//<2 '• "-, x .y 1 ** V^ REPORT ON THE REPORT ON THE CHOLERA EPIDEMIC OF 1866, AS TREATED IN THE MATER MISERICORDI^E HOSPITAL, DUBLIN ; WITH SNERAL REMARKS ON THE DISEASE. r BY DRS. HAYDEN AND CRUISE. rn Revised and reprinted from the Dublin Quarterly Journal of Medical Science, May, 1867. U*EAST. : ;••• ••• ••• DUBLIN: FANNIN AND COMPANY, GRAFT ON-STREET NDON : LONGMAN & CO., AND SIMPKIN, MARSHALL, & CO. EDINBURGH : MACLACHLAN & STEWART. 186 7. \aTC U4- yr. A» ytft, 7 JOHN FALCONER, PRINTER, 53, UPPER SACKVILLE-STREET, DUBLIN. REPORT ON THE CHOLERA EPIDEMIC OF 1866. MATER MISERICORDIiE HOSPITAL. In the subjoined report we propose to give the details of 197 cases of cholera, admitted into the Mater Misericordiae Hospital, and treated by us, or under our immediate direction, between the 17th August and the 17th December, 1866. By previous arrangement, all the cases admitted between twelve o'clock at night and twelve noon of the following day were placed under the care of Dr. Hayden, and those admitted between the hours of twelve noon and twelve at night were placed in charge of Dr. Cruise. Dr. Hayden was supposed to visit the hospital in the morning or mid-day, and Dr. Cruise late in the afternoon ; but all interesting, anomalous, and difficult cases were seen by both in consultation. The resident pupils, Messrs. Michael O'Hanlon and George P. Ryan, assisted by Messrs. Coyne and Finnegan, and subsequently Messrs. Conolly and M'Kenna, were in constant attendance, day and night, upon the patients, performing with their own hands the necessary operations, such as administering enemata, registering variations of animal temperature, giving inhalations, hand-rubbing the limbs, and often lifting the patients into and out of bed. These gentlemen likewise performed a large part of the B Report on Cholera, with Remarks. duty of reporting the cases, under our supervision; and to their intelligence and zeal in carrying out our instructions, and acting in emergencies in our absence, is in a great measure due the favourable issue of several cases, as well as the fulness and accuracy of this To the Sisters on duty in the cholera wards we beg to express our deep sense of obligation, not only for the scrupulous accuracy with which they carried out the details of treatment, but likewise for the valuable assistance which they afforded us in collecting materials for the history of several cases ; and to their courage, selfdevotion, and unremitting attention to the patients, and the wholesome moral effect wrought by their example in the minds of both patients and attendants, we have much pleasure in bearing our united testimony on this, the first suitable occasion presented to us. We have classified the cases of cholera under two heads — namely, choleraic diarrhea, characterized by purging, vomiting, cramps, and prostration, or at least by two of these symptoms conjoined; and algid cholera, marked by two or more of the preceding symptoms, either past or present, plus failure of the circulation, depression of temperature, and, in the great majority of cases, lividity of surface ; loaded and peculiar tongue ; urgent thirst; sunken features; shrivelling of the finger ends; and impairment or loss of voice. These constituted the essential symptoms, and in several instances served to indicate the disease, in the absence of any peculiarity of respiration, suppression of urine, restlessness, or thoracic oppression ; all of which, though present at some period in most of the cases, were, nevertheless, so frequently absent, that we are forced to regard them as accessory, rather than as essential phenomena. To each of these symptoms, and others which, being of rare occurrence, must be separately classed as epiphenomena, special attention will be directed in the sequel. In drawing up a report on cholera, or any other epidemic disease, the object which the physician should propose to himself, as it seems to us, is twofold : — Firstly, by a careful classification and analysis of his cases, to educe from them, in the aggregate, definite information in reference to certain questions of a general character, such as the typical features by which the disease may be identified ; the exceptional characters it may present ; the order in which the symptoms are usually manifested, and their relative gravity ; the mode of communication of the disease ; the predisposing 4 By Drs. Hayden and Cruise. and determining causes of the attack ; the influence of age, sex, previous health, and habits of the patients, upon the issue of the cases, and the relative value of different medicinal agents, and plans of treatment. And, secondly, to offer such opinions upon unsettled questions in relation to the disease under investigation, as his data, carefully considered and rigidly scrutinized, may seem to him to warrant. It is obvious that the conclusions arrived at under these two heads must possess very different value. The former, being the result of simple calculation, must be admitted, assuming the record and tabulation to be correct, whereas the latter, being matter of opinion, may be questioned, and can carry conviction to the minds of others only in proportion to the weight of evidence on which they are based. Under the two heads above stated we propose to offer the result of our experience during the late epidemic of cholera in Dublin. We would add that, in view of the possible, and by no means improbable, reappearance of cholera amongst us in the course of the present year, but certainly at no very remote period, it is, in our opinion, the duty of every physician who, with sufficient opportunity for observing and treating that disease, has made it the subject of anxious study, to publish the result of his experience, in the hope that, by a multiplication of carefully compiled statistics, and closely observed facts, our acquaintance with the disease in all its bearings and details shall become so intimate, that the precise nature of the morbific agent which produces it, and the means by which this agent is to be counteracted and neutralized, may no longer elude detection. It is not true to assert, as is the fashion, that medical men are ignorant of cholera. Its differential diagnosis has been clearly established ; its habitual routes traced and mapped out ; the conditions favourable, if not essential to its diffusion are recognized ; its prodromata and stages identified and distinguished, and the relative gravity of its symptoms duly. estimated; the media of its conduction have been all but universally admitted, and its morbid anatomy has been made a part of our settled medical literature. In short, our knowledge of the natural history and pathology of cholera may be pronounced as definite and complete as that of any other member of the great zymotic class. But, now, let us inquire in what that knowledge is defective. In relation only to the precise nature of the morbid 5 Report on Cholera, with Remarks. poison of cholera, and to an absolutely successful plan of treatment, can this be said to be the case. Various attempts have been recently made to isolate the morbific germs of those diseases which admittedly owe their origin to a toxic agent entering the circulation through the medium of the atmosphere; as, for example, scarlatina, measles, typhus fever, and influenza; but in no instance, hitherto, have these attempts been successful, and at the present time our knowlege of the diseases just mentioned, is, in this respect, quite as incomplete as it is in regard to cholera. It is not just, therefore, to assert that our knowledge of cholera, in regard to proximate causation, is in an exceptionally backward state. But, are we to abandon the inquiry into the mysterious agency by which cholera is produced, as one in which success is not attainable? By no means; we should rather hope that through the zealous co-operation of the great number of accomplished and enthusiastic investigators at present engaged in this field of inquiry, prospectively so fruitful in great results, the precise nature and properties of the cholera-poison shall be ultimately made out. Till then, and pending the active prosecution of this inquiry, it is our duty to take advantage, to the fullest extent, of the knowledge we actually possess, for the prevention and treatment of the disease. It seems to us that already a considerable advance has been made in this direction, chiefly by the method of exclusion, as exemplified in the valuable researches of the Rev. Dr. Haughton, recently laid before the Medical Society of the College of Physicians ; and we doubt not that when, by a further application of this method, the alleged causes of cholera shall have been, one by one, examined and set aside, the minds of physicists and chemists shall be so forcibly concentrated upon the few remaining possible causes, that success will become, as it were, a necessity. Here we would observe that a mere quality of the atmosphere, such as an excess or deficiency of ozone, irrespectively of specific contamination, fails to account for the origin and spread of cholera. The doctrine of contagion, if well established in relation to cholera, as we believe it has been by our experience of the recent epidemic, will of itself suffice to exclude this hypothesis; for, in the instance of a personal importation of the disease into an uninfected locality, it is impossible to conceive a contemporaneous importation of a special atmosphere, and without the atmosphere its qualities could not have been imported. 6 By Des. Hayden and Cruise. But if it be conceded that in the locality whence infection was derived, there existed in the atmosphere, by previous importation and reproduction, the specific poison-germs or elements of cholera, of whatever kind, then it will not be difficult to conceive an adherence of these to the dress and person of the infecting party, and a communication of them to the infected. Much confusion has arisen in the literature of cholera from the non-observance, by writers, of a precise distinction between direct and indirect causes ; thus, telluric influences are often mentioned as acting directly and immediately on the human body, whereas, manifestly, all telluric emanations operate through the medium of the atmosphere. The treatment of cholera, unsatisfactory indeed in its main results, is rendered so chiefly by two causes, namely, the neglect of premonitory symptoms, and the difficulty of bringing about reaction in the stage of collapse, owing to the state of all but complete abeyance of the vital functions which is involved in this stage. As already stated, we propose to divide cholera into two stages, those, namely, of choleraic diarrhea, and of algid cholera or collapse. But in a large per centage of cases, as will appear in the sequel, these stagesare preceded by diarrhea, well named • ' premonitory," and characterized by watery and painless evacuations, and associated with debility, languor, flatulence, thirst, repugnance to solid food, and feelings of muscular soreness rather than of pain, especially in the calves of the legs. After a period varying from a few hours to as many weeks, the symptoms which constitute the stage of choleraic diarrhea are superadded, namely, the alvine evacuations become more frequent, and assume a thin gruel, or rice-water character. There is vomiting, muscular spasm of the abdomen and extremities, a character of tongue which is sui generis, and eminently distinctive of cholera ; it is moist, comparatively cold, loaded with yellow creamy fur in the centre, and clean along the edge over a belt of about one-eighth of an inch in width. Thirst is now urgent, and the fluids taken are promptly rejected by the stomach. The pulse is weak, but not quick ; the features are somewhat shrunken and expressive of anxiety, and in many cases the pupils are dilated ; the conjunctivas are usually injected: the surface, in most cases, is dry, chilled, and pallid, but in a few it is suffused, and bathed in perspiration. With regard to the order in which these symptoms occur, we have remarked that when preliminary diarrhea has existed, vomiting has been only second in the order of succession, that is, in all such 7 Report on Cholera, with Remarks. cases it has been preceded by aggravated purging. But in those cases in which the stage of choleraic diarrhea has been at once ushered in, unpreceded by laxity of bowels, or in which the attack has been provoked by excess or indiscretion in diet or drink, vomiting has invariably taken precedence. In a very small proportion of cases only, have cramps been the first symptom exhibited. Collapse now rapidly supervenes ; it is at first characterized by the symptoms of the preceding stage, modified only by failure of the circulation. The body exhales a peculiar nauseating odour; it is cold and moist, and to the touch feels like that of a frog; the features are shrunken and livid ; the eyeballs sunken ; the conjunctiva 3 injected with purple blood, and smeared with viscid mucus; the pupils are in some cases dilated, and in others contracted to the size of pin-holes ; the breath and tongue cold, and the latter moist and coated as already described; the voice is hoarse and whispering, or entirely suppressed ; the ends of the fingers and toes are shrivelled, and the nails are of a purple colour ; the bowels are evacuated involuntarily, the dejecta being of a gum, or rice-water character, usually containing small white flocculi, and occasionally presenting a faintly pinkish tint. The contents of the stomach are ejected frequently, and with remarkable suddenness and force, often to a considerable distance from the patient's bed ; they consist of the fluids taken, intermixed with blood-serum, and often with bile. The patient in this stage is remarkably restless, flinging the limbs about in the most disorderly manner, rolling from side to side, and sometimes actually tumbling out of bed. There is usually complaint of dull aching pain in the loins, associated most commonly with suppression of urine ; likewise, of a burning heat in the epigastrium. The expression of suffering is usually subdued, but occasionally the moaning of the patient is loud and distressing to hear. Cramps are, from time to time, suddenly developed in the lower extremities, abdomen, forearms, and hands, causing incurvation of the toes, and rigid straightening of the fingers, and eliciting from the patient loud cries of anguish ; they cease usually a few hours before death. The respiration varies in different cases; most frequently it is natural, but in many cases, especially those that exhibit great restlessness, and in which the patients complain of oppression of the chest, the breathing is slow and embarrassed, and in some cases irregular. In a few cases it has been found quickened shortly before death, without a corresponding increase in the rate of the circulation. The pulse ranges most frequently from 80 to 90 in 8 By Dks. Hayden and Cruise. the minute, is small and thready, and soon becomes imperceptible ; it is occasionally irregular and intermittent, and this character may be regarded as of exceedingly bad omen. In the early period of collapse the heart's sounds are weak, but distinctly audible ; usually, after a short interval, the second sound is suppressed in the aorta, but continues to be audible in the pulmonary artery to a somewhat later period ; it next ceases to be heard here, and now the first sound, which had been gradually losing vigour, is likewise extinguished. Nevertheless, life may continue for an hour, or even longer, in this state. In a few cases we have noted intermittence of the heart and radial pulse in the advanced period of collapse ; and in one of these recovery took place under treatment with large doses of quinine. We have likewise observed in a few cases of collapse that the temperature of the rectum was- slightly in excess of that of the axilla ; these cases, and the observations made upon them, will be detailed further on in this report. The intellectual faculties usually continue unimpaired to the end, but in a few cases coma has supervened; delirium has very rarely occurred. We hope we may be excused for occupying so much space with a description of the typical and exceptional features of cholera in its several stages, already so well known to the profession. We deem it right, however, to place upon record the aspects and variations of the disease as presented to us during the recent epidemic, for the purpose of comparison in a future visitation. With regard to the suppression of the second sound of the heart in cholera, we are not aware that it has been previously observed. a A question of much interest has been debated in connexion with the premonitory diarrhea — namely, whether it should be regarded as being of a specific character, closely allied to cholera, and, in fact, constituting its first stage. We feel obliged by the evidence before us to answer this question affirmatively, and to declare our opinion that the premonitory diarrhea, so called, is, when present, the first manifestation of cholera. * It afforded us much pleasure to hear Dr. Henry Kennedy stating, in the recent debate on cholera at the College of Physicians, that he had made an observation similar to our own, with regard to the suppression of the second cardiac sound in the collapse of cholera. Doctor Kennedy's observation was strictly independent of ours, as reported in our abstract read before the College in the preceding week, and therefore the more valuable as confirmatory evidence. His observation refers to the second sound generally ; we should be glad to know whether he has observed the difference which we have mentioned, in regard to the period of suppression of the second sound in the aorta and in the pulmonary artery. 9 Report on Cholera, with Remarks. The well-known prevalence of diarrhea, preceding and during an epidemic of cholera, has been often, and we think with good reason, adduced as evidence of an " epidemic constitution " of the atmosphere, influencing the affected locality, and playing an important part in the causation of cholera. Conversely, it may be assumed that the diarrhea which is associated with this " epidemic constitution " is choleraic in its origin and character. The objection that this diarrhea, if early attended to, is amenable to ordinary astringent treatment, is of little weight, and demands a two-fold answer, viz., Firstly. The premonitory diarrhea of cholera is not amenable to the treatment successfully employed in ordinary diarrhea ; it requires a stimulant, and in some degree, a peculiar treatment. Chalk mixture with opium, catechu, &c, which promptly arrests simple diarrhea, has not, usually, an equal measure of success when administered in that which precedes cholera, whilst sulphuric acid is all but invariably effectual in checking it. 2ndly. The successful treatment by astringents, of diarrhea, regarded as an early symptom of cholera, only shows that the treatment of symptoms, in the absence of a better indication, should not be disregarded. A symptom is but the reflection of a morbid cause in active operation in a particular part or constituent of the body, and to arrest the process by which the symptom is produced, is, in effect, to suspend the activity of the cause, if not to neutralize it. Diarrhea is one of the earliest symptoms of cholera, and not the less choleraic because easily curable, and, as we believe, incommunicable in this stage. In all the alleged instances of importation of cholera by persons suffering at the time from diarrhea only, the infecting party has invariably passed into the more advanced stages of the disease before the infected have exhibited any of its recognized symptoms. In a large per centage of cases, as will appear from one of the subjoined tables (Table 5), diarrhea has preceded, often by several days, and in a few cases even by weeks, the manifestation of cholera in its typical form; and during an epidemic of cholera it is well known that diarrhea, if neglected, most frequently issues in an attack of that disease. Dr. Sedgwick Sanders, in a report upon the recent epidemic of cholera, presented to the Diseases Prevention Committee of the City of London Union," states: — "That the experience of the medical officers employed in the Union has confirmed the conviction Medical Press and Circular, February 6, 1867. 