SECOND REPORT ON THE PREVENTION AND TREATMENT OF SPASMODIC CHOLERA, MOST KRSPIiCTI-I'U.V Si:B.M!TTEU TO HIS EXCELLENCY THE LORD LIEUT ENA N T OF IKELAND, r.v THE GENERAL BOARD OF HEALTH, IN DUBLIN. DUBLIN: PRINTED BY GEORGE AND JOHN GRIERSON, PRINTERS TO THE KING'S MOST EXCELLENT MAJESTY. 1831. 3; lit ₯ * i »\ d *• » I 1 t \i\i* i I i\ T I lit•i 1 t r i \\ 4 \ i*i 11 if 1 IIC vJCllCltil DOtlrll OI IlC.lllll IltlVllli' Eit right that a more extended Report prevention of Spasmodic or Asiatic i comprehending also suggestions as ' to its treatment, should now be generally circulated in Ireland, respectfully beg leave to submit the following pages to His Excellency the Loud Lieutenant. SECOND REPORT THE PREVENTION AND TREATMENT ?y SPASMODIC CHOJiEIIA, &C. &c. 1 H E formidable disease, now distinguished by the several names of Spasmodic, Asiatic, or Malignant Cholera, commencing in the East Indies, has, in the course of thirteen years, traversed Asia, and Bie of the most populous countries of Africa ; h a gradual but steady progress westward, it has entered Europe, and moving through Russia, Poland, and Germany, to the shores of the Baltic and the mouth of the Elbe, it has reached the eastern coast of England. The very general extension of this malady, through any community which it invades, its painful symptoms, and above all, its extraordinary mortality, have made it the subject of great apprehension in every country toward which it has approached. As Spasmodic Cholera appears to have been little restrained in its progress by any circumstances 6 of locality, climate, or season, great fears are but too justly entertained that it will extend through Great Britain and Ireland, and the British Government has adopted such measures as practical and professional experience could devise foi preventing its introduction, and remedying its consequences. These measures have been detailed in Reports issued by the Board of Health in London, in Letters addressed to Medical Officers, in all parts of these countries by the Army Medical Board, am in the Proclamations circulated in maritime places relating to the rigid enforcement of Quarantine, and the detection of Spasmodic Cholera on its first appearance. Judging from the frequent recurrence of Epidemic Fever of late years in Ireland, it is much to be apprehended that the same causes which have contributed to extend Fever, would also render Spasmodic Cholera epidemic in this country. This view of the case, although leading to gloomy anticipations, is in one respect satisfactory, as a preventive system, founded on experience and of approved utility, has been gradually adopted in Ireland, and a large portion of the measures composing this system would be applicable to the prevention of Spasmodic Cholera. As the modes of adapting to the local circumstances of Ireland the system of measures which either originated with the General Board of Health in Dublin or was extensively put in practice by them, must be well understood by that Board, they have deemed themselves called on to submit 7 to His Excellency the Lord Lieutenant, their views on the different means to which it would be expedient to resort, in case Spasmodic Cholera should unhappily visit this part of the British Empire. Papers relating to this disease have been published at different times by the London Board of Health, under the authority of the Lords of His Majesty's most Honourable Privy Council, to these we would refer our readers. The valuable information contained in these papers will supersede many observations which theJGeneral Board of Health in Dublin {might have to offer, and form the ground-work of a portion of the preventive system which they would propose for His Excellency's adoption in Ireland : but the peculiar circumstances of this country, the frequent recurrence of Epidemic Fever in Ireland, and the existence of laws authorizing the community at large to take into their own hands, the application of preventive means when the country is visited by any contagious malady, seem to render it imperatively incumbent on the General Board of Health, to direct the attention of His Excellency the Lord Lieutenant to the means requisite for adapting to the circumstances of Ireland, the information of which the Board is now possessed : in this view of the case, their opinion is strengthened by facts communicated in the papers above referred to, from which it appears, that Spasmodic Cholera, in its second stage, has, in many cases, assumed so much of the form of Typhous Fever, as to be scarcely distinguishable from that disease. 8 I In many reports published by personal ob vers on the progress of Spasmodic or Asiatic olera through Asia and Europe, it is stated that : disease has prevailed with most frequency ongst the poor inhabitants of towns : for Itiis son it is much to be apprehended, that in the *er cities of Ireland, the present circumstances a great portion of this class of the population lid be peculiarly favourable to the extension the malady. trhe gradual progress of Spasmodic Cholera g the principal lines of communication bern countries, its following the movements of ies and other large bodies of men ; its appearj at different places, not simultaneously but sucively; together with the security which in nu-3iis instances has been observed to arise from ision, strongly confirm the opinion, that the ise is extended by human intercourse : an ainion which derives support from the complete idequacy of every other explanation hitherto proposed to account for the extension of Asiatic Cholera over so large a part of the globe. This view of its mode of propagation is now adopted, Honly by the Governments of those Countries eh it has invaded, but also by the British Government : the safety of this opinion is undeniable ; the adoption of a contrary opinion, if founded in error, must be dangerous in the extreme. A strict observance of the laws of quarantine is strongly enjoined in His Majesty's Proclamation now widely distributed along the sea coast of 9 Ireland ; which laws we have reason to believe are generally enforced : on this head the General Board of Health would recommend that magistrates, and other officers armed with authority in maritime places, should be warned of the danger arising from the infringement of these laws, and be required to use every means in their power for the purpose of preventing communication with vessels coming from countries specified in that proclamation. Still further, should fever exist on board any vessel lately arrived from a country where Spasmodic Cholera has at any time prevailed within six months previously, the passengers and crew should be compelled to perform Quarantine, as the fever existing on board may be that attendant on the second stage of Cholera; for this fever is known to be contagious, and to produce genuine Spasmodic Cholera. — See Papers on Spasmodic Cholera above referred to. With respect to other preventive measures, the Board would first direct the attention of His Excellency the Lord lieutenant, to those general means which the legislature has authorized in this country, when visited by any contagious distemper ; these are, Ist. The establishment of Boards of Health under the Act of the 58th Geo. 111. cap. 4«7« sec. 10. et seq. 2nd. The appointment of Officers of Health under the 59th Geo. 111. cap 41, sec. 1. et seq. By the first of these it is enacted, " That whenever in any city, town, or district, any fever or 15 10 contagious distemper shall appear or be known to exist among the poor inhabitants, it shall and may be lawful for any one or more magistrates upon the requisition of five respectable householders, to convene a meeting of the magistrates, and house-holders of such city, town, or district, and of the medical practitioners within the same, in order to examine into the circumstances attending such fever or contagious distemper, and the number of persons or families being sufferers thereby ; and if it shall be the opinion of such meeting, and of one or more magistrates attending, that such fever or contagious distemper is of a nature to require particular attention and circumspection to prevent the increase of the contagion thereof, it shall be lawful for two or more magistrates, authorized by such meeting, to join in an application to the Lord Lieutenant, or other Chief Governor or Governors of Ireland, for the time being, to appoint a Board of Health within and for such city, town, or district ; and it shall be lawful for such Lord Lieutenant, or other Chief Governor or Governors of Ireland, to appoint such Board accordingly, to consist of not more than thirteen commissioners, to be selected from among the governors or members of the corporation of any infirmary or fever hospital, or other hoslil, and from the parishioners and medical prac- Dners, to act within such city, town, or district, such manner, and under such regulations, as h Lord Lieutenant, or other Chief Governor Governors of Ireland, or his or their Chief 11 Secretary, shall from time to time order, direct, and appoint." The powers of this Board are then stated in sections xi. xiii. xiv. " That it shall be lawful for the commissioners to be appointed for the forming such Board of Health, or any five of them, to give all such directions for the doing