house. It was found to be impregnated with carbolic acid, which, on 32 If was traced to No. 1, where it had been used for dislg the excreta from the cholera patient before throwing • the receptacle of such matters, and from which it mdd into the water supply of No. 2, &c, as was clear from ilysis. gay here remark, that, in my practice, (with only one ion — the non-contagionist), a second case of cholera did cc place in the same house, owing probably to observance following directions, which I strongly impressed :—: — I. As regards the patient — 1. Immediately disinfect the evacuations. 2. Let fresh air constantly through the room. 3. Allow only his attendant or nurse to be with him. 4. Frequently give him fresh bed-covering and linen, and immerse in boiling water the soiled clothes, and drinking vessels, &c, used by him. 11. As to the premises : — 1. Day and night ventilate the house with fresh air. 2. Scour wood-work and furniture, and lime-wash walls. 3. Remove all nuisances, often flushing water-closets, sinks, sewers, &c, with solution of lime, carbolic acid, &c. L 4. Admit sun-light by removing, as far as possible, structions of whatever kind. 111. To the inmates I recommended :—: — 1. To avoid, if possible, the cholera room. 2. To cultivate temperance and regularity of habits of body and mind. t3. To take plenty of out-door exercise, shunning >wded places, theatres, &c. L 4. To wear warm clothing, especially a wide flannel It around the abdomen. 15. To eat good fresh meat and potatoes, and such urishing food, avoiding all green vegetables and fruit, b, seasoned meat, beverages such as lemonade, and 33 cold water, unless previously boiled. If habituated to strong drinks, moderate the quantity, and the time of using them. 6. To apply for proper medical aid immediately on the setting in of choleraic symptoms, or of diarrhoea. E before I pass to the concluding and more practical portion my subject, I may add a few. words regarding the cerebrolal and sympathetic phenomena of cholera. 1. Let me direct your attention to a manifestation of cerebro-spinal excitement which 1 have very constantly remarked, and which harmonises with the views I have expressed. It will be seen from Table IV. that the decubitus of the patient had been either that of opisthotonos, or he evinced a preference for the supine position, which I take as an evidence of preponderating cerebro-spinal influence, — a link of relationship between cholera, meningitis, and what has been commonly called, " Black Death." Pathological testimony supports this assumption Deep congestion of the meninges of the brain and spinal cord, engorgement of the cerebral sinuses, choriod plexus, puncta cruenta, and base of the brain, with effusion into its ventricles, have been generally found after death from cholera. 2. The sympathetic phenomena are numerous and striking. Amongst the most remarkable are those of the circulation — that wonderful current of lift^ which brings to each member of our organism requisites for its proper functional existence, and carries away effete material. Yet, what apparently weak means control this great vital stream ! " The pallid cheek of fear," " the blushing face of shame," what are they ? The expression in the one case of relaxation, in the other of great tonicity of the slender vaso-motor nerves. Throughout the economy their nature is the same. A blow over the epigastrium, a severe physical shock, or a great and sudden mental emotion may at once and entirely destroy the sympathetic dominion 34 over the capillaries of the alimentary canal, and with it life itself; and in cholera that relaxation obtains in a consummate degree, even to the extent of permitting those minute bloodvessels to pour out into the stomach and bowels, many of the constituents of the blood, along with the poisonous products of the disease. It is not my present purpose to discuss the difficult problem as to the period or mode in which the sympathetic nerves are acted upon, whether it be in the process of elimination of the materies morbi, and its products from the blood ; or afterwards from contact with those irritating matters in the alimentary canal. But I may remark, that, the latter appears to me the more likely, for I have so generally found the removal of those morbid products to be followed by such healthy reaction, that I could not refer the previous conditions of nervous depression, to a more probable cause. Here, too, I find some confirmation of my views from recent pathological investigations. From the cholera report of Mater Misericordise Hospital, it appears that the following conditions were found in bodies examined : — The mucous lining of the oesophagus projected into the stomach. Near the cardiac orifice, the membrane was mammillated, the crypts being distended with an opaque, white liquid. The small and large intestines were filled with a similar fluid. Brunner's, the mesenteric, the solitary, and agminate glands, in the jejunum^nd illium were enlarged and filled with fluid like pus. The mucous surfaces of the jejunum, illium, and colon were more or less vascular. One of Peyer's patches had discharged its contents, all its glandules