10 By Drs. Hayden and Cruise. that the early treatment of diarrhea cannot be too strongly insisted upon, as there is much reason to believe that this so-called disease is often an early symptom only, and must be looked upon as an essential premonition of the choleraic incidence, so that many cases treated successfully as diarrhea ought, nosologically, to be classed under the head of cholera cured in its early or premonitory stage. This admits of no more direct proof than any other negative proposition; but analogy and experience justify the assumption — hence the advantage of searching out such cases by daily house-tohouse visitation, and in this manner enabling the medical practitioner (by dealing with the disease at its inception) to arrest its degeneration into the more severe and less tractable phases." M. Borlee," writing of the recent cholera epidemic at Liege, states that: — " During an epidemic we all experience, in greater or less degree, the influence of the choleraic poison." If by this statement it is meant to be conveyed that in an infected locality a large" proportion of the inhabitants, reputedly in good health, experience malaise, characterized by nausea, partial loss of appetite and flatulence, and an indescribable sensation in the abdomen of an unpleasant character, with slight muscular pains, we quite concur with M Borlee in the opinion that the coincidence indicates the presence of a noxious atmospheric influence, operating upon the entire locality, and conveniently designated as an " epidemic constitution." The idea conveyed by the words " epidemic constitution" involves one of the deepest mysteries in medicine. It implies a condition of body favourable to the operation of a subtle and impalpable agent, diffused amongst the inhabitants of a limited district at particular times. What is the nature of this agent, and the medium of its conveyance ? and what the precise condition of body that favours its attack? In reference to the two latter questions, opinion is now all but unanimous in regarding atmospheric air and water as the media through which the poison of cholera is introduced into the body, and a certain undefined state of depressed vitality as the condition of its effective operation. But although our knowledge is practically advanced by these data, and we are thereby enabled to dispute the approach, and even to preclude the attack of the choleraic agent, still we require to be informed as to the distinctive peculiarities of the choleraic atmosphere, of the water contaminated with the poison of cholera; and as to the precise * Bulletin de l'Acad&nie Eoyale de M^d^cine de Belgique, Ann^e, 1866. 11 Report on Cholera, with Remarks. condition of body that constitutes a state of receptivity of that poison. Mr. Paget declares :: a — " That the existence of certain materials in the blood may determine the formation of structures in which they may be incorporated." It would seem, by a parity of reasoning, not unwarrantable to assume the existence of certain conditions of that fluid which may invite or determine the invasion of a morbific agent suspended in the atmosphere, or in the water made use of by a community. Of the existence of a definite condition of the blood, as necessary to the reception and development of morbid poisons, examples are afforded in the immunity from syphilis, small-pox, scarlatina, and other diseases of this class, enjoyed by individuals at particular times. Thus, of a number of persons inoculated at the same time with the vaccine virus obtained from one source, only a certain percentage will develop the disease, although at another time the persons who thus resist may be successfully vaccinated. Again, scarlatina or measles may invade a family of several children, of whom one or more may escape the disease, though exposed equally with those who contract it ; at a subsequent period these persons, though exposed perhaps in a minor degree, may receive the poison they had previously resisted, and develope the disease even in an aggravated form. In all such cases, of which examples are numerous, the legitimate and necessary conclusion is, that in the first instance a state of receptivity, or blood-affinity for the poison did not exist ; and that such inaptitude was of temporary duration, and coeval with the absence of those vital conditions that constitute a state of receptivity. We attach no importance to the allegations made in reference to coloured mists and vapours said to have been witnessed in localities visited by cholera, because they rest upon unsatisfactory evidence ; at the same time, we cannot admit the impossibility of such meteoric phenomena, holding as we do, that the atmosphere of a cholerainfected locality becomes, after a short time, charged with the poison of cholera extricated from the bodies of those stricken with that disease. The nature of this poison is as yet undetermined ; but if it shall be found to be organic, as seems to be indicated by the evidence we possess, then the presence in the atmosphere of myriads of minute organisms would afford, on physical grounds, a satisfactory explanation of the optical phenomenon of coloured mists. a Lectures on Surgical Pathology, Vol. i., page 27. 12 By Des. Hayden and Cruise. M. Chauveau of Lyons has recently proved experimentally* 1 that horses may be vaccinated by causing them to inhale the dried and pulverized matter of the vaccine vesicle ; in these instances the resultant vesicles were formed, not on the bronchial, but on the cutaneous surface, thereby showing the predilection of the disease for its ordinary habitat, irrespectively of the mode of its communication. These experiments, moreover, prove conclusively the communicability of zymotic disease, in a palpable form, through the medium of the atmosphere. In the capillaries of the atrophied intestinal villi of patients who had died of cholera, Dr. Beale b has discovered bacteria, and the sporules of fungi. We have, ourselves, found in the deposit upon the tongues of cholera patients, vibriones in active motion, and chains of sporules. No doubt, the infusoria and sporules of fungi so found may have been the products of decomposition ; but it is worthy of notice that in the deposit taken from the tongues of patients suffering from diseases, other than cholera, we have invariably failed to detect such products. The evidence before us, then, would seem to warrant the admission that cholera may have for its immediate cause minute living organisms, introduced as such into the body, or developed therein by a process of zymosis from a specific morbid ferment introduced by the lungs or alimentary canal. There are two opinions held in regard to the origin and propagation of cholera ; one, that it is of telluric origin, the atmosphere and water serving as media of dispersion, of unknown quality or nature, but having a special and peculiar affinity for the human body, and favoured, if not absolutely determined, in its invasion of individuals and communities by a lowered hygienic condition, the result of errors or imperfections in the supply of air, food, and water, or at least one of these. The other, that it originates only in, and is peculiar to, the human body ; that it is of the nature of a specific animal poison, organic or inorganic ; that it is communicated by the infected to the uninfected, either directly, through the excretions or emanations of the former brought into contact with, and introduced into the bodies of the latter by immediate personal or fomitic intercourse, constituting contagion ; or indirectly, through the air and water, constituting infection ; but in either case requiring a receptivity on the part of the infected as a necessary condition of attack. a Medical Times and Gazette, February 23, 1867. b Medical Times and Gazette, January 5, 1867. 13 Report on Cholera, with Remarks. Various modifications of these views are held, which it is unnecessary here to specify ; indeed, many of the opinions put forward in relation to the natural history and pathology of cholera rest upon mere assertion. For ourselves, we do not pretend to say how, or from what precise source, cholera has taken its origin ; this portion of its history, like that of other specific and contagious diseases, is absolutely unknown. That the history of cholera dates further back than the year 1817, when it is said to have first shown itself in the Delta of the Ganges, has been satisfactorily proved by Dr. Craigie, B who identified in the cholera of our own time a disease described under that name by Aretseus, as early as the reign of the Emperor Titus. Dr. Graves, b quoting from Le Begue de Presle, says: — "In 1762 it (cholera) prevailed very extensively in Upper Hindostan, and destroyed thirty thousand negroes, and eight hundred Europeans." The same learned writer gives several extracts from other authors and travellers in India, which show conclusively that as early as the last quarter of the eighteenth century cholera was familiarly known in that country. Of the precise nature of the poison of cholera scarcely more is known than of the date of origin of the disease. We have already given some evidence to show that the organic theory has most facts, rather, however, of an indicative, than of a positive character, to support it. It is to be remarked, also, that this theory best accords with the indubitable adherence of the infecting principle of cholera to the dress and furniture of the infected ; its rapid multiplication ; gradual decline ; and connexion with heat and moisture. 0 That it is not of a gaseous nature in a state of combination with the surrounding atmosphere, and independent of reinforcement from local sources, seems indicated by its indifference to strong winds, and by its property of self-multiplication, which is not characteristic of gases, or other inorganic bodies. Thermometric variations seem only to supply conditions that a Edinburgh Med. Journal, Vol. xxxix., page 332. Et sequent. b Dublin Journal of Medicine, January, 1840, Page 359. c There is good reason to believe that since the above paragraph was written, now (July 5, '67) more than two months ago, the cholera-germ has been actually isolated in Germany by Drs. Klob and Thome", independently of each other. At the last meeting (May 7) of the Pathological Society of London, the President of the Society, Mr. John Simon, exhibited a specimen of the cholera-fungus presented to him by Dr. Thome". This is now under examination, by a committee of the Society, and the result is looked for with great interest. 14 By Drs. Hayden and Cruise. favour or retard the progress of the epidemic, but never to give origin to the disease in the absence of its specific germs. We believe that between separate localities and communities the vehicle of conduction for cholera is man himself, infected by the disease, and manifesting at the time its unequivocal symptoms ; or his dress, bedding, or other articles in close relationship with his person whilst the subject of cholera. From this it follows that the rate of transit of the poison of cholera must be equal to that of man, and must vary with the rapidity of human intercourse. We regard it as proven, and will give evidence to this effect in the sequel, that the atmosphere of a cholera-stricken locality may serve as the medium of contamination for short distances, as between the different apartments of the same house, or the adjacent streets of the same town. It would seem, however, that the atmosphere must have attained what may be called the saturationpoint of choleraic impurity before it can serve in this manner. Cholera is, therefore, in this limited sense, infectious, and although direct importation by means of persons or fomites is necessary in the first instance, after the lapse of a certain period of time an " epidemic constitution " of the atmosphere is created in the locality by the multiplication of cholera-germs; and noAV the disease may spread within limited areas by the atmosphere alone, and irrespectively of personal communication. Subsequently it would seem that the condition of depressed vitality, whether due to personal or local causes, will alone suffice to determine an attack amongst the residents of a district so circumstanced. The sudden invasion by cholera of persons previously in good health, immediately, or within a few hours, after taking food or drink to excess, or of an unwholesome character, but free from the suspicion of containing cholera-germs, may be likewise adduced as evidence of an epidemic constitution. Of such a mode of seizure several examples will be given in the subsequent part of this report. In these instances the connexion as of cause and effect was too striking, and the coincidence mentioned of too frequent occurrence, to admit of the supposition that previous contamination by personal contact or otherwise had taken place. Moreover, in all these cases the premonitory diarrhea, which usually marks the accession of cholera contracted by exposure to contagion, was absent, whilst the causes to which the attack was attributed are admittedly incapable of producing it in ordinary times. 15 Report on Cholera, with Remarks. The explanation of these cases seems to be, that the excess or indiscretion committed, not only created a receptivity by diminishing vital resistance, but actually invited and promoted invasion by ushering in two of the most prominent symptoms of the disease, namely, vomiting and purging. The comparative want of success which has hitherto attended the treatment of cholera most certainly applies only to the stage of collapse ; the preliminary diarrhea is arrested, and cholera, as it were, aborted, by a few doses of dilute sulphuric acid conjoined with a regulated diet. Choleraic diarrhea, as will be shown, is likewise curable by the- same treatment with the addition of frictions, warmth, sinapisms, and a few other adjuvants. To this statement we have met with only four exceptions, which we beg to introduce here for the purpose of comparison, and because they serve to prove the general rule we have ventured to enunciate. Case I. — James Dowse, aged forty, of temperate habits, admitted into hospital October 20, at 9.30 a.m. The day previous to his admittance he had attended his wife's funeral, and subsequently drank to excess ; on the evening of that day he was seized with vomiting and cramps. On the morning of the 20th, when admitted, he was suffering from vomiting, purging, and cramps in the legs ; the surface was remarkably pallid, indeed blanched, justifying the designation of "white cholera;" the tongue was moist and coated, but not clean upon the edge as in all the other cases that came under our notice. Ten grains of calomel were given immediately ; and at 11 a.m., as the intestines seemed distended with fluid, a draught was given containing 01. Ricin. 3iv., Tinct. Rhei. 3ii-» aquae Menth, Pip. §i. — After this had acted calomel was again given in doses of gr. ii. every hour. Warm jars were applied to the feet and legs, and mustard cataplasms to the abdomen. The patient died in collapse at two o'clock on the morning of the 21st, twenty eight and a half hours after seizure, and sixteen and a half hours after admission into hospital. Whilst under treatment he took gr. xxxii of calomel. In this case, at the period of invasion, there existed the unfavourable condition induced by depression of spirits, and a debauch ; and the treatment did not include sulphuric acid and opium. Case II. — A woman named Johanna Burke, aged about sixty, was admitted labouring under " choleraic diarrhea," treated with 16 By Des. Hayden and Cruise. chalk mixture and aromatics she got better of the diarrhea, but passed into a low febrile condition, in which she died. Case 111. — Francis Clarke, aged thirty-eight, of very intemperate habits, was admitted to the hospital, October 18th, suffering from severe choleraic diarrhea, with vomiting and cramps. He had been ill twelve hours previous to admission, but was quite warm, and showed no symptom of collapse. Despite of treatment by calomel, sulphuric acid, stimulants, external heat, &c, he ran on into collapse, and died October 21st, having had severe convulsions before death. Case IV. — A shopkeeper, resident in Dublin, called upon his medical attendant late in the evening of the 9th October, to request that he would visit one of his children who was slightly ill ; this child was^ found tp be labouring under cholera, and despite the skilful treatment applied, rapidly passed into collapse, and died. Before the medical gentleman left the house another of the children was reported ill, and in defiance of the treatment promptly and assiduously employed, became collapsed and died. A third member of this afflicted family, a boy aged about nine, complained of being slightly ill when the medical attendant was about leaving ; he was put under appropriate treatment, but notwithstanding, upon a subsequent visit made within a few hours, he, too, was found in the stage of collapse, and died shortly afterwards. Thus, in this single house, three members of one family were seized with cholera, and carried off in the course of one night, in defiance of most skilful and assiduous treatment by a gentleman who has had large experience of the disease in former visitations. We have been informed by that gentleman that the nauseating odour which he experienced in that house, whilst in attendance upon these children, was of so overpowering a character, that he felt great difficulty in restraining himself from vomiting, and succeeded only by taking some brandy on the instant. On the following morning, by the advice of the medical gentleman in attendance, the mother and three remaining children were removed to an avenue in the suburbs ; within a few hours of their removal, one of these children, a girl, aged about fourteen, was attacked with purging and vomiting, and at five o'clock on the evening of that day she was visited by Dr. Hayden, in consultation with the family physician. The patient was found swathed in 17 Report on Cholera, with Remarks. flannel, and surrounded by hot jars. The surface was warm and perspiring ; pulse quick and firm ; there was purging, and occasional sickness of stomach; and cramps, not of a very urgent character, occurred at intervals. The patient was at once put upon the sulphuric acid and opium treatment; but, notwitstanding, collapse supervened within a few hours, and the patient died in the course of that night. In this case, therefore, we have an example of choleraic diarrhea of a typical character, resisting the treatment all but uniformly successful ; but the history of this child's family above detailed, justifies the conclusion that her hygienic condition was so depressed, and that she had received so large a dose of the poison of cholera, as to set all treatment at defiance. We here beg to introduce the following tables, in which will be found the most important particulars respecting the disease as witnessed by us : — TABLE 1, Showing the number of cholera cases admitted into the Mater Misericordiaί Hospital each week during the epidemic of 1866, viz., from the 17th August to the 17th December inclusive ; the average duration of illness, period in hospital, and result of these cases : — Average Average Result Wppk pmiino- No< of duration period Per cent. ween enaing caseg of illness, in hospital, mortality in hours in hours Died Recovered hours minutes hours minutes August 21, 1 600 0 432 0 — 1 — . „ 28, 4 134 0 28 45 2 2 50-00 September 4, 13 116 35 79 46 3 10 23"08 „ 11, 18 77 35 44 58 10 8 55-55 „ 18, 13 138 58 97 9 6 7 46-15 „ 25, 30 84 55 60 21 19 11 6333 October 2, 17 89 16 70 33 6 11 35-29 „ 9, 20 84 42 46 34 12 8 63-63 „ 16, 16 64 5 43 50 11 5 6875 „ 23, 23 141 4 91 29 12 11 47"62 „ 30, 11 204 18 63 37 5 6 45-45 November 6, 9 133 27 100 35 3 6 33-33 „ 13, 11 75 35 56 22 9 2 81-81 „ 20, 7 28 13 16 47 6 1 8571 „ 27, 2 92 7 76 52 1 1 50-00 December 4, 1 63 0 54 30 — 1 — U __ " 18*. 