and performing all acts, matters, and things, necessary for the preventing the communication of contagion, and for restoring the sick to health, as shall to such commissioners seem necessary and expedient ; and for that purpose to direct that all streets, lanes, and courts, and all houses, and all rooms therein, and all yards, gardens, or places belonging to such houses, shall be cleansed and purified, and that all nuisances prejudicial to health shall be removed therefrom ; and that all houses in which any sick person shall be, or shall have been, shall be ventilated, fumigated, and whitewashed, the windows and doors thereof opened, and all beds, bedsteads, bedding, and furniture therein, be exposed to the air, and be washed and cleansed, and if absolutely necessary, to be burned or destroyed ; and that some mark, number, or token shall be affixed on any house in which any inhabitant is infected with fever, denoting that some or one of the inhabitants therein are so infected ; and to direct that all other measures shall be carried into execution Ich to such commissioners shall seem requisite the purposes aforesaid." The Act in section authorizes these commissioners to employ any son or persons in the execution of the Several 12 powers to be exercised by them under this Act, and further states, " that it shall and may be lawful for the Lord Lieutenant, or other Chief Governor or Governors of Ireland, to order any sum or sums of money, to be from time to time advanced out of the growing produce of the consolidated fund in Ireland, for the payment of the actual expenses incurred by and under the said commissioners, in the execution of such powers, and that all sums of money so to be advanced shall be raised by presentments to be made by the grand juries, and raised off the county, or county of a city, or town, in which such expense shall be incurred." The Act then empowers the commissioners to have performed all that may be requisite for preventing the spread of contagion, and annexes penalties to which those persons become liable who shall give any resistance or opposition to the commissioners in the performance of their office. It also confers on these commissioners the power of ordering the removal of persons labouring under any infectious malady, to an hospital, in places where such hospital shall exist ; and it requires such commissioners to make weekly reports to the Lord Lieutenant, or other Chief Governor or Governors of Ireland, and limits the continuance of their powers to the necessity of the case. — See Section XV. It appears to the General Board of Health, that under this Act, ample powers are conferred on local Boards of Health for carrying into effect all measures that experience may point out to individuals, or local circumstances may render 13 necessary for prevention ; but the General Board of Health would recommend, that as this Act, when put in force, would produce expense to the public, the inhabitants of any city, town, or district, should not be called on to form a Board of Health until the existence of Spasmodic, or Asiatic Cholera shall be clearly ascertained, to the satisfaction of the General Board of Health. They would further recommend, that in every case where it is intended to carry this Act into effect by the removal of the sufferers from their families, that due regard should be manifested for the comforts and feelings both of the patients and of their relatives; as otherwise concealment will be adopted, the intentions of the Act ultimately frustrated, and great injury inflicted on the community by the spread of infection. By the second of these Acts, passed in the 59th of George 111. cap. 41, entitled An Act to establish Regulations for preventing Contagious Diseases in Ireland; it is provided, that in every city or great town where the Lord Lieutenant shall think tit that this Act should be carried into effect, Officers of Health shall be annually appointed, and the inhabitant householders of each and every parish, assembled in vestry, are required to elect and appoint any number of persons not less than two, and not more than five, to be Officers of Health for such parish, for the year ending on the 35th March next after every such election, and until new Officers of Health shall be in like manner appointed for such parish, for the year 14 ensuing. These officers are empowered to cause and direct all streets and lanes, and all yards and courts adjoining thereto, and all houses let in several tenements to roomkeepers, and the yards, gardens, or places belonging to such houses, to be cleansed and purified, and all nuisances prejudicial to health to be removed therefrom, and all public sewers to be cleansed, and where necessary to be covered over, and all lodgments of standing water to be filled up or drained off; and also to cause and direct all other matters and things to be done for the ventilation, fumigation, and cleansing of any house whatever in which fever, or other contagious distemper shall have occurred, and for the washing and purifying the persons and clothes of the inhabitants of such parish against the danger of contagion, unless due precautions shall have been previously taken for such purposes, by the inhabitants of such house ; and it shall be lawful for all constables and peace officers, and they are by this Act authorised, empowered, and required to be aiding and assisting to such Officers of Health, in the doing all matters and things whatsoever, in the execution of this Act. — See Section VII. The same Act also empowers these Officers of Health, where the scavengers or other persons who have contracted for cleansing or sweeping the streets shall neglect or omit to cleanse the streets and lanes, at least twice in each week, to direct such streets to be swept and cleansed, and the manure so collected to be sold, the produce to be 15 applied to thd purposes of the Act. A power is also vested by the same Act in these Officers of Health, to prevent the danger arising from strolling mendicants, and other idle persons seeking relief; a most powerful and active means of disseminating contagious disease, more especially in times of public distress arising from scarcity : and should Spasmodic Cholera manifest itself in these countries, the attention of all individuals who regard their own safety and the public health, should most particularly be directed to those fertile sources of contagion, mendicity and vagrancy. The General Board of Health would here recommend that a circular letter should be written to the parishes, in all towns of any considerable size, calling on the inhabitants to comply with the requisitions of the Act, and to appoint Officers of Health, at the next parochial meeting legally fixed for this purpose; in order that every due preparation may exist for at once arresting the progress of this formidable malady.* Such are the measures, under the sanction of legislative enactment, that may be adopted for preventing the extension of contagious disease ; but beside these, other means should be had recourse to, in which the co-operation of Government with the community would be required. Of these, the first and most important is, the immediate removal * The Act is in one respect defective, as it limits the time of appointing Parish Officers of Health to one month of the year; the present circumstances of Ireland shew that this appointment should take place when occasion requires it. 16 (the patient to an hospital ; thus cutting off the iree from which the disease can be propagated, r this purpose it appears advisable, that where circumstances will admit, one or more wards should be set apart, in existing hospitals, for the reception of persons suffering under Spasmodic Cholera. Advantage would arise from employing such hospitals in the first instance, as all the machinery requisite for the proper treatment of patients would be found within their walls in full preparation, and the delay attendant on forming new establishments would be avoided. In the City of Dublin, the Wellesley Hospital, attached to the House of Industry, a part of Steevens', and of Sir Patrick Dun's Hospital, of the Meath Hospital, and the New Whitworth Hospital, with the consent of their respective Governors, might be thus applied. In making this arrangement, it appears advisable that such patients should be kept altogether separate from other patients in these hospitals.* But the accommodation afforded by existing hospitals, or by those provided on the first breaking out of the disease, might not be found sufficient ; in this case, the parishioners of those parishes in which Spasmodic Cholera had appeared should be called on to provide temporary hospitals, " in airy and dry situations," for the accommodation of such patients j and in each * Other arrangements are in preparation, by which ample accommodation would be obtained for the reception of patients Kblin, in a disease which, on its first appearance in any ;, rarely attacks many individuals at the same time. 17 parish there should be at least one hospital. The number of beds in the hospital might be proportioned to the population of each parish to which that hospital is attached, and we would propose that Government should afford pecuniary aid towards the support of such hospitals, in the poorer parishes only. The population oi' the parishes of Dublin, according to the last census, is as follows:— Parish. iS». of Persons. Parish. 