being ruptured and collapsed. Similar post-mortem conditions have been observed by Dr. Parkes, and other pathologists. In my practice, I have not had occasion to examine such interesting pathological results. lam no less satisfied of the possibility and likelihood of those glandular enlargements and pustulations being the consequences of absorption from the alimentary canal 35 probable than such a result ; nothing more intelligible, if we >ear in mind the higher organisation, greater activity, and pecial functions of these glands. As to the roseolar eruption, have only remarked its presence at a late period of the disase — in convalescence ; and, therefore, it may be referred to he same origin, — absorption through those intestinal glands nto the circulation, whence it was developed vicariously on eric skih. The foregoing facts, associated with the late discovery in lie excreta of cholera patients of a fungoid growth, resembling be yeast plant, capable of rapid and diffuse propagation; and lso, the recent interesting and successful experiment, of proucing the disease in animals, by mixing with their food some f those noxious matters, have, it seems to me, enlarged our deas as to cholera, its contagious nature, the conditions favourable to its spread, and the means most likely to neutralise its fatal tendencies. I now beg to offer the following short summary of my treatnent. In all cases, I have employed an active mustard emetic nd with most satisfactory results. I regulated the dose by the ffect upon each individual. In no adult case, have I found less han an ounce sufficient. In some cases, I have been obliged to dminister three or four times that quantity, before free vomiting was brought on. I was careful, however, in not allowing the emetic to remain undiluted in the stomach longer than aboul two minutes. I then gave an abundance of very warm water which I found to be the best diluent, and at the same time a strong auxiliary towards raising the temperature, and inducing reaction. I used artificial means, — irritation of the pharynx, — to excite the stomach, where it seemed regardless of the emetic. I should in similar cases, and in collapse with inability 36 to swallow, introduce the emetic into the stomach through a pump, and afterwards wash out the organ. I have always applied counter irritation to the abdomen, and sometimes, also, to the feet. Sinapisms I preferred for that purpose. With the same intention I advised flannel to be rolled around the body afterwards. On leaving my patient, I generally prescribed a stimulating anodyne. I seldom saw a case which did not appear to be improved by it. In every case I carefully superintended the treatment, and remained with my patient, according to his improvement, from one to three hours, only leaving him when I thought him on the recovery. Such vigilance was, in my opinion, absolutely necessary, and, I doubt not, contributed largely to success, — the best reward of patience. I have been asked, what is the modus agendi of the mustard emetic ? I confess, I have not given this branch of the subject sufficient attention to warrant any decided opinion. I am, however, inclined to believe that its more immediate action upon the sympathetic nerves of the mucus membrane of the alimentary canal is mechanical, such as follows the application of any irritant ; and that its subsequent effects are chemical, especially the production of volatile oil, by the union of the mustard with hydrogen, which abounds in cholera, in the hypertrophied glands, follicles, and innermost lining of the stomach and bowels. Permit me to say a few words about mustard. This drug is reputed to be made from the seeds of sinapis alba and sinapis nigra, but it is so generally adulterated with flour, turmeric, capsicum, &c, that its therapeutic effects can hardly be estimated, which is a serious objection to its use in scientific medicine. I have, therefore, endeavoured to procure a true and becoming preparation of mustard possessing the active properties — " the volatile oil, and acrid principle of the drug," — and consequently, productive of its emetic, aperient, and neuro-tonic 37 effects, so well described by Dr. Pareira. At my suggestion, Dr. Butler, of Sackville-street, has succeeded in making " a concentrated tincture of mustard, " which, from recent tests, I have reason to believe, will attain the therapeutic advantages required. lam sorry to say that there is a probability of my having soon an opportunity of practically testing this preparation in cholera. In conclusion, I beg most respectfully to thank the Association for the honor it has conferred upon me, in allowing me to place before it my impressions upon the all-important subject of cholera. I trust our worthy associates may be induced to give my views an earnest consideration, and my simple treatment a fair trial, should occasion unfortunately arise. lam hopeful, that, the humble mustard seed, which in antiquity was divinely chosen as the medium of imparting to man a knowledge of the wisdom and goodness of the Creator, may become an instrument of inestimable service to His creatures, assailed by one of life's deadliest enemies.