1 26 0 19 0 1 — 100-00 General Aver. 197 104 45 65 51 106 91 53"3 18 As regards this (Mater Misericordias) hospital the epidemic lasted 18 weeks, during which period 197 cases were admitted. The average duration of illness of these cases, recoveries and deaths, both included, was 105 hours and 16 minutes, and the average period in hospital, 77 hours and 11 minutes. Total mortality, 106, or 538 per cent, of those attacked, and the recoveries, 91. It will be seen that whilst the largest number of admissions took place in the last week of September and the first half of October, the greatest per cent, mortality occurred during the first half of October and the middle (13th to 20th) of November. The first two weeks of October were, therefore, the most signalized, both in regard to the number of cases admitted, and to the deathrate. TABLE 2. Showing ages of patients within decennial periods ; previous state of health and habits ; average duration of illness ; period in hospital ; and result : — Previous health Poanit t>«- ! Per cent- Percent- No. and habits* Average Average Result P« , in em Aires of of an ,—, — duration period in — centage | * | ad Patients cases Good Bad t e £_ of illness hospital Die d mortality jf ealtn health health neaitn rj era + c TTnrW H. M. H. M. 10 years 37 32 5 - 96 42 70 19 20 17 54-05 86-49 13-51 10 to 20 27- 18 9 1 190 24 116 59 9 18 3333 66-66 33-33 20 to 30 47 34 10 6 102 14 79 7 19 28 40-42 72-34 21-27 30 to 40 35 29 4 10 78 42 37 40 22 13 62-86 82-86 11-43 4? to 50 26 22 2 4 99 4 5120 19 7 73-07 84 -81 769 50 to 60 13 11 1 2 45 43 25 48 10 3 76-92 8461 7"69 So to 70 8 5 3 - 149 37 75 32 5 3 62-50 62-50 3750 Above 70 4 2 1 1 46 0 30 0 2 2 50-00 25-00 G^Ave d r.l97~ls7^riT"Tos 45 66 55 IQ6~ 91 53-81 7766 17-76 » In the cases of 9 persons the previous state of health had not been ascertained. C Report on Cholera, with Remarks. TABLE 3 A. Showing number of persons, within decennial periods of age, admitted in stage of choleraic diarrhea; average period in hospital ; treatment ; and result : — No Average §3 gi| Age of period in Treatment" Died > « -g Cases hospital g »,= cs Under H. M. 10 years 6 40 0 Dilute sulphuric acid and tincture of opium, creasote water ad libitum, warm applications and sinapisms, hand friction, - - — 6 — 10 to 20 7 97 43 6 Dilute sulphuric acid and opium, &c, as above mentioned, 1 chalk mixture, - ¦ — 7 — 20 to 30 19 84 51 12 do. do. do. In one case this was preceded by a draught of castor oil, and in another it was followed by calomel given as stated below. 1 took tinct. opii. m.x. mixed in an ounce of brandy. Calomel was then given, followed bybismuth and chlorodyne draughts . 1, an oil draught with tinct. opii., and creasoted water for drink. In 4 cases purgatives were given, and one was treated expectantly, — 19 — 30 to 40 10 55 54 In one case acid and opium mixture, with creasote, and external heat, constituted the treatment. In 4, acid and opium ; 1, calomel and creasote ; 2, chalk mixture ;1, expectant, - - - - - - - — 10 — 40 to 50 4 31 37 In 1, tinct. opii. with nit. spirit of ether and camphor mixture was given, preceded by draught of castor oil. In 1, oil draught, followed by calomel in the usual doses. 1, chalk mixture ;1, acid astringent do. - 1 325 00 50 to 60 2 59 30 Acid astringent mixture, - - - — 2 — 60 to 70 4 127 0 1, acid astringent mixture; 1, calomel, followed by bismuth, chloric ether, and tinct. opii. in camphor mixture ;2, chalk mixture. 1 3 2500 70 to 80 2 44 0 1, chalk mixture ;1, spirit ammonias aromat. with tinct. opii., - - - - — 2 — 54 67 34 2 52 37 a For details of treatment, see Tables 4, A and B. N.B. — 'A third instance of death, the patient having been admitted in the stage. of choleraic diarrhea, occurred in hospital (viz., Case 3, page 17), and was, by inadvertence, not taken account of till after the calculations for Table 3 A had been made.. This case, therefore, does not appear in that table ; but allowance can be made for it in estimating the per cent, mortality amongst patients admitted in the stage of choleraic diarrhea. 20 By Drs. Hayden and Cruise. TABLE 3 B, Showing number of persons, within decennial periods of age, admitted in stage of collapse (algid cholera) ; average period in hospital ; treatment ; and result : — Result -g £" No. Average g-g Age of period in Treatment* He- ut. Cases hospital Diea covrd. £ § 10 years, - 26 86 1 21 were treated with calomel. In 3of these cases concentrated solution of camphor was likewise given, and in 2 also inhalations of the nitrite of amyl ; 1 was treated with the warm bath ; 4 with diffusible stimulants, and in 1 of these amyl inhalations were likewise given; 1, arsenic; sinapisms and creasote water generally, - - 15 11 57-69 10 to 20 - 10 135 5C In 13 calomel was given ; and in two of these also a draught consisting of liquor bismuth dr. i, creasote m. ii. ; chlorodyne m. x. in water oz. i. after each dose of calomel. In two cases in which there was intermitting action of the heart, sulph. quinise was given in doses of gr. ij and grs. ii. every 4th and every 3rd hour respectively, in 1 combined with chloric ether. 2 got stimulants ; 4 diffusible stimulants with effervescents. In one case, in which there was suppression of urine in the consecutive fever, the patient ultimately recovering, a diuretic draught was given every 2nd hour, consisting of tinct digitalis m. x.; spirit juniper, dr. i. ; spirit ether nit., dr. ii. ; aquas ad., oz. i. M. - 7 12 3684 20 to 30 - 2S 79 2 21 were treated with calomel, preceded by a draught of castor oil in 4 cases ; and in 9 followed by bismuth and chlorodyne draughts; oxygen inhalations were given in 2 cases, and nitrite of amyl do. in 1 ; venesection was practised in 1 case; 2 got diffusible stimulants and effervescents; 1 belladonna and permanganate of potass ; and 1 arsenic, - - - - , ". ; 17 8 cs ' 00 10 to 40 - 19 32 53 15 calomel, with sinapisms, heat, and friction; ot these 3 got brandy, 1 spirit of camphor, and 1 amyl ¦ inhalations. In 1 case permanganate of potass constituted the treatment, and in 1 hyposulphite of soda, in doses of gr. x., in combination with co. tinct. of cardamoms and syrup of poppies, of each dr. i. every 2nd hour; to these draughts tinct. digitalis (m.x ) was subsequently added, and the patient was dry cupped over the loins in consequence of suppression of mine. 2 were treated with stimulants, - - - ¦ - 16 3 8421 40to'>0 - 20 58 50 14 calomel; and in sof these also a draught consisting of liq. bismuth, creasote, and morphia, was given after each dose of calomel. Camphor in 2 ; amyl inhalations in 1, and oxygen do. in 1. In 2 cases a draught of castor oil was given before commencement of calomel treatment. In 2 diuretic draughts of tinct. digitalis, n. s. ether, and s. juniper, were given every 2nd and 3rd hour respectively ; 2 were treated with stimulants, - 16 4 80-00 <>0 tn CM - 10 24 48 9 calomel ; in lof these bismuth, &c. draughts ; in 0 l I also hyposulphite of soda, and in 1 oxygen inhalations were given. In 1 case there was no time for treatment, the patient dying half an hour after admittance, 10 0 100-0 fin tfl 70 3 43 7 1 calomel ; 2 diffusible and alcoholic stimulants— viz , sulph. ether, aromat. spirit of ammonia, spirit of camphor, and branfly ; external heat, 2 1 6666 70 to SO - 2 16 0 2 calomel; and in one of these diffusible stimulants also ; external heat, - - - - 2 0 100-0 Total, - 124 59 34 85 39 68 5 • For detailed account of the mode of administering the various medicines above-mentioned we beg to refer to Tables 4, A and B. 21 TABLE 4 A, Showing the comparative results of different plans of treatment in the two stages of the disease ; and the period under treatment : — CHOLERAIC DIARRHEA. „ Average Result Per Medicines given Mode of Administration of treatment, , Re- mor- CaBes in hours Died covred tality Sulphuric acid and opium, To an adult 10 drops of aromatic, or dilute sulphuric acid with 5 drops of tincture of of opium in an oz. of water, were given after each liquid stool. To children proportionately diminished doses; in many cases were added a few drops of tincture of capsicum, myrrh, and camphor, - - 30 63i Mustard cataplasms, and Assiduously applied until the subsidence external heat applied by of all urgent symptoms. means of hot water jars and cushions. Creasote water for a drink. Creasote water ad libitum— made by adding 3 drops of creasote to a pint of water. . In a few cases a dose of Castor oil was given when there seemed castor oil. to be liquid accumulation in the bowels. In one case the acid failed until the oil had been given, and had acted. Chalk mixture with aro- To an adult was given, after each loose matics. Mustard cata- motion, an oz. of chalk mixture with 5 plasms and extl. heat as grains of aromatic confection, 10 drops of above. Creasote water as aromatic spirit of ammonia, and a like above. quantity of chloric ether. In some cases a few drops of laudanum were added ; and in others, _ dr. doses of tincture of catechu. For the most part this method of treatment was used only in the milder cases, - 10 S9 1 •_ I0 ' u " Calomel. To an adult 10 grs. of calomel were at once given, and subsequently 2 grs. every hour, or second hour, according to the urgency of the symptoms. When the stomach was irritable, a draught was given after each dose, consisting of liqr. bismuthi dr. i., chlorodyne, 10 drops; water, oz. i. ; or liquoris bismuthi and Mustard cataplasms and ex- setheris chlorici, guttas, xv. ; tinct. opii, ternal heat as above. guttas iv. ; mixt camphorse ad oz. i. - 5 114| 1 4 JO'OO Creasote water as above. A dose of castor oil was given when indicated by the presence of accumulated fluid in the intestines. In one case the acid and opium mixture was given without effect before the calomel treatment was commenced, and in this case likewise, previously to the administration of the calomel, three draughts were given— one every second hour consisting of tincture of opium. 10 drops, in _ oz. of brandy. Purgatives. Mustard cata- Either a haustus olei ricini, or haustus plasms and external heat, rhci ; usually combined with aromatics, as above. Creasote water, and a few drops of tincture of opium and as above. peppermint water — repeated if necessary. Adopted in cases where imprudence of diet was the apparent cause of the attack, - -_ 5 53j _____ *> Expectant treatment. This treatment was adopted only in cases Mustard cataplasms and which appeared to be progressing to reexternal heat, as above. coveiy, • ; 2 fiS — 2 — Diffusible stimulants, with Scruple doses of sal volatile and chloric opium. Mustard cata- ether, with 5 drops of laudanum, every plasms and external heat, hour until symptoms abated, as above. Creasote water, 2 70 2 — as above. hrs. mm. 54 74 37 2 52 3-7 Showing the comparative results of different plans of treatment in the two stages of the disease ; and the period under treatment : — ALGID CHOLERA. Average RpHl] if p er No. period Besult Medicines given Mode of Administration of of treat- mor J cases ment, p taiit-v in hours Died J^ *** Calomel. Mustard To adults with urgent symptoms, gr. x. 95 73f 68 27 71 - 579 cataplasms, and ex- were given at once, and gr. ii. every half ternal heat applied hour or hour afterwards, till a favourable by means of hot changeoccurred,orallhopewasabandoned. water jars and To children proportionate doses. The cushions, were as- calomel was placed on the posterior part siduously used, of the tongue, and if rejected by vomiting Creasote water (3 a draught was given after each powder, drops to the pint) consisting of solution of bismuth, dr. i., for drink. Diffu- creasote guttas iii., tinct. opii. guttas v., sible stimulants at aquse ad oz. i. m. Occasionally the short intervals, creasote was replaced by 10 drops of When the vomiting chlorodyne. The circulation was fostered was urgent the epi- by hand-rubbing with flannel pads, and gastrium was at sometimes chloroform liniment, or equal once vesicated by parts of chloroform and sal volatile; also the free application diffusible stimulant drops were given of the nitrate of sil- every 10 or 15 minutes, consisting of ver. equal parts of tincture of camphor, tincture of capsicum, sulphuric ether, and sal volatile ; 20 drops for a dose, in water. In cases where the calomel was constantly rejected, mercurial inunction, with the addition of mercurial suppositories, was adopted. i Stimulants and se- Brandy was given to adults in doses of 21 55 12 9 5714 | datives,viz.,Brandy, oz. i. to oz. ii., in water, every hour, or camphor, ether, oftener, according to urgency of sympammonia, creasote, toms; 10 drops of tincture of camphor on chlorodyne, o Mustardcataplasms, tablespoonful of water at once, and J5 external heat, and drops every quarter of an hour after, until creasote water, as relief ensued. Vesication of the epigasabove. trium with the nitrate of silver Permanganate of Dr. i. of the officinal solution of perman- ! 2 73 2 100 potass and extract ganate of potass with 10 drops of chloroof belladonna. Mus- dyne in an ounce of camphor mixture, tard cataplasms, ex- was given, every third hour. Gr. £ of ternal heat, &c.,&c, extract of belladonna, in pill, at mas above. tervals. I Hyposulphite of Gr. x. of the hyposulphite of soda, with 1 37 1 — 100 soda, Mustard cata- dr. i. of compound tincture of cardamoms, plasms, external and dr. i. of syrup of poppies in oz. i. of heat, &c, &c, as camphor mixture, every second hour, above. Subsequently, owing to suppression of urine, 10 drops of tincture of digitalis were added to each draught, the loins were cupped, and mustard poultices — applied. 124 80h.17m. 85 39 68-5 Note to Table 4 B.— lt will be observed that on adding the cases in Tables 4 A and B a deficiency of 19 cases, out of the total of 197, will appear. These 19 cases are those of patients admitted in a moribund condition, and who either were dead before being carried into the hospital, or died immediately afterwards. Such cases offering no opportunity for treatment, are excluded from these tables, which illustrate the effects of various modes of treatment. Report on Cholera, with Remarks. TABLE 5, Showing the number of cases in which premonitory diarrhea had existed ; its average duration ; the order of occurrence of the three principal symptoms, viz., purging, vomiting, and cramps; number of cases in which there were assignable causes (exclusive of neglected premonitory diarrhea and contagion) ; number of cases in which the attack was fairly traceable to contagion : — Order of Number of cases in which N" N "™ c b s e [ n ° f Number of Average occurrence of the attack which the Total cases in duration of the principal was due to any attack was number of which there premonitory symptoms, viz., assignable cause, exclusive fairly cases existed diarrhea purging, of neglected diarrhea traceable to premonitory (in hours) vomiting, and and contagion contagion or diarrhea cramps infection j CASES P. V. C, 39 Intemperance, - 18 V. P., - 37 (9*l per cent.) P. V., - 30 Foul water, - 3 Not stated 30 Eating cockles, - 1 V. P. C, 26 Eating cold cabbage, 1 P., - 13 Eating fish, - 1 197 J 65 96 P. C, - 5 Eating pork, - 1 43 C. P. V., 4 Eating badly cooked 197 65 96 Total. 197 Total, - - 29 43 (33 ffi cent.) (147 $ cent.) |(21-Bs?cent) It is unnecessary to make any comments on this table, which speaks for itself. It is well, however, to direct special attention to the large proportion of cases (33 per cent.) in which neglected diarrhea was the assigned cause of attack ; and when the remarkable prevalence of diarrhea during an epidemic visitation of cholera is borne in mind, the above figures become very significant. The importance of promptly attending to diarrhea during such periods is still further enhanced by the striking illustration afforded by Table 3 A, of the curability of the disease, even in the more advanced stage of choleraic diarrhea, as indeed by all the returns recently made to the College of Physicians from the hospitals of Dublin, in which cholera had been treated during the late epidemic. The large per centage of cases in which the attack was attributed to the excessive use of alcoholic stimulants is likewise noteworthy. Scarcely any recoveries took place amongst patients habitually intemperate. The large proportion of cases (21*8 per cent.) in which the attack was presumably attributable to contagion is worthy of 24 By Dks. Hayden and Cruise. remark. Cases of cholera had occurred in the houses, or in the immediate families, of all the patients (43) included in this category, and in each of them, likewise, direct personal exposure was clearly established. In several instances three or four persons stricken with cholera were admitted from the same house. TABLE 6, Showing the number of cases in which secondary fever occurred ; the sex and age of the patients; the period of access; the duration ; and the result : — No. of Sex A ge, Date of Access Duration, Result cases Male | Female in y ea « in hours Died | Recovd. 1-24 sth day of illness 24 1 1 48 2nd „ „ 120 - 1 1-19 6th „ ; , 216 - 1 1-46 3rd „ „ 51 1 1-26 sth „ „ 144 1 - 1 16 Bth „ „ 120 1 1-61 4th „ „ 72 1 1-22 4th „ „ 109 - 1 1-42 10th „ „ 80 1 1 20 4th „ „ 72 1 - 1-24 10th „ „ 72-1 - 1 16 3rd „ „ 528 - 1 1 16 9th „ „ 48 1 - 1 61 3rd „ „ 168 1 1-7 4th ? ? 96-1 - 1 17 3rd „ „ 72 1 1 46 9th „ „ 96-1 1-35 3rd „ „ 48-1 1-8 9th „ „ 96-1 1-8 4th „ „ 172 - 1 1-19 sth „ „ 144 1 - 1 16 3rd „ „ 340 - 1 l-li Bth „ „ 96-1 23 14 9 — From 2nd to 10th Ay. duration, 9 14 day, 139 hours. $cent. ¦ 39-13 TABLE 7, Showing the number of cases in which calomel was used; the average quantity taken by each patient ; the number of cases in which mercurial action followed its use ; and the result. No. of cases in which calomel was used, - 100 Average quantity given, in grains, • - 35 grains. No. of cases in which mercurialization followed its use, 4 Result— Died, 69 Recovered, 31 25 Report on Cholera, with Remarks. TABLE 8, Showing the number of cases in which rubeola cholerica appeared ; the ages of the patients ; stage of disease preceding, and that coeval with, its occurrence ; period of its access ; length of time during which it lasted; quantity of calomel taken, if any; mercurial action, if any ; and result : — Form of Ante- Stage of the p .