2ft. of P.rsons. St. Peter - - 25,631 St. Audeon - - 4,599 St. Mark - - 14,81 1 St. Catherine - 21,981 tAnne - - 8,30 1 St. Luke - - G,GOS Andrew - - 7,870 St. James - - 9,927 St. John - - 4,851 St. Thomas - - 16,882 St. Werburgh - 3,384 St. George - - 11,543 St. Bridget - 12,543 St. Mary - - 25,3 1 1 St. Michael - - 2,288 St. Michan . - 23,918 St. Nicholas within - 1,845 St. Ffeul - - 10,570 St. Nicholas without - 12,023 Grange Gorman, - 6,188 Si. Patrick's Liberty - 2,291 Total - 232.3G2 In every arrangement of this kind it would appear advisable, either that the patients affected with Cholera should be kept apart from other patients, or that the hospitals receiving patients labouring under Cholera, should be applied to this purpose exclusively, and it should be observed, that from the hospitals which have hitherto received fever patients, it will be difficult to exclude patients labouring under Cholera in its second stage, from its liability to be then confounded with ordinary typhous fever. In many places, hospitals cannot be obtained ; (• 18 I which case it has been proposed that tents )uld be erected for the reception of the sick 1 this subject we would observe, that tents re extensively applied to the reception and acnmodation of fever patients in the year 1820, which period, fever prevailed most exten-3ly in Dublin, and it was at that time reported all the physicians in attendance on the patients eived into tents, that in these, recovery took cc as rapidly and completely as in the hospitals ; neither did it appear that relapse was more frequent among patients who had passed through the disease in tents, than in the ordinary wards of hospitals. It must be evident that ventilation of the patient's apartment at all hours during night and day, and the seclusion of patients affected with Cholera, from those labouring under other diseases, can be more completely effected in tents than in hospitals under the usual circumstances. For these reasons, added to the moderate expense at which they can be erected, it would appear that tents are well adapted to the accommodation of patients labouring under Spasmodic Cholera. But it has been objected, that persons who sleep near to the ground are most liable to be attacked by this disease ; this would be an objection to the use of tents, if patients who had suffered from Cholera were liable to relapse, which has not been found to be the case. Tents might also be applied to the accommodation of such patients during the second Bje of the disease, but the difficulty of keeping floor of a tent in a cleanly state, is a serious 19 objection to the use of tents during the Jirst stage of Cholera ; they would also be inapplicable to this purpose during the cold season of the year. View ing these circumstances, the Board would recom mend that tents should not be had recourse to unti the accommodation for such patients in the ordinary hospitals shall prove insufficient. To prevent the accumulation of persons suffering from Cholera in cities or large towns, it is desirable that hospitals containing a few beds for the reception of such patients, should be opened in the adjacent small towns, and in such case, that patients labouring under Cholera, or the symptoms immediately consequent on an attack of that disease, should be excluded from the hospitals of cities or large towns. For the conveyance of patients to the hospitals, carriages of a peculiar construction, similar to those of the Fever Hospital in Cork-street, might be provided in the larger towns of this country ; but to avoid the risk of extending the contagion of Cholera, these carriages should not be used for the conveyance to hospital of patients of any other description.* The removal of patients to hospital with as much expedition as possible, would not merely contribute to the speedy relief of the sufferer, but would afford the opportunity of cleansing and ventilating the apartment from which he had been removed, an operation which should be carefully * At Moscow, carriages with four horses constantly yoked, were kept for the immediate conveyance of patients to hospital. 20 put in practice in every instance, and under proper regulation and inspection. For this purpose, the windows and doors of every hotlse and apartment from which patients have been removed, should be opened, the air freely admitted, during at least twenty-four hours ; the floors then thoroughly washed, and the walls whitened with a wash composed of water and fresh slacked quicklime. The use of chloride of lime is recommended by the Board of Health appointed by His Majesty. This preparation is thought to possess considerable disinfecting powers. It can be obtained abundantly from manufacturers in this country. We do not think its application, much less that of quick-lime, ought to supersede the necessity of cleansing and ventilation, more especially in the habitations of the poor ; and it should be the duty of particular individuals appointed for this purpose, to ascertain that these processes of cleansing and ventilation, have been efficiently performed, and to report on them to the parochial committees to which these inspectors are attached. But it may happen that many individuals when labouring under the disease, will either object to be removed from their dwellings, or from the severity of the symptoms with which they arc attacked, may be deemed unfit for removal : for the relief of sufferers of this description it appears |)cdient, that in the larger cities, when visited by olera, several Medical Depots should be eslished, to which resort could be had, for imiliate medical advice ; and from which medicine 21 could be promptly supplied. At each of these Depots two or more medical practitioners shouh be constantly stationed, to whom immediate re ference could be made, for the purpose of visiting patients, ascertaining the existence of disease, di recting the immediate removal to hospital, if prac ticable, or promptly affording the requisite aid. This measure is strongly recommended by the great importance of early medical interference and the decided success which has attended the use o: proper remedies, at the commencement of the attack. Should any particular class of medicines be found efficacious in the treatment of Cholera, it should be the duty of the Inspectors* to see that a sufficient stock of such medicines is provided, and that they are of proper quality. Existing dispensaries in the city of Dublin, and in other cities and towns, would afford ready means of obtaining these objects, and where these dispensaries do not exist, other depots for medicines of the requisite class, should be established. In many accounts of the mortality occasioned by Cholera, the number of deaths appears to have been greatly diminished by medical treatment, applied in the early stage, and within the first lew hours of the disease. And it is for this reason we would lay peculiar stress on the part of the remedial system above proposed. At Moscow the mortality at first amounted to 9-10ths of the cases, but as the disease advanced, it diminished to l-3rd of these * To \>c more fully adverted to in the sequel. 22 cases ; the decrease was ascribed partly to a change in the virulence of the distemper, but principally to the zeal of the Government, in providing the means of subjecting patients in the poor ranks, to medical treatment at an early period of the attack. A remarkable instance is given of the efficacy of medical treatment, in the report of the Government of Saratov, where the disease was in general virulent. On the estate of Count Gurjev, in that Government, 166 persons were attacked, and 19 died, without any treatment ; but of the remaining 147 who were subjected to treatment at an early stage, 26 only were cut off, that is, little more than l-6th part. — (See History of the Spasmodic Cholera of Russia, by Bissctllawkins, M.D., page 113.)* The following stock of medicine and medical apparatus might be in readiness at each of the above proposed depots : Baths, Stomach warmers, Blankets, Flannel, Flannel bags, a Clyster syringe, as it may be needful to introduce opiates and cordials by means of that instrument; a supply of spirits, rectified oil of turpentine, pills marked anticholera, and composed of calomel half a drachm, powdered Turkey opium, powdered gum arabic, of each six grains, oil of cinnamon or of cassia six drops, with a few drops of water, made into a mass, to be divided into six pills. On the first appearance of Spasmodic Cholera, • The great advantage arising from the early application of remedies is strongly urged in various Reports on the Disease, as it appeared in India. 23 clearly ascertained to exist in any town or district, it is advisable that Medical Inspectors should be appointed. Their duties should be to visit all houses in which the disease is known or suspected to exist, and to urge the immediate adoption o means, either for the relief of sufferers, or for preventing the spread of- contagion. For the rapic attainment of the first of these objects it might be a part of the Inspectors' duty to carry with them about their persons, some remedial means, to be used by any patient labouring under Cholera on the instant of its detection. The utility of this plan must appear evident in a disease which often runs its course in a few hours ; the final issue as to death or recovery depending on the progress which it has made within six or eight hours after its invasion. Opium, calomel, bloodletting in suitable cases, various internal and external stimulants might be thus applied. Inspectors should be required to visit the houses from which any notice of the existence of the disease has been transmitted either to hospitals, or to the medical depots, and to give in from time to time, returns of the number of persons who were found labouring under Spasmodic Cholera, and of the means adopted for arresting its progress. They should visit the dwellings of every patient labouring under this disease, who had been received into an hospital, and report the number of persons belonging to the family, their age and occupations, and the state of their accommodations, with reference to health, and the origin of their illness. The Inspectors 24 should inquire into the prevalence of disease in the immediate vicinity, the existing nuisances, the supply of water both in that vicinity and the division in general. They should further inquire what means have been employed for the suppression of disease, and with what effect. Inquiry should also be made by the Inspectors into the state of the population in their respective districts. These Inspectors should be furnished with books, and their reports might be forwarded to the General Board of Health in Dublin, to be by them transmitted to the Board of Health appointed by His Majesty in London, as occasion may require. The returns may be digested under the following heads : 1. Number and names of the applicants for relief, with the occupation of the males and of the near relatives of females. Q. Date of the inspection. 3. Residence. 4. Number in family. 5. Number of persons previously attacked. 6. If admitted to hospital. 7. Houses and rooms requiring cleansing and fumigation. 8. Nuisances to be removed in houses, including infected clothes and bedding. 9- Probable cause of disease. 10. Supply of water. 11. The existence or sale of unwholesome food. V 2 General observations. By the adoption of this plan, in connexion with that of hospitals for the reception of patients, correct views will be obtained of the progress of the disease as to its increase or diminution, and of those means which have been found most emcacious 25 for prevention or relief; and the information being transferred to a common centre, can be thence diffused through every part of the country. It would also be advisable that should any particular street or lane appear peculiarly infected, the disinfecting process should be extended to every house. If the disease be contagious, or propagated by human intercourse ; of which no doubt should be entertained ; it will be in vain that these processes are applied to the rooms and furniture of the dwelling, unless the persons also of its inmates are purified from infection. It is therefore desirable that the attention of the inhabitants of towns should be particularly directed to the system of cleansing houses, as adopted in the years 1818, 1819, in St. Peter's parish in Dublin, and in the city of Waterford, of which the following is a brief account. Under the management of benevolent individuals a house was provided and fitted up, with a view of subjecting infected bed-clothes and apparel, to such processes as are best calculated to destroy infection. The persons of the sufferers also underwent a cleansing, for which, baths and other requisite accommodation were amply provided. The following extract from an' account of the proceedings of an association in St. Peter's parish, will sufficiently explain the details of this plan. " The usual manner of proceeding at the cleansing house, was, 1 . To warm water. 2. To i) 26 send for the people who were to come in. 3. To wash their persons with warm water and soap 4. To dress them in the house clothes. 5. To give them their dinner in a separate comfortable room. 6. To stove their woollen clothes.* 7« To wash their linen clothes. »S. To dry the linei clothes in the stove after the woollen clothes have been removed. 9. To give them supper. 10. To dismiss them between 5 and 0 o'clock. 11. To stove the house clothes which had been won during their stay in the house." During one month iy(i persons availed them selves of the advantages here offered to them, am more individuals presented themselves than couk be received. A similar plan was followed in Water ford, and with good success.! It has been proposed that a supply of hot water, in different places throughout the city, where it can conveniently be obtained, should be suffered to flow into reservoirs, for the accommodation of the poor class in washing their clothes. We have reason to believe, that an establishment for supplying the poor with the means of washing their clothes with hot water could be fitted up at the expense of about .§£loo, and that its annual expense would be about .€"80. The importance of such establishments, in the present circumstances of Ireland is quite obvious. * It is advisable that the heal applied in Btoving the woollen clothes should nearly equal that of boiling water. f See account of Fever, epidemical in Ireland daring the years 1817, 1818, 1810, by Dr. Barker and Dr. Cheyne, vol. ii. p. 360. ->7 I For the full attainment in the City of Dublin the preceding objects of prevention so deeply olving the interests and safety of all classes, l General Board of Health would propose the lowing plan, which might be adopted with the iations required by local circumstances in other ies or towns of Ireland. 11. That the city should be divided into Nine stricts j each District including certain parishes ntiguous to each other. I That these Districts should be as nearly al to each other in their number of inhabitants as they can be made, consistently with this paro chial arrangement. Thus it is proposed that the Districts and the Parishes in each District shoulc be as follows : — DISTRICT, No. 1, CONTAINING Parish. Population . St. Catherine's - - - 21,981 DISTRICT, No. "2, CONTAINING St. Nicholas without - - 12,023 St. James's - - - 0,9:27 St. Audeon's - - - 4,599 DISTRICT, No. 3, CONTAINING St. Nicholas within - - 1,845 St. John's - - - 4,351 St. Bridget's - - - 12,643 St. Patrick's Liberty - - 2,291 St. Luke's - - - 0,605 DISTRICT, No. 4, CONTAINING 28 DISTRICT, No. 5. P CONTAINING Parish. Population. St. Mark's - - - 14,811 St. Andrew's - - - 7,870 St. Werbtugh'i - - - 3,884 St. Michael's - - - 2,288 DISTRICT, No. 6, CONTAINING * St. Paul's .... 10,570 DISTRICT, No. 7, CONTAINING St. Milan's - - - 23,918 Grange Gorman ... 6,188 DISTRICT, No. 8, CONTAINING St. Mary's - - - 25,311 DISTRICT, No. 9, CONTAINING St. George's - - - 11,543 St. Thomas's - - - 16,822 Let each District have two Medical Depots, one of which may be a dispensary, where this can be obtained. These Depots to contain a supply of medicine and apparatus as specified at page 22. At each of these let two Medical Officers be in constant attendance, each during such number of hours of the day and night as circumstances may require ; to attend to the call of each applicant, to visit the sick, and afford with all possible promptitude the required means of relief. The places of these depots to be printed and posted at the • This parish cannot be added to any other district conformably with the principles of arrangement here adopted, as will appear from inspecting a map of the city. 29 corners of streets in each parish, together with advice for prevention and remedy. Let there be also for each District two or more Inspectors, for the purpose of visiting all neighbourhoods where disease is known to exist, and of acting occasionally in concert with the Parish Officers of Health, and of reporting twice in each week, or oftener if necessary, to the General Board of Health ; a list to be kept of all cases of Spasmodic Cholera occurring to the Inspectors, the number of these cases to be added to that of patients received into hospital, and reports of the total number of cases to be published in the newspapers. We would further recommend that a portion of the above proposed Medical Officers should consist of practitioners who have witnessed the disease in India, or the North of Europe, when such Officers can be obtained. By the arrangement above proposed, the Districts would be of moderate extent ; the Medical Officers could concur with the Officers of Health and Inspectors, in putting in force all measures requisite for the prevention or relief of disease, whilst each set of Officers would act as a check on the rest. For the purpose of defining exactly the limits of these Districts, and of showing the streets and lanes included within each, lithographed maps of the Districts might be prepared at a moderate expense ; or reference might be had to printed lists of the streets and lanes of Dublin, specifying the parish to which each street or lane belonged. Some 30 Sues of these lists are now in possession of the neral Board of Health, and ready for delivery, en the preceding arrangement shall be adopted. tThe Board would further propose that this mgement should not take place until it is sfactorily ascertained that Spasmodic or Maligtt Cholera has manifested itself within the city or its immediate neighbourhood ; as the experience of other places in the northern parts of Europe has showed, that the disease does not at once break out in full activity, and the preparation already made, or in forwardness in the city of Dublin, would be sufficient to meet its first onset. It would also appear desirable that the inhabitants should be recommended to adopt a system of inspection in every street, and that persons should undertake the office of Visitors, and by regular inquiry at each house, ascertain whether the preventive measures had been carried into effect. The General Board of Health would further propose, that on the first appearance of Cholera, in any particular quarter, as for example, in a village, street, or lane, the intercourse with the places where the disease prevails, should be limited in such manner as the Boards of Health have authority to do, by the 58th Geo. 111. cap. 47, until infected patients have been removed from their dwellings, and the requisite disinfecting processes fully put in practice. This, however, should be done with due regard to the feelings of the inhabitants, and continued only so long as the necessity of the case might require. 