„. nf «*„, Result §1? cedent Disease disease at Period of No. of -a 2l- Si irrr Sr =! sss =? H! * J o a oj h SjS Ruhpolft mentoi niness taKen, «,js .« » » |S 1 1 c R h^ c e e r f c c a a (in hours) if any 3 fi «§ 1 ii _ i SSee^ ec e d r rayr y 208 48 25 - - 1 2 8 1 Ditto, 220 48 77 — — 1 3 16 — 1 Ditto. 292 72 10 — — 1 4 16 — 1 Ditto, 192 60 24 — — 1 5 19 — 1 Ditto, 192 72 42 — — 1 6 24 1 — Ditto, 240 72 50 slight — 1 7 46 1 — Ditto, 53 24 none — — 1 8 46 — 1 Ditto, 268 48 none — — 1 Total- - 2 6 Secondary Ay. dura- - 1-8 fever, 8 ££££. tion,ss^h. TABLE 9, Showing the number of cases, and the absolute per cent, mortality in the two sexes. No. of cases Died *£gfe , Males, .... 91 S3 58-6 Females, ... 106 53 500 Total. .... 197 106 53-8 26 By Dks. Hayden and Cruise. We now propose to make a few general remarks on those points connected with cholera, upon which we have not yet touched ; and first, with reference to the disputed point of Contagion. A most important question for a community amongst whom cholera has actually entered, and scarcely less so for one threatened with its visitation, is, whether that disease is communicable by personal intercourse, or through the medium of clothes, furniture, merchandise, &c. It is our decided opinion that cholera may be communicated in both these ways, and that it is therefore contagious, but in a degree inferior to many endemic diseases ; for example, small-pox, typhus fever, scarlatina, measles, and hooping cough. This question is of such vast importance at the present time, that we hope to be excused for adducing in support of the opinion just given, not only the evidence afforded by our own experience during the late epidemic, to which this report has immediate reference, but likewise such examples of personal and fomitic contamination from other sources as seem well established. The late Dr. Graves 8 gives the following instances. The first was communicated by Mr. Ellis: — " A fisherman, named Kenny, seeking the price of oysters sold to a person living in Great Britain-street, in Dublin, was told that the party who owed him the money was lying dead of cholera in the room adjoining the shop or cellar ; he waited, however, until he obtained the money, and on his passage from Dublin to Arklow, was attacked with cholera, and died on the following day in his own house. The second and third cases of cholera which happened in Arklow were persons who had been in attendance on this fisherman, and his wife and child were the fifth and sixth cases." This statement has reference to the epidemic '48-49 — Arklow having been, previously to the importation by this fisherman, free from cholera. The following case, of which an abstract is given, was reported to Dr. Graves by Mr., now Sir William Wilde: — "For many weeks the sanitary cordon (around the village of Kilmaine, which is on the road between Galway and Casilebar, both places then devastated by cholera) was preserved with great strictness, and no one was permitted to remain in the town, who, it was believed, had come from any of the infected places around, until a family removing from Galway to Castlebar arrived late at night in the a Dublin Quarterly Medical Journal, February, 1849, page 36, et sequent. 27 Report on Cholera, with Remarks. village, unknown to the police or the usual watchers, and took up their residence at the house of a man named Mulvey, a shoemaker, where they remained till morning, but departed early, fearing the police. I subsequently learned that this family proceeded to Castlebar, the wife being at the time ill of cholera, where she died a few hours after her arrival. The next day the shoemaker in whose house the family had sojourned for the night, was attacked with cholera. The case lasted more than two days, and the man appeared to die of the consecutive fever." Deputy Inspector-General Barrow a gives the following strong exemplification of the spread of cholera by contagion ; — we give an epitome of his report. The emigrant steamship, " England," left Liverpool for New York on the 28th March, 1866, having on board 1,200 persons, including the crew. On the 2nd April cholera broke out amongst the passengers, and on the 9th the ship put into Halifax in distress. The disease spread so rapidly on board that in the twelve hours- ending on the morning of the 11th, forty deaths had occurred. On the day of the ship's arrival at Halifax (9th), three persons, a pilot named Terence, an assistant, Purcell, and the son of the latter, approached the ship in a pilot boat, and were by it towed to some distance by means of a ten fathom rope, and having sent their official papers on board, they departed without having boarded the ship. Purcell returned to his home, a distance of eleven miles from Halifax, on the following day (10th); on the 11th he had an attack of diarrhea; this continued; and on the 15th vomiting was superadded. On that day two of his children, aged three, and five and a half years respectively, were seized with vomiting and great weakness ; on the 16th his eldest daughter, aged fifteen years, was attacked with all the symptoms of true Asiatic cholera, followed by severe consecutive fever. There were no deaths in this family. Mr. Barrow, who visited the man's house, and obtained the particulars from himself, declares that the house was in a high sanitary condition as regards situation, air, and cleanliness. Terence again visitedthe " England" on the 10th, as pilot to the block-ship " Pyramus," to be used as an hospital, and having received back his papers sent on board the preceding day, he returned to Halifax without having gone on board the " England," a Narrative of the late Outbreak of Asiatic Cholera on board the Steamship " England,' by Deputy Inspector-General Barrow, P.M.0., Halifax, N.S,, in Army Med. Keports for 1864. 28 By Drs. Hayden and Cruise. as affirmed both by himself and the captain of the ship. On the night of that day (10th) he was seized with purging, vomiting, and cramps, in a lodging-house in Halifax, and next morning returned home in a boat to Portuguese Cave, where Purcell lived ; collapse set in, followed by low fever, of which he died on the 19th, after an illness of nine days' duration. On the 14th April, three days after Terence's return home, his daughter, aged five years, was seized with cholera, and died after an illness of fifteen hours. Next day (15th) three other children were attacked; of these, one, aged three years, had slept with her father; she died on the 17th with all the symptoms of cholera. Another, aged nine years, was seriously ill, but recovered after a consecutive fever ; a third, aged one year, was on the point of death, but recovered. Of five children in this family, only one escaped cholera, and he slept in a room apart from the others, and Avas out of doors all day; the mother also escaped. The cottage in which this family resided was also visited by Inspector-General Barrow, and found in a filthy state. There had been no cases of cholera in Halifax, or in the province, for several years previous to this date. It is noticeable, in connexion with this report, that there had been no direct personal communication between the passengers of the " England" and the men Purcell and Terence; nor was there any indirect communication between the former and the ship, except through the atmosphere. The attack in this case, therefore, must be regarded as an example of cholera infection; but in the case of Terence, there was indirect communication through the papers taken on board on the 9th, and returned to him on the following day ; and, therefore, possible contamination also per fomites. Dr. Hardie, surgeon 73rd Regiment, has recently,* in an excellent memoir on the doctrine of cholera-contagion, given the following example in support of the affirmative view: — " At this time I was quartered in the barracks of the Port of Flacq, a village and harbour on the opposite (windward) side of the island (Mauritius) to Port Louis, and twenty-one miles distant. All was apparently well at the port, so far as I knew, up to the 30th May. On that day a Mr. Re'naud came down from Port Louis (where cholera then raged) with his family, ten in number, on a visit of flight to Mr. * Illustrations of the Doctrine of Contagion in Cholera, drawn from the Epidemics of 1854 and 1856 at Mauritius, read before the Cork Med. and Surgical Society session 1866-67, and published in the Dublin Quarterly Journal, Feb., 1867. 29 Report on Cholera, with Remarks. Veron, whose family numbered twelve, exclusive of seven servants. The family occupied a small one-storied house of two rooms, and outhouses. "On the 31st I was called to see the infant child of Mr. Renaud, ill with purging and vomiting. The child, which was at the breast, had had diarrhea before leaving Port Louis. It recovered, but another of the children, aged three, died of cholera after forty hours' illness, on the 2nd June. From this day onward this house was a scene of constant misery and death. The child was buried on the 3rd, and the Renauds returned to Port Louis the next day. The same day Mrs. Veron and her son, who had both been assiduous in their attention to the children, were seized with cholera; Mrs. Veron died that night, the son on the 6th. The eldest daughter was seized on the 7th. Mr. Veron was seized on the 10th, and died on the 12th. On the 14th another daughter died; on the 15th one of the servants; and on the 16th an old friend who had assisted in nursing them, died. Two servants died on the 18th. and on the 20 th another servant and child. Two more of the family were attacked, but recovered. " In all, between the 31st May and the 21st June, there were sixteen cases in this one house, of which eleven proved fatal. " Contagion here showed itself in its full potency. The house, with its outhouses, was much too small for the original family. The overcrowding of ten more, laden with the germs of cholera, will adequately account for the pestilential outbreak, with its catastrophe." Dr. Hardie very truly adds : — " No more directproof of importation and contagion can well be adduced." In the Lancet of August 11th, 1866, the following example of contagion is reported from Guy's Hospital. "A. B. and C. are sisters, and W. is their sister-in-law. A., who lived near Templebar, washed the clothes of a cholera patient, took the disease, and died. During A.'s illness, B. C. and W., who lived together in Park-street, Bermondsey , a locality then free from cholera, went to her, and after her death returned home. The same evening B. was taken ill with cholera and died the following morning. Two hours after her death, C. was attacked, and died within two days in the hospital, whither she had been brought. W., shortly after this death, was attacked in the morning with pain in the stomach and diarrhea ; she was likewise admitted into Guy's Hospital, where she was treated for cholera, which passed on to collapse." 30 By Des. Hayden and Cruise. Deputy-Inspector General Maclean, Professor of Military Medicine in the Army Medical School, Netley, in a lecture published in the Lancet of February 3rd, 1866, furnishes a strong body of evidence in support of the conclusion at which he has arrived, namely, to use his own words : — " That the pestilence is propagated by human intercourse, and in all probability, mainly by the poisonous action of the excretions of the affected after they have undergone certain changes." In reference to this point, we would specially call attention to the recent account of the "epidemic of cholera of 1866, in Bristol, published by Dr. Budd, in the British Medical Journal of April * 13th, 1867. Dr. Budd, in addition to other valuable information, gives very strong evidence to show that cholera is communicable by contagion ; he says : — "From that time (21st July, 1866) to the 12th of November following, the disease made its appearance in twenty-four other distinct localities, making, in all, twenty-six infected spots. In five of these instances, as in the case from Rotterdam (making six altogether), the disease was distinctly traced to importation from without. In five others importation was probable, but could not be actually proved. In two the disease was derived from a previously infected spot in Bristol itself. In the remaining instances, to the number of thirteen, the source of the infection could be neither made out nor guessed." It would thus appear, that in addition to the first case, which Dr. Budd proves to have been imported in the person of a sailor from Rotterdam, where cholera was in active operation at the time, importation from infected centres was the immediate cause of attack in five instances. In five others it (importation) " was probable, but could not be proved," whilst in thirteen instances (each having, as in the preceding instances, a distinct locality in the city, and being the first case that occurred there, as shown in Dr. Budd's map), no clue could be obtained as to the mode of entrance of the disease. From time to time examples of invasion similar to those last mentioned, will, of necessity, be presented, in which the contact theory fails to afford a full explanation. But are we in possession of all the facts connected with these cases ? In the case of Mrs. Gaffney, given at page 34, we were all at fault for several days in regard to the mode of communication of cholera, till the circumstance of her having slept in an infected lodging-house the night before she was admitted into hospital, was accidentally brought to light. If 31 Report on Cholera, with Remarks. this had not occurred her case would be regarded, as are many others of a similar kind, as affording negative evidence against contagion. The remarkable outbreak of cholera in the Mountjoy Prison on the 23rd December last, as reported by the medical officer, Dr. Macdonnell, to the College of Physicians, as also the two isolated cases that occurred in the General Prison at Perth, and were reported by Professor Christison and Mr Thompson," are simply inexplicable according to our present knowledge ; but, it is worthy of remark, that both in Dublin and in Perth, cholera existed epidemically at the time these institutions were visited by it, arid that the most rigorous measures of isolation and disinfection were immediately adopted. To this, no doubt, as in the case of the Bristol epidemic, the rapid disappearance of cholera from these two prisons should be ascribed. The members of the " International Sanitary Conference," in their report on the origin, &c, of cholera, given in abstract in the Medical Times and Gazette of October 6th, 1866, have arrived at the folloAVing, amongst many conclusions, viz. : — " All the facts at their disposal prove convincingly that cholera is propagated by man, and with a rapidity which is greater the more active and expeditious his migrations." That ". it is a law, up to the present time without exception, that cholera has never marched more rapidly than man in his migrations ; that it has radiated to, and declared itself only in, those places where there have been communications with infected places, and in no others. " The Commissioners are acquainted, up to the present time, with no fact to prove that cholera can be propagated to a distance by the atmosphere alone, whatever its condition may be." In these conclusions the Commissioners were anticipated, by twenty-six years, by the late Dr. Graves of this city, who, in his most learned and elaborate paper, " A Sketch of the Origin and Progress of Asiatic Cholera," published in January, 1840, b writes : — " It is remarkable that it (cholera) never traversed the ocean at a rate exceeding that of ships." At the recent Cholera Conference which was held at Weimar (April 28 and 29, 1867), and included many of the most eminent savants of Europe, it was held to be proved beyond doubt that cholera spreads through intercourse, and discussion on this point was considered unnecessary. Surgeon Leith Adams and Assistant- Surgeon Welsh, in their report on the cholera epidemic of 1865 at Malta, 0 state that the a British Medical Journal, Jan., sth and 19th, 1867. b Dublin Journal of Medical Science, Vol. xvi., Old Series, page 369. c Army Medical Reports, 1864, page 331. 32 By Drs. Hayden and Cruise. first undoubted case of cholera among the natives occurred, July Ist, at the village of Birchircara, in the person of a white- washer. This man had been employed two days previously at the Lazaretto, where the disease already existed, and died at his own residence, the case being returned as " gastro-enteritis." In his report on the outbreak of cholera at Finglas, in 1854, Dr. C. F. Moore a states, on the authority of Dr. Hill, Medical Inspector, that " the first case of cholera was a labourer who had just returned from Belfast, and became ill after drinking a gallon of porter, and eating a liberal supply of bacon for his breakfast. This was on August 13th; he recovered, but shortly after, two cases occurred in the same house, in children, one of whom died on the 20th August." " The number of cholera cases recorded to the 24th September, from its first appearance on the 13th August, was sixty-six, of which twenty-eight proved fatal." " It is said about 100 persons fled out of the village on the 18th and 19th, of whom it was ascertained five died within a few days, one in Liverpool, and the others within the environs of Dublin. Some of these refugees were the means of conveying the disease to another locality favourable for its development, where, in a few days, twelve persons died out of a very small number of inhabitants. The cottages, composing the hamlet (Kill-of-the-Grange), being badly ventilated and dirty, and the drinking water very indifferent." A medical gentleman of this city has Furnished us with the following particulars: — In August, 1849, two relatives of his, an old lady and gentleman, came up to Dublin from the country, with the view'of spending some weeks at the seaside. They took apartments at Blackrock, and on the following day our informant was hastily summoned to visit the lady, who was reported seriously ill. On arrival at the railway station he engaged a car to drive him to his friend's lodgings, on approaching which, the driver, knowing he was a medical man, inquired in a very significant manner, whether " there was any one else sick there." On being questioned as to his meaning he declared that on the morning of the preceding day a person who had died of cholera had been removed for interment from that house. The lady who, as was afterwards ascertained, occupied the room and bed vacated by the cholera patient on the previous day, had a severe attack of cholera, from which she was convalescent, when her husband became affected with choleraic a A Sketch of the Recent Outbreak of Cholera at Finglas. Dublin Quarterly Journal, Nov., 1854. 