31 §Tbe following advice the Board would recomid to have printed and widely distributed on tirst appearance of Cholera in Ireland. I In proposing this advice, addressed to all classes the community, for the prevention and relief ot olera, the Board feel that the peculiar circumnces of a large portion of the lower class of >ple in Ireland oppose many difficulties in the y of its adoption. The population of this country, re especially in cities and large towns, abounds h numerous individuals in extreme poverty and titution ; in almost complete want of those main :essaries of life, food, fuel, and clothing; withthe means of providing comfortable dwellings, I from this cause congregated in small filthy rooms, where ventilation is either imperfect or unattainable ; when employment can be obtained, with wages scarcely sufficient for their support, endeavouring to procure food and pay the rent of a miserable lodging : in this, perhaps a single room of a few feet square, several individuals, males, females, children, and adults, of the same or different families, are, during the night, crowded together, many of them occupying the same bed, thus seeking by mutual contiguity to supply their want of bed covering and to obtain warmth. Much of the squalid wretchedness so frequently observable among the lower class of this country arises, with other causes, principally from the want of profitable employment ; much also from the habits of the people, more especially from intemperance ; the produce of labour being in too many instances 32 exchanged for ardent spirits ; a practice which of all others lays the most certain foundation of both want and disease, and in the present awful circumstances of society is most earnestly to be deprecated. The Board would here advert to a fact well established in the northern parts of Europe hitherto visited by Cholera, that indulgence in the use of ardent spirits greatly favoured the progress of this disease, and that its most certain victims were drunkards. In the circumstances of extreme poverty above described, much of the system of prevention becomes impracticable. Ventilation of dwellings can with difficulty be adopted by those who are in want of sufficient fuel and clothing ; and all preventive measures attended with expense, such for example as require the aid of hot water, soap, brushes, washing cloths, fumigating or disinfecting materials, are utterly beyond their reach. The Board would therefore premise, that a great part of the following advice is addressed to the class of society placed in circumstances which enable them to adopt it : but to every class they would recommend a strenuous endeavour to conform to the advice, so far as their circumstances will permit; and on the superior class of society they would strongly impress the urgent necessity of well-timed exertion to assist their poor neighbours in resisting the progress of this formidable scourge, which, in its extensive ravages over the globe, has not been confined to the obscure and indigent, but has extended from the hovel to the palace. 33 ADVICE ETHE MEAN'S TO BE ADOPTED FOR RENDERING SELLINGS HEALTH Y, AND THEREBY DIMINISHING X FROM THIS INFECTION OF CIIOLERA. Numerous causes exist either within dwellings or in their vicinity, which, although not absolutely productive of Cholera, are known to favour its progress, and to make the human system susceptible of its attack. For the purpose of obviating these causes, every class of the community should carefully attend to the following precautions. 1. Nuisances, consisting of collections of filth, or heaps of manure immediately contiguous to dwellings, more especially If evolving any offensive effluvia, should be removed as soon as possible. Depositories of filth so frequently connected with houses in Dublin, here named Cesspools, should be thoroughly cleansed, and means employed to deprive them of their odour, by having a quantity fecently burned and slacked quicklime occasionthrown into them. With the same view, all rnant pools in the neighbourhood of dwellings uld be rilled up or drained.* 12. Damp of dwellings, arising from imperfec[ of the roof or floor, should in every possible 5 be obviated. The practice so frequently (The want of Privies connected with poor lodging houses in towns, obviously contributes to the production of the most sive nuisances, and should he made the subject of Municiji.il ation. i: 34 t>pted in Ireland, of building cabins with the •r below the level of the external ground, must d to make the rooms damp and to injure health j in such cases, drains surrounding the cabin, extending downwards below the level of the floor of the dwelling, should be constructed. The mode of building a cabin with a dry floor is given with a plate in a former Report of the General Board of Health, published in the year 1822. 3. The admission of chilling currents of air into sleeping rooms during the night time, occasioned by imperfect construction or closing of the windows, more especially during severe weather, should be carefully guarded against. We are aware that in many parts of Ireland, the poor class are unprovided with windows, and we would here advert to a plan adopted by a Benevolent Society, formed in the town of Ballytore, during the prevalence of epidemic fever in the years 1817, 1818, 1819, of providing windows, and selling them at half price, thereby contributing to give to the poor, light, air, and comfort. 4. Ventilation of all dwellings should be promoted as much as possible, by opening the doors and windows during several hours of the day ; this practice is more especially requisite in apartments unprovided with a fireplace and flue. Cccasional fires, in rooms having a flue, greatly promotes a salutary renewal of the air, and renders the walls and furniture dry. 5. The crowding of dwellings should be obviated as much as can be done, as it must tend 35 I Inseminate, If not to engender disease, and it iears advisable that in towns, a system of inction should be adopted for its prevention. 6. Cleanliness of the floors and furniture of apartments should be obtained by frequent washing. The walls in many instances may be limewashed once or twice in the month with advantage ; and if Cholera should prevail, a solution of the chloride of lime, which is considered to possess some anticontagious properties, may be applied to the floors, walls, and furniture. The floors, after scraping and washing them, might, with probable advantage, be covered with a thin layer of quicklime, or lime washed on each of two or three successive days. Cleanliness of apartments and furniture, so conducive to health in general, recommends itself also on the ground that personal cleanliness can scarcely exist in a dwelling filthy and neglected. It has been proposed that the poor class should be paid for cleansing their apartments ; this proposal, which is attended with many difficulties, might in some places be tried on a small scale, under proper check and regulation, and if found beneficial, adopted more extensively. IFor the attainment of the preceding objects, abundant Supply of pure Water is requisite ; if lodging houses are to be licensed, it should on the condition of their having a supply of er near at hand. 7. Old and unwashed clothes in closets, drawers, chests, or presses should be removed and subjected 36 I washing, and care should be taken to avoid ming collections of such clothes, more especially dwellings where Cholera is present, or has 2\y existed. 18. Should Cholera prevail in this country, the abitants of all poor dwellings are earnestly ommended not to harbour strolling mendicants, n all cases of epidemic disease, such individuals c been found to convey contagion, and their aission into towns and villages should be preted by the interference of the inhabitants. Jn Indian reports on Cholera, the remark is made t " travellers seem on all occasions, to be more ioxious to its attacks than residents, and seem able of carrying with them a sort of infected )lera atmosphere." lI.— ADVICE On the measures to be adopted by individuals FOR THE PRESERVATION OF HEALTH, AND OF GUARDING AGAINST AN ATTACK OF CIIOLERA. I. The means generally known to be conducive :he preservation of health should be observed h more than ordinary strictness, in case of the learance of the Cholera in this country : Of se the principal are, X Exercise in pure and fresh air. Persons cond in impure air are most liable to its attack. I Regularity as to the hours of going to rest and ng. Night-watching and exposure to night air noticed as occasional causes of this disease, eping in the open air during the night, more 37 especially on the ground, is reported as peculiarly injurious. Temperance. It is observed that Cholera proves most fatal to the intemperate, and in a most remarkable degree to dram drinkers. The use of all kinds of food or drink, producing much excitement, as this is always followed by debility, should be avoided ; and with this view much animal or highly seasoned food, or the liberal use of tea or coffee have been considered as disposing the system for the reception of this disease. 2. All food likely to cause indigestion, vege table food imperfectly cooked, including potatoes half boiled, which, as we are informed, are used ii preference by the poor class in some parts of this country, should be avoided, and in general, every kind of diet, which by individual experience is found to disagree, especially such as produces an over lax state of the bowels. Should constipation of the bowels exist, it may be obviated by the occasional use of warm laxatives ; such as twenty grains of Rhubarb, with an ounce of Cinnamon Water, or the same quantity of Rhubarb, with five grains of Ginger, taken in a wine-glass of water, or two or three tea-spoonfuls of the Tincture of Rhubarb, with the same quantity of the Tincture of Senna, taken in a wine-glass of water, or other warm medicines of the same class j but saline purgatives, such as Epsom and Glauber Salts, should be avoided, as their use is said to have been followed by an attack of Cholera. 3. Personal cleanliness should be strictly observed, 38 and frequent washing of the hands, face, and occasionally of the body, put in practice: where it can be employed, the warm bath at a moderate temperature, little exceeding that of the human body, would no doubt prove a valuable preventive. Linen and other articles of clothing should be frequently changed, and when changes of clothing are made, care should be taken that the fresh clothing is perfectly dry ; damp clothing has been observed to give rise to an attack of Cholera, and should therefore be studiously avoided. 4. In the cold seasons of the year all persons should increase the quantity of their clothing, more especially over the stomach and bowels. We are informed that a flannel belt applied so as to surround the lower part of the trunk of the body has been recommended to be used by the British troops; a judicious precaution indicated by that extreme disorder of the digestive organs which is usually attendant on this malady ; those accustomed to such additional clothing should not suddenly lay it aside and resume a lighter dress. 5. As cold of the feet is in some constitutions productive of bowel complaints, which have been observed to predispose to or induce an attack of this disease, cold and wet of the feet should be guarded against, particularly by persons accustomed to warmth and dryness of these extremities. (5. To remain in a crowded room and suddenly to pass from this into the cold external air, is reported to be an exciting cause of Cholera ; but all 39 crowded assemblies, by bringing individuals carrying in their persons the infection of Cholera ncai to those who are uninfected, and susceptible of its attack, or into contact with them, should be shunned during the prevalence of Cholera. 17. It is a practice with many of the lower class purchase and wear second-hand clothes, and we uld here warn them of the danger of putting on icles of clothing without previous washing and rification ; we believe the exposure of such 'thes previously washed with hot water, in a ye to a heat nearly equal to that of boiling wa, to be the best mode of purification.* 18. Let all unnecessary intercourse with indiviils, either labouring under Cholera, or lately reered from it, or even with their families, be Jiously avoided. To promote the important ect of diminishing the risk of infection, patients private families should be placed in large and 1 ventilated rooms ; or if such accommodation not be obtained, sent to an hospital ; by which ceeding, all intercourse with the rest of the family will be completely intercepted. From the experience of past epidemic diseases in this country, we have little apprehension that the cautions here given will interfere with the claims of the sick on the humanity of friends, relatives, or attendants ; and it may encourage those who shall feel bound to perform the sacred duty of attend- ¦ Tho attention of Magistrates should be particularly directed 0 sale of old rat^R, which must at times be vehicles of infection. 40 ance on their suffering friends to be informed, that in many places the number of those individuals who are susceptible of this disease most probably bears but a small proportion to the total number of the whole community, and that medical and other attendants on the sick have in many places escaped its attacks. We would further remark, as an encouragement to those on whom the office of Nurses must principally devolve, that in many parts of the globe, females have appeared less liable than males to suffer from attacks of Cholera. Lastly, we would recommend such occupations as have a tendency to divert the thoughts from the apprehension of danger, and to produce a cheerful mind, toward which, in the opinion of all thinking persons, nothing can contribute more than the consolations of religion, and a firm trust in the superintending care of Divine Providence. lII.— ADVICE On the means to he adopted by private individuals PREPARATORY TO, OK AT THE COMMENCEMENT OF, AN ATTACK OF SPASMODIC CHOLERA. These may be divided into two kinds : — First, those means to be had recourse to when symptoms occur which give warning of an approaching attack. Secondly, those to be employed when the disease has assumed its confirmed form. We would premise that these means are suggested in cases only where medical assistance cannot Immediately be obtained, and in the hope that by their application the progress of this disease may in some 41 les he arrested, and are by no means put forward ,li the intention of superseding the excellent .'ice, which, in most parts of this island, can obtained from well educated and judicious praconers. 1. For the symptoms giving warning of its approach ; sense of general uneasiness, sinking of the strength, pain in the stomach, and sometimes an over lax state of the bowels; an emetic has been recommended. By what channel the contagious matter which gives rise to this disease is introduced into the system is a question involved in much obscurity ; but symptoms would lead to the inference, that its primary action was exerted on the membrane coating the internal surface of the stomach and intestines. Should the deleterious agent from which this disease originates have been introduced into the stomach, it is obvious that an emetic, administered previous to the action or absorbtion of the poison, may remove it. For this purpose, a teaspoonful, or a little more, of good finely pulverized Mustard-seed, as used in preparing mustard for the table, diffused through a tea-cupful of warm water, has been recommended as a ready means of speedily producing the act of vomiting ; and at the same time of imparting that warmth and excitement to the digestive organs, which appears opposed to a further developement of the disease: perhaps ten or fifteen grains of the powder of Ipecacuan (Hippo, as commonly called) might be combined with it, and contribute to break F 42 the chain of morbid actions on which the disease depends. 