33 Report on Cholera, with Remarks. symptoms, and imprudently announced the fact to her. She was unfortunately of a nervous temperament, and, as a consequence of this startling intelligence, had an apoplectic seizure, which carried her off. The husband, who was likewise attended by our informant, recovered after a protracted illness; but a servant of the house, who was subsequently attacked, died. These parties came from a part of the country where cholera had not appeared ; they had no apprehension of danger from cholera, and were entirely ignorant of the antecedents of the house in which they lodged. The recent importation of cholera from Liverpool, with the consequences of which we all have been made familiar, as detailed by the able and efficient officer of public health, Dr. Mapother, a affords a convincing illustration of the contagiousness of cholera. Dr. Alderson b quotes from a French source experiments made upon animals with the excreta of cholera patients ; these were given, soaked in bibulous paper, to the animals in their food. No effects followed when the dejecta were administered three days after being passed ; but when given between the third and the sixth day they produced most of the symptoms of cholera, viz. : — purging, cramps, suppression of urine, and convulsions ending in death. After the sixth day they were found to be inert. M. Kobin c has likewise proved experimentally the infectious property of the vomited and excreted matters of patients suffering from cholera, by injecting them into the veins and trachea of two dogs ; to a third dog he administered the matter vomited by a fourth, which had drunk the blood and serum of a cholera patient. "In all there were vomiting and other symptoms of cholera." The following case is extracted from our own Register : — Bridget Gaffney, aged twenty-seven, a native of the County of Meath, was admitted into hospital on the 6th November, '66, in charge of her infant, upon which she wished to have an operation performed for talipes. The woman was in good health, and occupied, with her child, a bed in the female surgical ward, on the second floor of the hospital. There was no communication whatever, direct or indirect, between the inmates of this ward and the cholera patients, who occupied two wards on the third or upper floor. Each of these wards had a separate staff of nurses and assistants, and no contact or approach was permitted, or possible, between the two a Lectures on Public Health, Enlarged Edition, February, 1867, page 440. b Lancet, January 12, 1867. c Lancet, January 13, 1866. 34 By Des. Hayden and Cruise. classes of patients. The woman Gaffney was seized with cholera in the surgical ward on the morning of the 13th November, and was at once removed to the cholera ward up stairs, where she died at nine o'clock that evening. Some alarm was felt in consequence of this case, lest cholera was about to spread amongst the general patients of the hospital, and the most strict and searching inquiry was instituted, with the view of ascertaining whether the woman had approached the cholera wards, or been in any way exposed to contagion in the hospital. The result was the conviction that no such exposure had taken place, and that, during the period of her residence in the hospital, previously to the choleraic seizure, she had not once gone beyond the adjoining corridor. No other patient was attacked with cholera in the hospital, either previously or subsequently. The uneasiness at first felt had entirely subsided, and Mrs. Gaffney's case had been placed in the category of cholera puzzles, when, on the 16th November, her husband came up from the country to take home the child, and in a conversation with one of the Sisters relative to his wife, remarked that on the night of her arrival in Dublin she had slept in a lodging house where cholera had been, and suggested that it was there she took the disease. Inquiry was at once set on foot to find out this lodging house, and ascertain all particulars relating to it. The result was as follows : — The house was 20, Greek-street ; the woman Gaffney and her child slept there on the night of November sth. In that house there had been a case of choleraic diarrhea on the 20th September ; and in the adjoining house, No. 21, no less than five cases of wellmarked cholera had been treated by the district medical officer in the interval between the 12 th September and the end of October. From the next house but one, No. 22, one case of cholera had been admitted into the Mater Misericordia? Hospital on the 14th Sept. ; and from No. 24 two cases on the 14th and 17th September respectively. From No. 10 in the same street another case was admitted on the 23rd October. Thus, on the night of the sth November this poor woman had unconsciously placed herself in a focus of cholera; for, irrespectively of the case that occurred on the 20th Sept. in the house in which she stayed, there had been, within a short time previously, no less than nine cases in the immediate neighbourhood. It will be difficult to resist the conviction, indeed no other explanation seems admissible, that this woman, who had come from a district of the country where cholera had not appeared, received the poison of the disease T) 35 Report on Cholera, with Remarks. in the house 20, Greek-street, on the night of the sth November ; and in the week from the 6th to the 13th November, during which she was in hospital, developed the germs so received into a fatal attack. In this case, therefore, it would appear that the period of incubation was seven days. Upon reviewing the registry of cases admitted to the Mater Misericordia3 Hospital, we find that in a very large proportion contagion, or infection, is- distinctly traceable. 11 It would occupy too much space to enter into the history of each in detail, but we cannot refrain from quoting the following instance. On the 29th of October a young woman named Mary Hart, and her infant, aged tAvo months, were admitted. Both were in the collapse stage of cholera. The child died the evening after admission, the mother rallied, and was convalescent by the 4th of November. The history she gave was as follows: — She had been living in the County of Kildare, and had placed her child at nurse with a woman residing in Cork-street, Dublin. Hearing that this woman was ill, she came to town a few days before her admission to the hospital; and finding the nurse ill of cholera, took away her baby, which at that time was perfectly well. They went to a lodging in Kelly's-row, off Marlborough-street. Next day the baby sickened; the following day she herself was taken ill with vomiting, purging, and cramps, and, as before stated, both entered the hospital collapsed in cholera. It is not easy to set aside the belief that in this case contagion played an active part. Many other confirmatory circumstances might be adduced, such as the appalling fatality amongst those students in Paris, who so heroically devoted themselves in the late epidemic to nurse-tending and hand-rubbing the cholera patients ; but we shall confine ourselves to the mention of one more case which came under our special notice. One of the writers of this report (Dr. Cruise) was called upon in the afternoon of the 26th of October to visit a clergyman at Clondalkin, in consultation Avith Dr. M'Crea. On arrival at four o'clock p.m., the patient was found collapsed in cholera, and despite of treatment he sank rapidly, and died that night. The history of his case was as folloAvs : — The night previous he was summoned from his bed to administer the rites of the church to a poor woman in Clondalkin, who was labouring under cholera, of Avhich she died. a See Table 5. 36 Having remained with her for some time, he returned to bed ; awoke, ailing, next morning; sickened decidedly about eight o'clock, and soon had such marked symptoms that Dr. M'Crea of Clondalkin was called in. He at once pronounced the disease to be cholera, and prescribed accordingly. Notwithstanding prompt aid the patient sank, and by the afternoon was in a hopeless condition. Let us now investigate the history of the poor woman, in attendance upon whom this clergyman thus nobly sacrificed his life. The facts are these:— She had a brother who resided in Kingstown. A few days previously this brother took cholera and died. She repaired to Kingstown for the wake — remained there three clays, and on her return to Clondalkin immediately took ill of cholera and died. We think it difficult to resist the conviction that in these cases the propagation of the disease was effected by contagion. It may be urged by non-contagionists that such instances are^ merely coincidences ; nevertheless we hold that a fair and natural interpretation of the doctrine of probabilities— and, in truth, all medical belief must finally rest upon probability, greater or less— leans irresistibly in the opposite direction.* Receptivity and Resistance.— lmmediately connected with the question of contagion in cholera arises that of the capacity of receiving or resisting its poisonous influence. A state of good health on the part of individuals and communities is eminently unfavourable to the invasion of cholera. By this assertion is not meant the absence of positive disease, but rather of that depressed standard of health, short of actual disease, in which most of the vital functions are performed indifferently ; the appetite bad ; the stomach and bowels deranged; sleep broken; the pulse slow and feeble; langour and depression of spirits habitual. This state of health, most frequently due to irregularities in diet, the use of unwholesome articles of food or drink, the respiration of impure air, or actual want of the necessaries of life, constitutes what is known as an " unfavourable hygienic condition." A state of individual and public health, the reverse of this, confers a vital resistance to the poison pf cholera, or immunity from attack under circumstances of exposure to cholera contagion. . It occurs to us that herein may be found an explanation ot the » We would beg to call attention to the report of the isolated outbreak of cholera at Cloughey and Calham, in October last, by Dr. Filson of Killoughter, as published by the Rev. Dr. Haughton in the Medical Times and' Gazette of May 11, 1867, as further evidence of the contagiousness of cholera. . < 37 disagreement amongst physicians as to the contagious properties of cholera. Thus, one observer may have witnessed an indubitable example of contagion, or, perchance, many such, and become thenceforward an advocate of the doctrine of contagiousness. In this case, or cases, presumably the two necessary conditions of exposure and receptivity were supplied, and hence the positive result witnessed. Another person may have witnessed one or more cases in which, the degree of exposure being the same as in the former, contamination, nevertheless, did not follow, and may have become, in consequence, a staunch supporter of the doctrine of non-contagiousness. In the examples presented to him the condition of receptivity had been wanting, and hence the negative result from which he deduced his opinion. Let these two persons meet and discuss the subject of cholera contagion — each will probably unsettle the opinion of the other, and no definite conviction will remain to either. Should the same individual have witnessed the opposite results mentioned, he cannot have arrived at any definite opinion on the subject, as deduced from his own experience, and will remain neutral in regard to this question. In these hypothetical examples the error is one, not of fact, but of observation, and consists in the omission to take cognizance of the actual state of health of the parties exposed to the contagion. We feel certain that numerous examples, equally illustrative of this error, might be adduced from actual practice, and that, to the confusion thence arising, may be in great measure attributed the present unsettled state of opinion as to the communicability of cholera from person to person. The immunity from attack of infants at the breast, even when sleeping with, and subsisting upon the suck of, cholera patients, deserves to be noticed in connexion with this part of the subject. The following are examples of this kind : — Dr. Maxwell Adams says: a — " In nine instances children at the breast escaped the disease, although their nurses laboured under it." Dr. Brassington b mentions the case of a young mother attacked with cholera, who continued, whilst in cholera, to suckle her infant child in the same bed with herself, as long as she had suck to give it. The mother died of the disease,, as likewise did her little boy, aged two years, but the infant was not affected. The woman Gaffney, who was attacked with cholera whilst an inmate of one of the surgical wards in the Mater Misericordise Edinburgh Med. and Surg. Journal, Vol lxxii., 1849, p. 306. b Medical Press and Circular, October 24, 1866. 38 By Drs. Hayden and Cruise. Hospital, as already stated, likewise continued to suckle her infant, ten months old, up to the time of her removal to the cholera ward. The mother died on the evening of her removal, but the child remained unaffected, and under observation in the hospital for three days, when it was taken home. It has been since heard of, and, at the date of report was in good health. We may quote here another similar case : — Eliza Young, aged 24, was taken ill with purging and vomiting in the forenoon of September 24th. At five o'clock, p.m., she was admitted into the Mater Misericordise Hospital, being then perfectly collapsed and livid, and having nursed her baby up to the time of admittance. The baby was then taken from its mother, who died the following day, the child continuing unaffected. On the other hand, we have met one instance in which an infant at the breast appeared to have contracted cholera from its nurse, in the person of Mary Hart's child, mentioned at page 36. Were infants, circumstanced as in the preceding instances, in a condition favourable to the development of the cholera poison, they could not escape attack, even though the mammary secretion were untainted, which is very improbable ; for the infant, occupying the same bed with its nurse, must absorb in some measure the exhalations from her lungs and skin, and the vaporized excreta with which her dress and bedding are soiled. Yet no authenticated example, with the above single exception, of an infant so circumstanced taking cholera from its nurse, has come under our notice. A healthy infant, nourished exclusively at the breast, offers a typical example of a human body in a purely physiological or normal condition. Its food is unsophisticated, and contains, in the requisite proportions, the elements necessary for its sustenance and growth, and no other. Its sleep is regulated only by the requirements of its system, and its clothing selected and fashioned to retain warmth, without restricting the natural movements of the chest and abdomen. Such a condition of body, as being the antithesis of disease, is eminently antagonistic to the development or reproduction of morbific matter. Similarly exposed to the contagion of small-pox, scarlatina, or measles, if unprotected by vaccination, or by a previous attack, it is well known that infants rarely escape; but as the condition of body, and the degree of morbid receptivity, are presumably the same in all these cases, the difference in the result must be due to the more intense infectiousness of the diseases mentioned as compared with cholera. 39 Report on Cholera, with Remarks. It is right, however, to mention that a case has been seen by one of the authors of this report in which a baby continued to suck its nurse up to the seventh day of typhus fever, and yet escaped without contracting the disease. We are not disposed, in this report, which is intended mainly as a commentary upon the result of our own observations, to enter upon a lengthened discussion of the arguments put forward by noncontagionists; we shall merely, in passing, allude to those most frequently dwelt upon. It is often urged that cholera is not propagable by contagion, because cases occur under circumstances where it is impossible to trace their origin to this cause. We grant that such cases occur, but add in reply that the same must be admitted in reference to typhus, small-pox, and other acknowledged contagious, diseases. Again, it is urged that cholera is not contagious because instances may be adduced of prolonged and thorough exposure without the spread of the pestilence. To this we answer that precisely analogous examples of non-propagation of typhus, scarlatina, &c, may be produced. The greater number of physicians who have had large experience of cholera in India are non-contagionists. While we duly respect their opinions we cannot relinquish our own — namely, that cholera, as we have seen it in this country, and as the bulk of information upon the subject which we have been able to obtain, inclines us to believe, is decidedly propagable by contagion, although in a less degree than typhus, scarlatina, and the like complaints. In brief, we believe that cholera is propagable by contagion ; that two elements play essential parts in its transmission — namely, first, the active element, or poison ; and secondly, the passive element or capacity of receiving the poison. We think that there is no evidence, at least none hitherto brought forward, to support the theory of non-contagiousness, which might not with equal truth, though in a different degree, be adduced to prove non-contagiousness in typhus, scarlatina, small-pox, and other diseases admittedly contagious. In fine, we conceive that the most righteous and humane course which we can take is to declare this opinion, regardless of the moral effect upon the multitude, convinced that the knowledge of the truth is the true key to the means of prevention of this terrible scourge, and consequently to the saving of human life. Atmospheric influence. — We have already expressed our opinion that in a limited space the atmosphere may become so charged with 40 By Drs. Hayden and Cruise. the poison of cholera, as to be capable of communicating the disease to receptive subjects who come within its sphere. It would seem also that air so 'impregnated, if confined in a close space, may retain its specific contaminating property in undiminished potency for several months. The following is an example in point, and is quoted from Dr. Hardie, Surgeon, 73rd Regiment. 11 " About 300 yards from the sugar-mill of Clemencia we stopped at a closed shop, near which are several cottages of Creoles, from whose account we got as follows: — " During the first epidemic (1854, at Mauritius), about four months since, two persons, one of whom was the owner of the shop, had died of cholera, since when it had remained closed. On the 13th of this month (November), Madame Alfred, sister-in-law of the former owner of the shop, wishing to know if her shawl was in the house, had a window-shutter opened, put her head through the window, and saw her shawl on the floor ; she did not remove it, but remarked, on withdrawing her head from the room, that she was " Frappee par la mauvaise odeur." The same night she had looseness in the bowels. She went into the woods next day, but during that night became worse, and next evening cholera had fairly declared itself. She died on the 17th A child whom she had adopted, aged two, was taken ill the same evening, and died the same night." This case is an example of cholera infection; for, it will be remembered, the woman did not even touch the shawl. It further shows that the air of an apartment contaminated with cholera, and confined for a period of four months, may, at the end of that time, communicate the disease. In the course of the recent debate on cholera at the College of Physicians, Staff Surgeon Major Laing, said: — "I was stationed in Kurrachee, in Scinde, in the month of June, 1848 ; cholera came on on the 14th of June, and in the first twenty-four hours one hundred men came into hospital. It appeared as if a cloud came across the sun ; and at six o'clock that evening the men began to come into hospital ; and before seven o'clock there were thirty men lying dead. The disease went on for ten days, and in that time we lost two hundred and forty men. The men suffered dreadfully; but of the officers in the cantonment only one was attacked, and he a Illustrations of the Doctrine of Contagion, drawn from the epidemics of 1854 and 1856, at Mauritius. Dublin Quarterly Journal, February, 1867, page 243. 41 Report on Cholera, with Remarks. recovered. The atmosphere was most oppressive. It was a remarkable fact that the Brahimine kites and crows, which collected about the cantonments to pick up the offal, disappeared altogether, and did not return until all the cases of cholera had ceased. The domestic fowls about the cantonment died ; and I was told that the sheep in the neighbourhood suffered severely." These observations are of great value in reference to the question of atmospheric contamination, or the existence of an "epidemic constitution" of the atmosphere in districts actually suffering from cholera. Fomites.— Of the communicability of cholera by fomites, such as the dress and bedding of cholera patients, the following examples are forcibly illustrative : — The four first are taken from Dr. Graves' paper. 0 " Mr. Beatty, the apothecary who died in Sligo, was a Tirera man, and when he died his clothes were bundled up and sent to Tirera ; the girl who took them to the river, where for safety they were sent to be washed, was attacked with cholera that night, and died." The particulars of the three following cases were furnished to Dr. Graves by Dr. Nelson of Killala, in whose practice they had occurred. " When the cholera raged at Ballina, as elsewhere, the panic was considerable; they buried clothing, and destroyed bedding, &c, by throwing them into the river Moy. " About a mile down the river a fine feather bed was seen floating by a woman, who carried it off about ten miles from Ballina, to the village of Mullinacrush. She was seized with cholera that night, and died in a few hours. Her sister, in the same house, sickened and died in a few hours after. Three children in the same house were all attacked, of whom one died, and the immediately adjoining houses were attacked. A female friend, who lived in an isolated cabin, visited this house, and was attacked immediately on her return, and died. No other cases occurred in the neighbourhood." " Cholera first appeared in Tuam (Co. Galway), on the 4th of June, 1832, having attacked Galway, the nearest seaport, on the 12th of May preceding. The first case was a fish kedger's wife, who had purchased the clothes of a woman who died in the cholera hospital of Galway. She died the following night. Her sister, from a remote part of the town, who attended her and washed her body, was the second. A relative from a neighbouring village, a Dublin Quarterly Medical Journal, February Ist, 1849, page 32, et sequent. 42 By Des. Hatden and Cruise. who also attended her and assisted in the washing, was the third. None lived above twelve hours." " Cholera ceased for the first time in Tuam, in August. The bedding was all put up clean in store. In September the courthouse (which had been our hospital) was required* for the sessions. Mr. Hartnett, the dispensary apothecary, with two other persons, was employed for nearly a whole day in the removal of the stores. Mr. Hartnett and one of the men were seized with cholera the following night, and both died. There had not been a case of cholera in Tuam for upwards of a month." This case likewise exemplifies the retentive property of clothing in regard to the infectious principle of cholera, when stowed away, and not freely exposed to the air. The next example is taken from the report of Surgeon Leith Adams, and Assistant- Surgeon Welsh* on the epidemic of cholera at Malta in 1865:— " On the 3rd of July it (cholera) proved fatal to a woman in Valetta. She was a tailoress, and had received, four days prior to her decease, old clothes, as patterns, from a merchant's family fourteen days arrived from Alexandria, in a vessel with cholera on board." Deputy Inspector-General Barrow gives the following example of contagion by fomites: b — " A poor man named Evans, his wife, and two children, lived in a miserable and unwholesome house near the sea, at a place called Freshwater, the southern suburb of Halifax. A large quantity of bedding, saturated with cholera discharges, had been thrown overboard from the ship " England," and for many days allowed to float about the harbour. Some of this bedding had drifted ashore at Freshwater, and Evans' children had been seen playing with it ; it is even more than suspected that the Evans family had lain upon a mattress so obtained. On the 22nd of April Evans' eldest child, a girl about two years, was seized with cholera, after having had diarrhea for nearly a week ; she died next day in the city hospital. The entire family was then sent to the hospital, and kept in a state of isolation. On the 24th the second girl, aged thirteen months, was attacked ; her case was severe, but she recovered. The mother, aged 35, was seized on the 25th, and died of exhaustion on the 30th. These cases (he adds) prove the infectiousness of cholera, and the communication of the disease by fomites (infected bedding)." * Army Med. Report, 1864, p. 331. b Opus citat. Army Reports. 43 Report on Cholera, with Remarks. Dr. Mapother, a writing of the recent epidemic in this city, says : — " The clothes of some cholera patients who had been in the Meath Hospital last August were sent to be washed by a woman residing in Chamber-street, where the disease had not been previously, and in three days she was seized with cholera, which proved fatal to her and to a man residing in the same house, and spread extensively in that street, which is built along the Poddle." b The persistent adhesion of the poison of cholera to the dress and furniture of the infected, taken in connexion with the remarkable tenacity of its specific contaminating property which it exhibits, as exemplified in some of the foregoing cases, would seem scarcely reconcilable with the opinion that it is of a gaseous, or of an inorganic nature ; whilst, on the other hand, these characteristics are eminently distinctive of organic germs. Water. — That water may serve as the medium of communication of cholera is now generally conceded. The following examples show the agency of water in the production of cholera in a strong light. Dr. J. W. Bain c writes: — " The same localities are attacked as before, but with one remarkable exception. In one entire street, where in the epidemic of 1849 forty- three persons died of cholera in a month, not one case has occurred. As this has never been published I may mention it now. The street is Cold Harbour, at Black wall, running parallel to the river. About one-third of the houses face the river, and were supplied, in 1849, with filtered water from a barge coming out twice a week from the West India docks. The remaining two-thirds on the land side of the street were supplied with water from a pump. Forty-one of the inhabitants of this side died, and only two on the other, and it is believed that these were in the habit of sending for the pump water. After the epidemic had ceased it was discovered that the sewer in the rere of these houses, originally made of wood, had become rotten, and leaked into the well. I myself attended most of these cases, but at the time my attention was not drawn to the water supply, or its different distribution on the two sides of the street. The forty-one deaths occurred in about twenty-nine houses." Dr. Thomas More Madden, in his recent valuable brochure, d gives the following striking example of the contamination of pump- a Lectures on Public Health, February, 1867. 0 This statement, as regards the washerwoman, is confirmed in the abstract of report of cholera from the Meath Hospital. c Lancet, September 1, 1866. d A Statistical Inquiry into the Sanitary Condition of Kingstown, &c, 1867, page 5. 44 By Dks. Hayden and Ckuise. water: — " In one of the best terraces of Kingstown several deaths from cholera occurred, and measures of disinfection were adopted. At the same time the pump- water in one of the houses was observed to acquire suddenly a very remarkable and offensive taste and odour. An eminent chemist was now requested to analyse the water, and in it was found a large quantity of carbolic acid, together with organic matter. The explanation of this was, that a case of cholera had occurred next door, and that carbolic acid had been poured into the water-closet; and this led to the discovery of the poisonous character of the water." Dr. Mapother* gives the following example of a similar kind : — " After two cases of cholera, one of which was fatal, had occurred in the house of a friend of mine, which is situated in one of the best parts of that town (Kingstown), he poured a quantity of carbolic acid into the sewer, and found that the water of the adjoining well tasted of that substance for many weeks after." The following cases are copied from our own hospital record : — John Thomas, aged fifty-three, mate of the ship " Olive," from Liverpool (called the " teetotal ship," because of the strict abstinence from all spirituous drinks enforced on board), was attacked with purging, vomiting, and cramps, at 8^ p.m., October 4th, and admitted into hospital at eight o'clock the following morning ; he was then in profound collapse, and died at three p.m. the same day. Thomas Hartley, aged sixty-three, captain of the same ship, was seized with cholera at ten o'clock on the evening of October 4th, and admitted into hospital at 9| a.m., on the sth, in a moribund state, and died twenty minutes afterwards. 7 J Willy Seamer, aged seventeen, cabin boy, also of the " Olive," who had attended the two former whilst sick on board, was attacked with slight choleraic symptoms at 11 p.m., on the sth October, and was admitted at 10^ a.m., on the 6th ; he was then suffering from diarrhea, nausea, and occasional vomiting This boy, who was the only survivor of the crew of the ill-fated ship " Olive," was discharged cured after treatment in hospital extending over 168 hours. Thus, on board this ship two persons were seized with cholera on the evening of the 4th October, and both died on the following day; and on the afternoon of that day (sth) the only surviving member of the crew was also attacked, but recovered after a protracted illness. Dr. Mapother b reports: — " The drinking water of Opus citat, page 458. b Opus citat, page 475. 45 Report on Cholera, with Remarks. the " Olive" was shown by Professor Cameron to contain ten grains per gallon of organic matter, and infusoria visible to the naked eye."* In the foregoing cases, as indeed in most others of the alleged communication of cholera by means of water used in drinking, it is impossible to prove the introduction of the choleraic agent through this medium. Indeed, in the majority of such cases we are of opinion that the impure water operates by creating a predisposition to attack (the principle of infection being supplied through the air), rather than by serving as the medium of communication. It is, however, conceivable, and highly probable, that cholera is frequently communicated in this way. Sewers and Privies. — Of the unfavourable influence of ill-constructed and neglected sewers and privies, in close proximity to human habitations, during an epidemic of cholera, the evidence is conclusive. The following are examples : — In Dr. Barry's report of the cholera epidemic of 1848 at Malta, as it affected the 69th Eegiment stationed at Lower St. Elmo, b it is mentioned that " several cases of cholera occurred in rapid succession, and that it was specially noted that the greater number of cases were admitted from the rooms in the immediate vicinity of the common drain and men's privy ; and that, moreover, on previous occasions these identical rooms had been frequently temporarily abandoned, on account of the great amount of sickness they had produced in comparison with others in the same barracks." On the visitation of cholera to the same island (Malta) in 1850, Surgeons L. Adams and Welsh 0 state that the " Ospizio di Vecchi (a peculiarly unwholesome establishment) as usual came in for its share early in the outbreak, as well as the madhouse, where everything sanitary was most defective. Here the disease raged with great virulence, and the unfortunate inmates dropped off in numbers, until suspicion was aroused that the general state of filth, and an extremely noisome latrine, might have something to do with the evil. This was at once filled up with lime, and the cholera as quickly disappeared from the establishment." On Professor Pettenkofer's theory of the mode of propagation of cholera we do not undertake to offer an opinion, beyond this, that the denial of the communicability of cholera by direct contact, as involved in that theory, seems very questionable, and is contrary a The italics are not in the original. b Quoted by Drs. Leith Adams, and Welsh, Army Med. Reports, 1864, page 313. c Opus citat, Army Med. Reports, 1864. 46 to all our experience of the disease. Of this theory, which, in deference to the great reputation of its author, we feel bound to notice here, an excellent abstract has been published by Dr. H. Weber. a Pettenkofer believes that cholera is propagated by human intercourse, and never without this, but through the soil, and not by direct contact. The two essential conditions are, human intercourse yielding the germs in the excretions of cholera patients, and the soil developing this germ into activity. As regards the soil, he holds that two conditions are essential to the propagation of cholera, viz., a porous character, and the presence of ground-water, or subsoil water, varying between five and fifty feet below the surface, the level depending upon that of the first impermeable stratum. The most fatal period is when this water recedes from the surface, viz., in July and August. The cholera-germ must be developed in a suitable soil before it can become active, and it may then enter the body by inhalation, &c. We now beg to submit the result of our observations on the symptomatology and morbid anatomy of cholera. Action of the Heart. — In collapse we have noticed, in several cases, a total absence of the second sound, the first sound being distinctly audible and normal in character. The failure of the second sound has taken place, first, in the aorta, and, after an interval of a few hours, but varying with the gravity of the case, in the pulmonary artery also. For some time longer the first sound continued to be audible, ultimately failing, and in a few instances, several hours before death. This phenomenon is noteworthy, as indicating a dynamic state of the heart, the antitype of that witnessed in typhus fever, in which, as Dr. Stokes has remarked, the first sound of the heart is occasionally abolished, the second continuing unimpaired. In typhus fever the failure of the first sound has been justly attributed to softening and muscular debility of the ventricles, as noticed by Louis. In cholera, as is well known, softening of the tissues of the heart does njot occur ; on the contrary, the walls of the ventricles, especially the left, have been found firmly contracted and unyielding in nearly every instance in which an examination of the body has been made within a few hours after death. Herein, we believe, an explanation is to be sought of the persistence of the first sound in cholera-collapse. The absence of the second sound is probably due to the want of sufficient tension of the aorta and pulmonary artery to induce strong elastic reaction, and forcible and sudden closure of the semilunar valves. a Lancet, January 6, 1866. 