2. But premonitory symptoms are not always perceived, for the patient is sometimes struck at once with the severest symptoms of Cholera ; or the ordinary symptoms may proceed in their usual course, after the above means have been tried ; the prompt application of other remedies will therefore be required. Of these symptoms the most prominent are, coldness of the external surface, and sinking of the vital powers. To obviate which, the patient shouldbe placed in a dry and warm bed, in a warm airy room, having a fire-place with a lighted fire. The external application of dry heat is generally preferred. For this purpose common bricks (fire bricks are best,) may be heated in the fire, until their temperature exceeds that supportable by the hand but is not so great as to scorch flannel ; then wrapped in one or two folds of flannel, and placed under the bedclothes. Several of these properly disposed in different parts of the bed will soon produce an increased temperature. Bottles filled with water nearly at the boiling heat and well corked may be applied in a similar manner ; they will be less liable to leak at the cork if all air has been completely excluded. Tin cases ca refill ly made, capable of containing two or three gallons of water, and so well soldered at the joinings as not to leak when filled with boiling water, are even preferable to the Kans above proposed, but are not in all circumlces obtainable. Canvas bags filled with heated 43 sand may also be employed. Friction of the body and extremities with flannel cloths well heated may, at the same time, be had recourse to. To prevent abrasion of the skin, the parts to be rubbed may be covered with starch powder, or the hand smeared with camphorated oil. Remedies calculated to allay the vomiting and purging, and to excite the vital powers, should at the same time be employed. Among these, Opium, either solid, or in the form of the Tincture commonly called Laudanum, has obtained the general preference. In the solid form it may be given to adults in doses of from half a grain to a grain every half hour until some effect is produced, and in smaller doses varied with the age, to young persons and children. If rejected by vomiting, the dose should be repeated. Its action is more rapid in the liquid than the solid form, but it is more apt to be rejected by the stomach. When thus employed, its dose may amount to from twenty-five to thirty-five drops. Some of the essential oils, as that of Peppermint, in the quantity of two or three drops, may be combined with it, and the dose given in a small quantity, not exceeding a desert spoonful, of some fluid vehicle. At the same time hot drinks should be administered. Spirit of Hartshorn given in doses of twenty or thirty drops in a little whey every half hour, will favour the excitement of the system, and the return of the blood to the surface. Brandy, in combination with the opiate, may also be given where much coldness of the surface exists. The pills as 44 Icribed at page 22, may also be employed mid of the Opium or Laudanum alone. A (lbination of twenty-five or thirty drops of Lauuim with half a teaspoonful of Ether in a little :l water has also been employed with advantage. b quantity in which Opium or Laudanum should given according to the patient's age, may be s stated :—: — Ape. Medium Dose of Opium. Medium DoM of Laudanum. 21 Years 1^ Giain 30 Drops. 14 Do 1 Do '20 Do. 7 Do £ Do 10 Do. 3 Do 4 Do 5 Do. 4 A prudent caution has been suggested, that inflammation of the bowels be not mistaken for Cholera, and the above remedies employed with those pernicious consequences which in such case might be expected to result from their use. To guard against this error, it should be observed that inflammation of the bowels begins with a fit of shivering, and is attended by much pain, greatly increased by external pressure. These symptoms do not in general accompany Cholera. Inflammation of the bowels is also a rare disease. With these distinctions in view, there is little danger to be apprehended that a misapplication of remedies will take place. tThe above mode of treating Spasmodic Chol when its premonitory or commencing sympis occur, is proposed in order that patients who not obtain immediate medical advice may not It from the want of a prompt application of ledies. 45 I That all persons who have the means of makprovision may be prepared to meet an attack this disease, which often occurs in the night c, the following remedial means should be >t in readiness : Pills, each containing one in of Opium ; Laudanum ; Pills as directed at je 22 ; two ounces of good Ether ; two drachms of the essential oil of Peppermint ; a pint of good Brandy ; a dozen of fire bricks ; and a sufficient quantity of flannel to envelope them ; and a quantof sand, which may readily be heated in an pot ; together with a few canvas bags. We would again recommend that medical aid should be obtained with all possible expedition, and the treatment as soon as possible confided to the judicious physician. The Symptoms of Spasmodic Cholera as it has ¦t I leal< h. 63 should sec that effectual means arc provided for affording a sufficient supply of pure water to the neighbourhood, without which, most of the proposed measures of prevention will be completely frustrated. I Reports, published from time to time on the jase, in each place where Cholera has showed If, would be highly useful, by showing its pro- SB, and the effects of the means employed ; and the information thus obtained aiding the efforts hose who are engaged in its suppression. The fbling report, filled up as a specimen, to be published ?kly or daily, would give much information : Malm. Femakt. Total. Numberof patients remaining on the Ist June, 10 20 '30 do. do. since admitted to hospital, 20 SO 50 d<>. do. since found at their homes, 7 12 19 Ist Total, ... 37 G:> 99 Male*. Females. Tola!. Nnmberof patients recovered since last report, 18 .'}(> 54 Died since lust report, 19 8 20 Remaining on Brd of Juno, 15 10 25 2,1 Total, 45 ;V4 99 If the report is made with correctness, the >t and second totals should be equal. A Report of the Edinburgh Board of Health Kjust reached us (sth January, lSJ'i.) It is lished in the Edinburgh Medical and Surgical rnal for January, IS.'W. It contains valuable proposals for prevention and treatment, and deserves the attention of those who may be concerned in directing the efforts of commu- Kes visited by Epidemic Cholera, or in the 64 cure of patients attacked by this disease. Part of the advice of the Edinburgh Board, not contained in the present Report, appears particu- Ily to deserve attention. Together with other uable suggestions it is recommended, that durj the prevalence of Epidemic Cholera all persons >uld take food before they go out in the morning. iat a heating apparatus should be provided certain medical stations throughout the city ; i that the carriages for the conveyance of :ients to hospital should be so contrived as to ye as dry-heat baths, and thus to prevent the chilling effects of removal from a warm bed and a *se room, which must add to the danger attendon this disease. These suggestions are well deserving of attention. I The General Board of Health would conclude holding out the encouraging view, that the disposition to this disease, in any community the Northern parts of Europe, has not appeared be very great, especially where attention was en to preventive measures similar to those iposed in the preceding pages ; and they humbly trust, that the efforts of all classes of the fple in this country may become the instruments, he hands of Providence, either of warding off visitation of Epidemic Cholera, or of diminishits destructive consequences. FRANCIS BARKER, M.D. Secretary. APPENDIX TO 111 II SECO N 1) II EPO R T OF THE GENERAL BOARD OF HEALTH CM SPASMODIC CHOLERA Drnux, 13th January, 1832. Ice the foregoing pages were printed, the folowing Paper was received by a Member of this Board, on the 12th instant, from Dr. Lindsey. 't details cases of the Epidemic Cholera, as it ippeared at Sunderland, and corroborates the itility of Mustard Emetics, administered in an sarly stage of the disease : for these reasons, ogcther with the valuable hints contained in he Paper, it appears to deserve publication. Bs addressed to the Central Board of Health, i London, by whom it is published. rhe treatment of Cholera, particularly with reference to the use of Mustard Emetics. By Dr. Lindsey, Deputy Inspector- General of Hospitals. To the Central Board of Health. Ethe Spasmodic Cholera, so far as my observations extend, th occasional exceptions of sudden and violent seizures) pr*>by certain premonitory symptoms, of which diarrhoea is the i 66 most prominent, and I believe an invariable one, although too often overlooked, it becomes of vital importance to attend to every case of purging- that may occur, and to lose no time in arresting its progress by such means as may be best adapted to each individual case. Emetics will in most cases be found effectual. I am so fully persuaded of the good effects resulting from a prompt attention to the diarrhoea, that I rirmly believe the actual Choleric symptoms may, in a great majority of cases, be thereby averted. I could adduce several well authenticated cases in support of this opinion ; they occurred in families where a number ot persons had fallen victims to Cholera, preceded by neglected diarrhoea. By treating other members of those families for that affection the moment it occurred, (having previously directed their attention to the subject) they were, in every case of this description that came under my notice, exempted from the attacks which otherwise would have been inevitable. The fact of diarrhoea occurring as a preliminary symptom in this appalling disease is, it is much to be regretted, too generally overlooked. It is seldom reported by the patient, and it is only ascertained to have existed by minute inquiries, when it is too late to profit by this information. I beg leave to quote one melancholy example (out of many) confirmatory of my statement. The wife of a respectable person in comfortable circumstances, residing in the parish of Sunderland, was attacked with diarrhoea on the morning of Thursday, the Lsth inst. She did not apply for medical aid, nor take any medicine, but pursued her usual occupation, and went to the market on Saturday evening. On Sunday morning, about two o'clock, she was seized with vomiting, purging, and cramps. I saw this person at half-past one, p. m. on the same day, with my friend, Dr. Brown, of Sunderland. She had been bled previously to our arrival ; we found her suffering severely from cramps ; she was pulseless, cold, and in a state oi extreme collapse. A mustard emetic was given immediately, which did not produce any good effect, and she died aboul five o'clock in the evening. On this case I conceive it unnecessary to make any comment, as the deduction is too obvious to require it. Whilst tit Sunderland and at Newcastle I endeavoured to impress on thfi unfortunate people, who wore exposed to the Insp, tin 1 necessity of medical advice being afforded *»t thf» ni'iit they felt any ot the preliminary Bymptoms, ami I hail satisfaction of knowing th.it my counsel was in many instances tided to. My friends, Dr. M'Cann nnd Mr. Melin, wore also most stn'imous in directing their attention to the same object, in which Dr. Brown, one of the leading physicians in Sunderland, most fully concurred, as also Mr. Frost, a very intelligent practitioner at Newcastle, who assured Mr. Melin and myself, that by carefully attending to his cases of Diarrhoea he had comparatively but few cases of Cholera in his district. I hope it will not be thought that I have dwelt at too great th on this point, which the importance I attach to it, has imeptibly led me to do. I rarely occurred at Sunderland that medical aid was applied until several hours had elapsed from the commencement ol attack. The seizures generally took place about 2 o'clock in morning, nnd they were probably not visited before 8 or mid often ut v much later period. It is worthy of remark th.' deaths for the most part occurred about 5 o'clock in the ling. Is the poor cannot be treated in their own habitations with any pect of recovery, or with safety to the medical attendant, it ost desirable to adopt such measures as may tend to remove • existing prejudices, and to induce them to view the hospital ie only place where they can have the necessary comforts, proper medical assistance. It is above idl things essential nsure the early reporting of the cases, which has hitherto i most lamentably neglected by the poor of Sunderland. Khis will, no doubt, be a difficult task, and can only be niplished by judicious sanative regulations, rigidly carried effect. On my arrival at Sunderland, I suggested a trial of a mustard emetic in the early stage of the disease, as I had formed a favourable opinion of the effect of emetics in Spasmodic Cholera, and it occurred to me that mustard, from its stimulant qualities, seemed likely to be the most useful of this class of remedies. I found it had been recommended by Dr. Gibson before my arrival, but that it had not been put into practice by any of the 07 68 liical men there. I soon had an opportunity of trying its M:s in an incipient case of Cholera ; the result in this cast u:ed me to prescribe it in other cases of an aggravate) ire, of which the following may suffice to prove the efficacy le remedy in giving an impulse to the heart and arteries, am ging the diaphragm into full and vigorous action in the y stage of the disease, and before the stomach has lost its I!a8I I. — 10th December, 1831 — Timothy WardelJ vet. 43 — ding in a house in Mill-street, where some persons had died -Spasmodic Cholera, says he had been afflicted with diarrhoeasome days, and with giddiness in the head; complains of i in the epigastrium, accompanied with heat, and inclination omit ; has this morning had numerous gruelly-looking stools ; eB4 and weak ; skin cool ; countenance anxious ; and he is a c deaf. Kniiit. pro Bmetico Misturam c. Sinap. pulv. Drachinis dual* us uae tepidss Unciis sex : et repetatur si opus sit. tp. m. Full vomiting was produced by the mustard emetic, the second dose of the mixture. A teaspoonfull of the ! mixture was given every ten minutes for two hours, as a sible stimulus; has had a copious bilious evacuation, and id some urine; is now in a profuse perspiration. ¦Ith December, 11 A.M. — This man is free from any complaint a certain decree of debility. B. B. Dr. Monies of Edinburgh, who was indefatigable in iring information in the disease, attended this case with me. lase II. — 14th December, 1831 — Quarter before 3p. M. — liaiu Tate .net. 59 — admitted into the hospital; was taken ill i o'clock this morning with vomiting and purging, and at 4 ick was seized with cramps in the legs and abdomen, which 1 continued with violence up to tlxis hour ; was seen by Mr. in and myself about twenty minutes ago, previous to being reed to the hospital, in the act of vomiting, and the fluid (which characteristic of the disease) was ejected in large quantity, considerable force, as if squirted from a syringe. At present ulse ; tongue very moist, and colder than natural ; epigasii tender on pressure; skin cold and damp; countenance en, ghastly, and strongly marked; has passed no urine since 69 the attack; two drachms of brown* mustard in four ounces vi' water to be given immediately. 3 i\ m. — Full vomiting produced by the mustard emetic, with restoration of the pul-e, which is now about HO and soft; countenance less anxious, and lips of natural colour. Quarter-past 3r. M. — Return of cramps in the legl with extreme violence, with cessation of the pulse; mustard emetic repented. Half-past 3 P.M. — Full vomiting again produced, with immediate restoration of pulse ; 4 P. M. — Has just had a copious fluid evacuation from the bowels, manifestly containing feculent matter, and passed some urine ; pulse about 90, soft and compressible. 5p.M. — Has taken the solution of mustard; a desert-spoonful every hour ; vomited only once ; is now better in every respect ; had no cramps since 4 o'clock ; feels comfortable ; skin moderately warm ; pulse 80, and soft. BP. m. — Has had a return of the cramps in the legs, but no vomiting- or purging ; skin not so warm as at last visit ; pulse not so full ; had had some sleep, and is now free from pain. To have ten grains of calomel and forty drops of tinct. opii. 15th December, 11 A.M. — Pulse 80, soft and full, countenance much more natural, skin natural, no coldness of the extremities, had some sleep. Had cramps during the night, no return of the vomiting; has had two copious stools, and passed some urine — is this moment free from any uneasiness ; a slight confusion of the head, and some tenderness of the epigastrium on pressure ; tongue dry and rough in the centre, but moist at the edges. ]£, Liq. Ammon Acetat, Uncias duas. Aq. pur. Uncias sex. M. A wine-glassfull to be taken every hour. 19th. — This man had no return of Choleric symptoms, but fell into the consecutive fever of a low type, and the last two days the head became sensibly affected ; yesterday he was bled freely from the arm, which at first relieved the head, but he soon again became comatose, and died this morning. He had received a wound in the head some years ago, and had been since very liable to various distressing affection! from it, and at times symptoms of epilepsy occurred. The preceding case was attended by Dr. M'Cann and myself. ? Much of the Bulphur.coloured Flour of Mustard which i? on ule ij very inert] (hat which has a greenish brown tings should bu inefrrml— Editurt. 70 Cask 111. — On the nighi of the 15th December, al II o'clock, niv friend Dr. Brown took me to see Mrs. X., residing in h wretched hovel, in Stob-lane; she had been ill about twenty hours. We found hei in a state of extreme collapse — the pulse was imperceptible, tongue cold, moist, and whitish; skin cold, damp, and livid; countenance much sunken; she was vomiting imperfectly, and passing stools involuntarily. Although Dr. Brown and 1 thought it likely the stomach had lost its vitality, and that, the case was hopeless, we administered a mustard emetic, conceiving it to be the only chance left of producing reaction. The emetic caused full vomiting, with immediate restoration of the pulse, which Dr. Brown counted at 5)0 — a small quantity of brandy and water was then given, and repeated occasionly during the night. I have just received the following letter from Dr Brown, which contains an accurate account of the case up to its termination : Sunderlandf January 2, 18.32. My Dkak Nik, — You will recollect that it was on the night of December 15, that a mustard emetic was given to the woman Kenuen, and that the effect of restoring the pulse, which was previously imperceptible, wus produced. On the 16th the vomiting still continued at intervals, and she, remained low and sunk ; but the urinary secretion was restored, and focal stools took place. Pills, with calomel and a small proportion of opium, a cordial mixture with some magnesia, and a blister to the epigastrium, wore the remedies this day. Her state remained nearly unchanged throughout the 17th, ami the same medicines were continued. On the 18th the febrile stage was fully formed ; she lay indifferent to what was passing around her, excepting when roused by questions; the tongue was dry, with a disposition to become furred; there was no vomiting, the urinary secretion continued free, and the motions bilious. The opium was omitted from the pills, which were continued with a mixture simply containing calcined magnesia; mere diluents as diet. 10. State continued the same, with increase of stupor and indifference; vessels of the sclerotic a much injected.