47 Report on Cholera, with Remarks. It has been remarked by Skoda that obstruction of the pulmonary circulation, to whatever cause due, is followed, as a necessary consequence, by intensification of the second sound in the pulmonary artery; hence, he regards an accentuated second sound in this vessel as of great value in the differential diagnosis of mitral valve-disease; a remark, the justice of which we have frequently verified. That in the collapse of cholera there is obstruction of the venous circulation in the lungs, the engorged state of the pulmonary artery and right side of the heart, found after death, clearly shows ; hence, probably, in the last stage of cholera, the continuance of a second sound on the right side for some time after it has ceased to be audible on the left. The following cases, given in abstract, illustrate the foregoing statement : — Case I. — Philip Sheridan, aged thirty-eight, was admitted into hospital at eight o'clock, a.m., on the 20th October, in a state of collapse. He had been intemperate ; and, for three weeks prior to the date of admittance, had been suffering from diarrhea, for which he received no treatment. There was no pulse at the wrist, and the first sound of the heart only was audible when he was admitted. Death took place two hours afterwards. Case II. — Catherine Fitzpatrick, aged thirty, was taken ill at five a.m. on the 15th November, with purging and vomiting, and was admitted into hospital at ten o'clock on the same morning. She was then pulseless and livid. Rallied somewhat after inhalation of nitrite of amyl, the pulse becoming perceptible for a few minutes, but soon relapsed into her former condition, and died at half-past two o'clock on the evening of the 16th. In the afternoon of the 15th it was remarked that " the second sound of the heart was not audible anywhere^ but the first sound was remarkably clear." Case 111. — Timothy Flynn, aged thirty-four, was attacked with diarrhea on the morning of the 12th November. In the eveningvomiting set in, and in the course of that night severe cramps in the legs and abdomen. He was admitted into hospital at a quarter-past seven a.m. on the morning of the 13th, and at half past ten was seen by the physician on duty. He was then in a state of incipient collapse ; pulse quick and very weak; tongue furred in the centre, but clean and moist at the edge ; eyes sunken and areolated ; face pale ; surface, tongue, and breath cool ; finger ends livid and slightly 48 TTjr*"**-^^ corrugated ; heart's impulse not perceptible ; first sound faint, but distinctly audible ; second sound not audible over apex or right base, but audible over, and in course of , pulmonary artery. No urine passed since yesterday; patient to have digitalis draughts, and to be cupped and poulticed over the loins. Nov. 14. — Patient is weaker; no urine passed; pulse barely perceptible ; first sound of heart scarcely audible, and, no second sound to be heard anywhere. Diarrhea continues, but not vomiting. Death took place at three o'clock that evening (14th), no urine having been secreted since the 12th. Case 1 V. — Laurence Clinton, fifty-five years of age, was admitted into hospital on Monday the 26th November, at ten o'clock a.m. At four o'clock that morning he was taken ill with purging ; at half-past six vomiting set in, and shortly afterwards severe cramps in the legs, thighs, and abdomen. On the evening of the 25th he took ar full meal of bacon and cabbage, and to this he attributed the attack which occurred about ten hours afterwards. When visited at a quarter past eleven a.m. on the 26th he was livid ; features collapsed ; eyes sunken and areolated ; tongue moist, coated, and cold, and the calomel shortly before given lay upon it; breath tepid ; surface cold ; finger-ends corrugated and livid ; pulse at wrist barely perceptible, and not to be registered. Heart's action weak, arid only one sound to be heard, viz., the first. Involuntary evacuation of bowels; no urine passed since he was attacked; ordered to have oxygen inhalations every third hour ; to be dry cupped, and have mustard poultices over loins. After the first inhalation of oxygen it is noted that " the second sound was audible at intervals ; but the second inhalation produced no such effect." This man died eight hours and a quarter after admittance. Case V. — Laurence Toole, aged thirty-six, taken ill at five a.m. October 23rd, with vomiting, purging, and cramps, and admitted on the same day at nine a.m. He was then livid in the face, but not elsewhere; was cold, and tortured with cramps ; conjunctive deeply injected ; neither heart sound to be heard ; no cardiac impulse to be felt. This man was treated with calomel, brandy, and mustard applications ; he died at half-past eleven p.m. on the day of admission, having been in hospital fourteen and a half hours, during which he took gr. 38 of calomel. State of the Pupils and Conjunctives. — This has been found to vary, not only in the different stages of cholera, but likewise in the 49 Report on Cholera, with Remarks. same stage in different cases. In the stage of choleraic diarrhea the pupils were usually normal and equal ; in a few instances they have been found widely dilated in this stage, but these were instances in which the patients, having been exposed to the contagion, were profoundly alarmed at the appearance of the symptoms of cholera. The following is an example : — Denis Kelly, aged twenty- four, was attacked on the Bth September with diarrhea and sickness of stomach, and was admitted into hospital on the 10th; pulse full and quick; tongue coated; pupils much dilated; conjunctive injected ; surface bathed in perspiration, and face presenting a remarkable expression of anxiety. This man, who was a labourer in the employment of the Ballast Board, lived in the same house with a family named Corrigan, of whom one (the father) died in the hospital on the 4th, and another (a girl aged seven) on the 9th September. Kelly was much alarmed at the close proximity of danger, and when himself attacked, was overwhelmed with fear. To this latter circumstance the dilatation of the pupils on admission was attributed ; after a few hours the man's confidence was restored, and the pupils resumed their normal dimensions. This patient had consecutive fever and choleraic rubeola, and was discharged cured after a residence in hospital of 312 hours. No one state of the pupil is characteristic of collapse ; it is, however, in this stage, either widely dilated, or contracted to a minute point. The former state (dilatation) is of much more grave significance, and is associated with more or less of coma and suppression of urine, and likewise with effusion into the cerebral ventricles, as we have found to be the case in four of our post mortem examinations. In the consecutive fever the pupil is generally contracted in the early stage, but in fatal cases it becomes dilated towards the close, coma and suppression of urine supervening at the same time. We have not met with a case in which the pupils were contracted in consecutive fever, at the same time that the patient was partially comatose, as has occurred in the experience of Dr. Munro, a nor can we subscribe the statement of Dr. Parkes b that in consecutive fever "the pupils are generally contracted," unless it is meant to apply exclusively to the early stage. Case I. — John Morrow, aged forty-six, was attacked with diarrhea at eleven a.m. on the 19th October, and admitted into a Report on the Epidemic Visitation of Cholera in the 93rd Sutherland Highlanders in 1862.— Army Med. Reports, 1862. b Parkes on Cholera, page 132. 50 By I)rs. Hayden and Cruise. hospital at half-paSt nine a.m. on the 20th ; he was then in collapse ; no pulse at the wrist ; eyes sunken and surrounded by dark areolse; conjunctive injected with purple blood, and pupils greatly dilated; choleraic voice, and violent cramps ; he rallied under treatment with large doses of calomel (gr. x., immediately, followed by gr. ii., every hour), and a draught every second hour, composed of bismuth, chlorodyne, creasote, and morphia. On the 22nd (third day of illness) reaction was fully established, and the patient was passing into the consecutive fever; tongue dry ; pulse 108 and full; pupils contracted. At ten o'clock he had a rigor. The head was then shaved; a cold lotion applied, and a draught was given every second hour containing tinct. digitalis m. x. and nit. spirit of ether m. xx. 23rd. Pulse 102 and of moderate volume ; skin hot ; tongue dry and crisped in the centre and at tip ; pupils dilated; mind unaffected ; diarrhea and vomiting arrested. On being questioned, the patient admitted that he had not passed water for the preceding twenty-four hours. The loins were cupped to giv., and the digitalis draughts continued. He wandered a little that evening, and somewhat later the pupils became largely dilated; he died comatose at two a.m. on the following morning (the 24th). Case II. — Stephen Curtin, a boy twelve years of age, was seized with cholera on the 6th September ; admitted on the 7th at 3 a.m.; he was then pulseless, and perfectly livid; pupils dilated; conjunctive injected, and eyes prominent ; this boy moaned most piteously, and was remarkably restless. Case 111. — Michael Monks, aged forty-five, attacked with vomiting and purging on the morning of October 21st. On Monday the 22nd he was admitted into hospital, at one o'clock a.m. No pulse to be felt; surface cold and blue ; eyes sunken, and conjunctivse injected ; secretion of urine suppressed. Treatment consisted in large doses of calomel, and warmth to surface. On the following morning (23rd) he had several epileptiform fits in rapid succession ; suppression continued, and pupils became widely dilated ; he died October 23rd, at three p.m. Of the opposite condition (contraction) of the pupils in collapse, the following is an example :—: — Case IV. — Mary Parrot, aged seventy, taken ill with diarrhea and vomiting at 3 o'clock in the afternoon of the 12th October. Admitted at eleven a.m. on the 13th, at which hour she was visited. The surface was then cold and livid, but not remarkably so. No 51 Report on Cholera, with Remarks. pulse to be felt at the wrist. Eyes sunken, and pupils contracted to the size of pin-holes. Well marked arcus senilis. Respiration slow and unembarrassed ; no diarrhea, vomiting, or cramps, since admittance ; calomel placed on the tongue was not swallowed. To have spirit of camphor-drops every few minutes ; died at half-past two p.m., that is, three and a half hours after admittance. In one instance we observed inequality of the pupils a few hours before death. In that case the conjunctivse were ecchymosed, and the eye in which contraction of the pupil existed was remarkably prominent ; the other pupil was natural. In the great majority of cases of collapse, and likewise in bad cases of choleraic diarrhea, the vessels of the conjunctivse are injected with dark purple blood. Indeed, the peculiar appearance given to the eyes by this state of the conjunctivse, conjoined with the characteristic tongue previously described, may be regarded as pathognomonic of cholera. Consecutive Fever. — The fever of reaction has occurred only in a limited proportion (23 in 197) of the total number of cases. The period of its accession was from the second to the tenth day of illness — most frequently about the fifth day. Its average duration has been 139 hours, and the deaths have been to the recoveries in the proportion of 9 to 14, or 39*13 per cent, of those affected. This fever, which is rarely if ever witnessed in a severe form, except consecutively to collapse, is characterized at its access By gradual increase in the rate and strength of the pulse, elevation of surface-temperature, and crisping of the tongue, and when fully pronounced, is distinguished by rapid and sharp pulse, hot and dry skin, headache, contracted pupils, and injected conjunctivse; dry and brown tongue, suppression of urine, and return of vomiting. In fatal cases death has been usually preceded by coma. In eight instances a remarkable cutaneous eruption has appeared in the course of the consecutive fever. This may be regarded as peculiar to the febrile stage of cholera, and more closely resembles measles than any other eruptive disease associated with fever. Hence we would designate it as "rubeola cholerica." The surface of the entire body, but less frequently the face than other parts, is covered with large irregular blotches of a dark or lobster-red tint, usually discrete, and separated by portions of unaltered skin. There is generally cough, congestion of throat and conjunctivas, and weeping from the eyes. But these last-mentioned 52 By Des. Hayden and Cruise. symptoms are not of invariable occurrence, as in true measles. The rash, like that of measles, passes off by desquamation. It generally occurs in young subjects ; the ages of those affected by it, having been, with two exceptions, under 25 years. In six instances it occurred in the reaction from collapse, and in the remaining two, in the mild consecutive fever which occurs in convalescence from choleraic diarrhea. The average period of its appearance after first illness has been 208 hours ; and the time during which it remained out 55 hours. In no instance, in our experience, has death occurred in which this eruption appeared. It has been attributed by some writers to the free administration of calomel or of opium in the treatment. In six of our cases calomel had been given. In one of these, a case of choleraic diarrhea, in which 50 grains of calomel had been taken, there was slight mercurial action ; but in the others, which were cases of collapse, and made good recoveries, no evidence of mercurialization was exhibited. In two of the cases opium was given, viz., those in which no calomel had been taken, and in these cases only in very small quantity. 11 We cannot therefore admit that the eruption in question is the result of the constitutional action either of mercury or of opium. We regard it, on the contrary, as peculiar, though not essential, to cholera ; as eliminative in character, and as affording strong evidence of the presence of morbific matter in the blood. Doctors Woodman and Heckford b have had three cases of this rose-rash at the Limehouse District Cholera Hospital, London. No opium had been given in these cases, and calomel only in one (probably) before admission. It appeared in raised patches, more or less distinct ; there was little or no itching or smarting ; it made its appearance from the sixth to the twelfth day of illness, usually subsiding in about three days, and followed by desquamation. The urine was albuminous during the continuance of the rash, and in some cases after desquamation ; and under the microscope was found charged with tube-casts and epithelium. In the Lancet of August 11, 1866, is reported a case of choleraic roseola in a boy 1 6 years of age, who was taken ill with diarrhea on the 28th July, and admitted into St. Bartholomew's Hospital on the 31st. On the 7th August, i:e., ten days after first illness, the rash appeared, accompanied by much itching. • See Table 8. b Lancet, September 29, 1866. 53 Report on Cholera, with Remarks. Doctor Sutton, of the Bethnal Green Hospital, 8 mentions another case of " roseola "in a child. It appeared like nettle rash on the tenth day, and on the next it resembled roseola. Doctor F. Makenzie b has seen six cases of roseola in cholera, in none of which opium had been given. Doctor A. Clarke, of the London Hospital, 0 also reports a case of " roseola " in a child aged six years, who was admitted in collapse. On the tenth day reaction set in, and with it " roseola " on arms, which quickly became confluent. It disappeared suddenly on the third day of eruption, and immediately violent and continuous cramps of hands and feet set in, lasting six days. Ultimate recovery. Also a second case, viz., in a boy seven years old, not collapsed, " roseola" appeared on the tenth day of illness, and disappeared on the third day of eruption. Spasm of feet and legs set in immediately on the disappearance of the eruption, and lasted five days, when the boy died. A case of " roseola " has been published by Dr. H. Weber, d the eruption appearing on the tenth day after attack, arms chiefly affected, but trunk and legs also. Eruption resembled measles, but on the second day was of a more deeply scarlet tint. In several of the cases of secondary fever we noticed a peculiar aphthous sore mouth as a very late symptom. It in no wise resembled mercurial sore mouth, and appeared in one case in which no mercury had been given. In one case, likewise, it gave rise to abscess in the substance of the soft palate, which required to be freely opened by incision. Animal Temperature The observations which we have made upon this subject have yielded the following results : — In a man aged thirty-six, dying in collapse, the temperature of tne rectum five hours before death was 90§° F., and in the axilla 98 40 F. In a man aged twenty-four, suffering from choleraic diarrhea, the temperature, as registered on the fourth day of illness, was, rectum, 97f° F.; axilla, 96 £° F. A boy, aged twelve, in incipient collapse, on second day of illness, and four days before death; the temperature in the rectum was 98^° F. ; and in the axilla 97° F. The pulse was then 102, and hardly to be felt ; finger ends white and bloodless ; backs of hands presenting a dusky reticulated appearance. Vomiting in jets; was drowsy. Lancet, September 22, 1866. b Lancet. c Ibidem, September 8, 1866. A Ibidem, August 25, 1866. 54 By Drs. Hayden and Cruise. After inhalation of the nitrite of amyl the temperature in the rectum fell I^° F., whilst the pulse descended eight beats. The foregoing results will not warrant us in subscribing the statement of Dr. M 'Kenzie a that — " It may be stated as a general inference, from the observations made, that in proportion as the external temperature of the body is diminished, that of the internal passages (rectum, vagina, &c.) is increased." In a few instances we have noted an elevation of surface temperature within an hour or two after death. Incubation. — The period of incubation, by which we mean the time that elapses between the reception of the morbific poison and the first manifestation of specific symptoms, has been differently estimated. The "International Sanitary Conference" Committee state, b that in no well established instance has it extended beyond " a few days." Dr. Parkes estimates it at from three to four days. Drs. Adams and Welsh 0 give examples which show that in their experience it has been from two to three days. Deputy Inspector-General Barrow, d writing of the communication of cholera from the emigrant ship " England " to the men Purcell and Terence, and through the latter to their families, at Halifax, Ba y S : — « Of these nine persons one suffered on the second day after exposure ; two on the third day ; three on the fourth day ; two on the fifth day, and one on the sixth. It would appear, therefore, that in the greater number of these cases cholera had developed itself from the third to the fifth day after exposure. In the case of the woman Gaffney, already detailed in this Report, as illustrating the contagious property of cholera, the period of incubation was seven days. In the cases of Mary Hart and her baby, and that of the clergyman at Clondalkin, the period was much shorter. Cramps and loss of voice. — Cramps are, in our opinion, due to want of arterial circulation in the muscles, whether this be the result of spasm of the vessels, viscidity of the blood, or insufficient propulsive power in the heart. We believe that failure of voice is due to want of power in expiration, conjoined with "a diminished volume of air in the lungs," as stated by Dr. Parkes. In connexion a Lancet, August, 1866. b Medical Times and Gazette, October 6, 1 866 c Opus citat, page 331, et sequent. d Opus citat, Army Med. Report, 1867. 55 Report on Cholera, with Remarks. with this subject, a case of venous injection in cholera, recently published by Dr. L. S. Little of the London Hospital,* possesses much interest. The case was the following: — A woman in the collapse stage of cholera, suffering from severe cramps, and with total loss of voice, was treated by alcoholic injection into the veins, to the amount of nearly ten pints ; immediately after the injection the cramps ceased, and the voice was restored; this patient recovered. Treatment. — The general plan of treatment which we have pursued is sufficiently exhibited in Tables 3 and 4 A and B. Very few remarks are therefore required here. Creasote water, allowed ad libitum, and composed of m.iii. of creasote to a pint of cold water, we have found most beneficial, not only in appeasing the thirst, but likewise in allaying the irritability of the stomach. Nitrite of Amyl. — In the year 1863 Dr. Richardson of London, reported upon, and exhibited, at the meeting of the British Association for the Advancement of Science at Newcastle, the action of this agent, administered by inhalation ; and again, at the meeting of the same association at Bath in the following year, he further illustrated its action. When inhaled for a few moments, he showed that it is capable of so exciting the circulation that the face becomes flushed, accompanied with a thrilling sensation. It occurred to us, that in virtue of this remarkable property, the nitrite of amyl might be useful in re-establishing the circulation in the collapse of cholera. In one case, that of a man forty-two years of age, admitted in incipient collapse, the pulse rose from 102 to 1 14, and the temperature in the axilla from 95]° F. to 96^° F., after inhalation of the nitrite of amyl for three minutes. The inhalation appeared to aggravate his thirst. In another case, that of a woman aged thirty-four, also in collapse, the pulse became perceptible after inhalation for a few minutes, and the patient seemed otherwise improved. Thirst seemed aggravated by the inhalation in this case also. A boy, aged four, in collapse, inhaled the amyl for a few minutes, after which there was a slight appearance of colour in the face ; the boy strenuously resisted its further administration, owing to the obstruction to free respiration which it occasioned. In several other cases the amyl was tried ; but, although when • Medical Press and Circular, Feb. 27, 1867. 56 By Drs. Hayden and Cruise. inhaled for a few minutes it usually heightened, in some degree, the colour of the face, and surface-temperature, the difficulty of inducing the patients to continue the experiment for a sufficient length of time, owing to its interference with respiration, and the increased thirst which it occasioned, caused it to be abandoned. Oxygen. — Inhalation of oxygen, by means of Dr. Richardson's apparatus, was also made trial of. In one case, that of a woman in collapse, the pulse became perceptible for a few minutes. A woman, aged forty-four, in collapse, inhaled oxygen for eighteen minutes, the pulse, previously all but imperceptible, increased in strength, and the temperature of the surface was slightly elevated. In a third case, that of a girl, aged twenty-four, oxygen was administered on three several occasions; the temperature rose slightly after the first administration, and the patient requested that she might have it again, " as it gave her relief." The oxygen, like the amyl, though of temporary advantage, was found to produce no permanent benefit, and was therefore discontinued. State of the Blood.— ln connexion with the pathology of cholera, a full and accurate knowledge of the state of the blood has been much desired, and is still wanting. We believe that not only is the blood the primary seat of the choleraic agent, but that, to the physical and chemical changes wrought in it by the operation of that agent, and the consequent depravation of its vital or nutritive properties, are due the prominent symptoms and fatal tendency of cholera. Mr. Sedgwick denies the existence of a specific morbid poison in the blood in cholera, and refers all the phenomena of that disease to functional derangement of the centres of the sympathetic system, excited through the medium of the stomach. No doubt the stomach is functionally deranged, but the derangement may, with as much show of reason, be referred to cerebral irritation as to sympathetic ; and even more plausibly, because there is, almost invariably, engorgement of the cerebral vessels, whilst congestion of the sympathetic ganglia has not been observed in cholera. No doubt Delpech" declares that he has found traces of inflammation in the semilunar ganglia of persons who had died of cholera ; but Cruveilhier b has not met with this or any other organic change in these bodies, or in the solar plexus emanating from them. * Etudes dv Cholera Morbus en Angleterre et en Ecosse. Paris, 1532. Svo. b 14 c Livraiaon. 57 Report on Cholera, with Remarks. In the post mortem examinations made by us, of the bodies of those who had died of cholera, we have likewise failed to find congestion or other alteration of the abdominal sympathetic system. The doctrine of " derangement of the ganglionic system of nerves," to which vascular engorgement and arrest of secretion in cholera have been attributed, is therefore unsupported by facts ; whilst the blood-doctrine has in its favour the admitted fact of chemical alterations in that fluid, which, by impairing or annihilating its chemical and nutritive affinities for the vessels and tissues through which it circulates, would account for the arrest of pulmonary and general circulation, and of glandular secretion. Dr. Parkes" says :—": — " It will be seen that the leading idea I have formed of the nature of cholera is, not only that it is primarily a disease of the blood, as has been so frequently surmised, but that the changes induced in the function of respiration, directly consequent on the alteration of the blood, are the proper and distinctive symptoms of the disease." " That there is some impediment or arrest of the circulation in the capillary system generally, and in the pulmonary capillaries in particular, appears almost certain ; and it is by no means improbable, from the whole bearing of the facts, that this is due to a chemical change in the fibrin, and in its mode of combination, consequent on the direct agency of the active cause." He has found the blood, in the majority of cases, uncoagulable, and its colour dark. The blood in the collapse stage of cholera, as is well known, is dark and viscid — the latter quality being so decided as to render it difficult to obtain even a small quantity of blood by venesection. In one instance we succeeded in obtaining an ounce and a half with great difficulty a few hours before death. In another, on making a puncture in the vein, a large drop of dark tarry blood welled up, and effectually blocked the opening, remaining fixed to the wound ; no more blood could be drawn. The blood of the former patient, examined microscopically, exhibited the red corpuscles dwarfed and crenated. Some blood obtained by cupping from the loins of a man in the consecutive fever, twenty-four hours before his death, showed the red corpuscles of normal size and shape, but aggregated in rouleaux. In one instance we tested the reaction of the blood, and a Opus dtat, pages 4 and 112. 58 By Drs. Hayden and Cruise. found it alkaline, contrary to the experience of Dr. Marcus at Moscow. a Dr. R. D. Thompson b has analysed the blood in cholera, and found the water diminished, whilst the solids were all in excess of the normal proportion. Thus — SYNOPSIS OF DR. THOMPSON S EXPERIMENTS. In Cholera. In Health (Lecanu.) Water 717*8 ... 790-00 Fibrin 45 ... 295 Globules and albumen ... 268-8 ... 19955 Insoluble salts 1-8 ... 1.00 Soluble salts 71 ... 650 10000 100000 Schmidt* 5 has found a deficiency of water, salts, and fibrin, and has observed the loss of these constituents of the blood by transudation into the alimentary canal, to occur in the order in which they have been just mentioned. He likewise found the blood corpuscles considerably altered, both physically and chemically, mainly by loss of water and chloride of potassium, and a reduction, by onehalf, of the amount of oxygen normally contained in them. Morbid Anatomy. — The post mortem appearances in the bodies examined by us (four in number), were nearly identical with those observed by Parkes d and Munro, c and likewise described and illustrated by Cruveilhier f and Craigie. g The autopsies were made from five to six hours after death. The rigor mortis was absent, and the bodies were much less livid than in the last hours of life. Cranium. — The sinuses of the dura mater, and the cerebral veins, were engorged with dark blood. The pia mater investing the brain generally, but more especially at the base, was congested. The choroid plexus was remarkably congested, and of a slate colour. On making a horizontal section of the cerebral hemispheres the a Aitken's Science and Practice of Medicine, Vol. i., p. 634. b Chemical Researches on the Nature and Cause of Cholera, Medico Chirurg. Transactions, "Vol. xxxiii. c Aitken's Science and Practice of Medicine, Vol. i., p. 632. d Opus citat. c Opus citat. ' Opus citat. PI. 1, 2, 3, 4, and 5. B Edinburgh Med. Journal, Vol. xxxix. 59 Report on Cholera, with Remarks. puncta cruenta were observed to be large and numerous, and from each welled up dark liquid blood, which, in a few seconds, formed a patch of ecchymosis. The cerebral ventricles contained a good deal of clear serum — in one instance they were distended with it. The membranes of the upper portion of the spinal cord were similarly congested, but its white substance, and grey centre, were free from vascularity. Thorax. — The lungs were somewhat congested posteriorly, but still resonant on percussion, and crepitant. In the infero-posterior portion of one lung there was much dark blood, mixed with serum. The anterior portions of the lungs were of a light colour, and free from congestion. The right cavities of the heart were full of dark, tar-like blood, which, in the right ventricle, was enveloped in a capsule of fibrin one-eighth of an inch thick, and extending into the pulmonary artery. The left chambers were empty and contracted ; the left ventricle much diminished in capacity, firm, and thickened, manifestly by strong contraction of its walls. Abdomen. — The peritoneal surface of the hollow viscera was smooth, white, and glistening, as in a state of health. Liver, spleen, and kidneys normal. Mesenteric glands all more or less enlarged — some of the size of peas. The semilunar ganglia, solar plexus, and splanchnic nerves presented a natural appearance, and were free from congestion. The stomach contained a quantity of gruel-like fluid. The mucous lining of the oesophagus projected into the stomach, forming a radiated disc with a festooned border, of a pale colour, and sodden-looking, and presenting the appearance of a piece of wet parchment (Fig. 1). In the immediate neigh- 60 By Drs. Hayden and Cruise. bourhood of the cardiac orifice the mucous membrane of the stomach was remarkably marnmillated, the crypts being distended with an opaque white liquid (Fig. 1). Both the small and large 61 Report on Cholera, with Remarks. intestine were nearly filled with a liquid of the colour and consistence of thin boiled starch, in which small white flakes were suspended. Brunner's glands were enlarged, and of a light colour. In the jejunum and ileum the glands, both solitary and agminate, were enlarged, and filled to distention with an opaque fluid resembling unhealthy pus (Figs- 2 and 3). The mucous surface generally was vascular in the jejunum and upper portion of the ileum. The lower portion of the ileum was free from vascularity ; the solitary glands were here remarkably distinct, and one of Peyer's patches was found to have discharged its contents, all its glandules being ruptured and collapsed, and each presenting a distinct aperture on the surface, by which the contents had escaped (Fig. 2). The entire surface of this patch, which measured about three inches in length, was depressed below, and contrasted markedly with, the surrounding surface, on which the solitary glands were prominent and distended (Fig. 2). The liquid contents of one of these glandules, examined microscopically, were found to contain large granule cells, like mucus-corpuscles, and amorphous granular matter. The enlarged solitary glands extended quite to the ileo-cuecal valve. In the ascending colon some slight vascularity was apparent. The above description applies in all essential particulars to the three bodies in which the stomach and intestinal canal were carefully examined ; the correspondence in regard to the state of the intestinal glands in these three bodies being especially remarkable. The larynx of a woman who was admitted in collapse, with total loss of voice, and died two hours afterwards, was examined ; the true vocal chords were thickened, their sharp angles rounded off, and the ventricles of the larynx diminished in capacity by thickening of the mucous membrane. There was, however, no abnormal vascularity. The state of the intestinal glands demands special observation ; Dr. Parkes, who, in his work on cholera, notices this state, regards it as a consequence of the diarrhea. We cannot coincide in this opinion, being aware that in other diseases complicated with intestinal lesion, diarrhea is a frequent consequence, though rarely if ever a cause, of glandular enlargement. Moreover, in the neighbourhood of these glands there was no appearance of irritation or abnormal vascularity, such as Dr. Parkes' view of the pathology of their enlargement would necessarily imply. Our firm conviction is, that the engagement of these organs, their distention with a fluid of an apparently specific character, and subsequent discharge of it by rupture of their walls, as exemplified 62 By Drs. Hayden and Cruise. in a few of the patches of Peyer, are, like the diarrhea, eliminative in character and purpose, and to be regarded as evidence of the presence of a specific morbid poison in the blood. Further evidence of this is furnished, as we believe, by the peculiar roseolar eruption previously noticed under the name of rubeola cholerica. We are indebted to Mr. Oldham, of Rathgar, for the beautifuF woodcuts annexed, which he has engraved from the original drawings of the late Mr. Connolly, whose recent death inflicts a loss upon the medical profession in Dublin which it will not be easy to repair. It is our firm conviction that cholera, although when advanced to the stage of collapse, an appallingly fatal disease, is, nevertheless, preventible in the strictest sense ; and eminently curable in the stages preceding collapse. Of the truth of the latter assertion a direct confirmation will be found in Table 3 A of this report. As regards preventibility, very important evidence has been recently furnished by the Registrar-General of England, showing the effect upon the mortality of cholera, of well-devised and wellexecuted sanitary measures. It appears from his returns that the death-rates per 10,000 of the population in England and Wales, during the three last epidemics, have been as follows, viz. : — 1849 ... 62 1854 ... 43 1866 ... 18 Per 10,000 of population. M. Dumas a stated at a recent meeting of the Academy of Sciences, Paris, that during the cholera-epidemic of 1865, not one of the women employed in washing the linen of the Paris hospitals (which was always, in cholera cases, disinfected as soon as brought from the wards), fell a victim to cholera. Moreover, only one of the employes of the Administration dcs Pompes Funebres, amounting to nearly 1,100 persons, died from cholera; the Administration having rigidly insisted on the observance of the requisite hygienic precautions. Dr. W. Budd, in a carefully compiled and able report on the recent epidemic of cholera at Bristol, illustrated by maps, shows, in a striking manner, the efficacy of sanitary measures and prompt disinfection. He says: — " A comparison of the numbers swept off by a Medical Times and Gazette, Feb., 1867. 63 Report on Cholera, with Remarks. cholera and diarrhea in Bristol (including Bedminster and Clifton, which, with Bristol, are practically but one town) in the four successive outbreaks of 1832, 1849, 1854, and 1866, will be the best introduction to what is to follow. These numbers are, respectively, 1832, 626; 1849, 1,979; 1854, 430; 1866, 29. From these figures it will be seen that the deaths which, from something below a thousand in 1832, had risen to nearly 2,000 in 1849, fell to 430 in 1854. This great drop, in exact accordance as it was with the corresponding abatement of the mortality from the pest in other cities, was at the time, and no doubt rightly, ascribed to the sanitary improvements which had taken place in the city in the interval between the two epidemics, and especially to the construction of a better system of sewers, and the introduction of a pure supply of water." " But the fall from 1854 to 1866 is much more remarkable. For while the deaths in 1854 amounted to about one-fifth of those of 1849, the deaths of 1866 were one-fifteenth only of those of the former year. Part of this result might, no doubt, be reasonably ascribed to progressive sanitary improvement, but the very abruptness of the contrast between the mortality of the two years naturally suggests to the mind the intervention of some new controlling condition." " As a matter of fact such a condition did exist in the shape of the vigorous employment of the disinfecting plan. An analysis of the facts will leave no doubt, I think, in any reasonable mind, of the reality, while it alone can give an exact measure of the extent of the operation of this plan in preventing the spread of the disease." Doctor Mapother, in his recent work on Public Health, 11 declares that "he is convinced, from a comparison of the last with the previous epidemics, that cholera will be a more frequent visitor, and our safety lies in sanitary work, which will, with positive certainty, render its attacks less formidable." In this statement we entirely concur ; and we feel satisfied that if the air breathed, the water drunk, and the food taken be of a wholesome character, individuals and communities so circumstanced will suffer comparatively little from cholera epidemics. Of the air and the water consumed by a population the public authorities of the place are the legitimate and responsible custodians, and no remissness of action in regard to these essentials to public a Opus citat, Feb., 1867, page 453. 64 By Drs. Hayden and Ckuise. health should be permitted upon their part. They are now armed with sufficient power, under the law, to enforce the observance of sanitary precautions, not only in thoroughfares, but likewise in private residences, and if they do not use them to good purpose, they should be held to strict account by those whose interests are thus intrusted to their care. Every enlightened man in a community, as it seems to us, (and more especially physicians, who are, upon questions of this kind, presumably better informed than others,) should be a sanitary public officer, to the extent of co-operating, to the utmost of his power, with the persons deputed by law to supervise the public health. It is notorious that in the successive epidemics of cholera, the disease has visited and desolated the same streets, and the same houses, where, in the intervals, sanitary improvements have been neglected. The address of every house in this city in which a case of cholera occurred during the recent epidemic, and a record of the number of cases in each house, is in the possession of the dispensary and hospital physicians who had charge of these cases. We would venture to suggest that this mass of local information be utilised for the construction of a system of house-to-house visitation, which, we believe, if fully and conscientiously carried out, would effect the utmost that is possible towards the prevention of cholera in the future. We beg to subjoin a brief summary of the principal conclusions, which we think are fairly deducible from the foregoing report : — 1. The diarrhea so prevalent amongst the inhabitants of localities actually suffering from cholera, is a premonition, and the earliest manifestation, of cholera. 2. Cholera is a disease strictly preventible by sanitary and hygienic measures, and, in nearly all cases, curable in the stages preceding actual collapse. 3. The treatment which we have found most successful in the stage of choleraic diarrhea is sulphuric acid and opium ; with sinapisms, external heat, and creasote water. 4. In collapse we have had more success with calomel given in large doses than with any other medicinal agent. In several cases, besides those in which recovery took place, reaction set in under the calomel treatment, but death occurred in the consecutive fever. 65 5. We believe cholera to be contagious, but in a hiuch hss degree than the principal endemic contagious diseases of tl is country — viz., typhus, scarlatina, measles, and small-pox. 6. As regards individuals exposed to the contagion of cholera, 3 state of good health, and proper sanitary and dietetic precautions; afford a strong assurance of immunity from attack. 7. Immediate attention should be given to derangement of stomach, or laxity of bowels, during a cholera epidemic; and to insure this amongst the poor, house-to-house visitation seem? indispensable. 66