PATHOLOGY AND TREATMENT ASIATIC CHOLEEA, SO CALLED. BY A. L. COX, M.D. .Seconlj Edition. NEW YORK: JOHN WILEY, 161 BROADWAY. 1849. PRICE TWENTY-FIVE CENTS. TH E PATHOLOGY AND TREATMENT O F ASIATIC CHOLERA, SO CALLED. B Y A. L. COX, M.D. •SramlJ^lSljttton. NEW YORK: JOHN WILEY, 161 BROADWAY 1849. Entered, according to Act of Congress, in the year J849, by A. L. COX, M.D. in the Clerk's Office of the District Court of the Southern District of New York. R. CRAIGHEAD, PRINTER, 112 FULTON STREET. T. B. SMITH, STEREOTYPER, 216 WILLIAM STREET. TO HORACE GREEN, M.D., SE^tse pages are matrifcctr, AS A TESTIMONY OF RESPECT FOR professional abtlity 'and PERSONAL WORTH, BY HIS FRIEND, THE AUTHOR. PREFACE TO THE SECOND EDITION. In presenting to his profession and the public a second edition of this little work on the prevailing Epidemic, Diarrhoea, and Collapse, the writer may be permitted to express his gratification that what was prepared chiefly for his patients and friends has been received with approbation by a circle of readers so much larger. It has also added to his pleasure to find so many unexpected supporters in the number of his medical brethren, both among those who " have always pursued this practice," and others, who with a candor and generosity he fully appreciates, have given the principles contained in this work, though new to them, their cordial approbation. In this latter class he takes pleasure in reckoning some whose names, if names were wanting to add force to truth, would be to him a tower of strength. With the hope of making this treatise more worthy of the favor it has received, he has introduced some cases which have occurred in the present epidemic, which he thinks interesting, and calculated to illustrate important pathological views, with such other matter as he has judged essential to the fuller development of the principles he has designed to communicate. He still feels that from want of leisure he has fallen far short of doing full justice either to himself or the subject. JVo. 8 Union Place, JVew York, July 27tA, 1849. PREFACE TO THE FIRST EDITION. In the months of April, May, and June, 1832, the writer of the following pages, being invited at various times by other practitioners, was enabled to see and to study the cases of Cholera which began even then to occur in the practice of some gentlemen in this city, whose duty led them more to the haunts of poverty than to the abodes of affluence. These gentlemen reported their cases as they took place, but complained of being harshly dealt with by those in civic authority, to whom the law obliged them to make the communication. The truth of their reports was openly denied until the Ist July, when the occurrence of some fifty cases rendered it impossible any longer to disguise the fact of the existence of the epidemic. Much censure was attached to the young physicians, who were said to have created the alarm from interested motives ; but it gives the writer great pleasure to be able to say that in one of the destitute families he then visited, he was informed by an aged and widowed mother, who in her poverty was doomed to witness the awful death by collapse of two daughters — her only dependence — that, for the forty-eight hours of their illness, the sole support of the family was derived from the benevolence of the " young physician" who attended on them, who also rendered his professional services without reward. One is induced to ask if even a single case of such unpretending benevolence might not inspire the public, and the press particularly, with more regard for the feelings of this very class of men, who, without remuneration of any kind, take the whole charge of the sick poor, and whose usefulness may bear a comparison with that of any other class in the community. During the entire period of its prevalence here, even during the time that its existence was strenuously denied, the writer had ample opportunities of studying, and he honestly thinks of ascertaining the nature of this disease, as well as the true principles of its cure. At least, he had seen no cause to change his views in regard to the principles here laid down and defended, more especially as the treatment which it is his purpose to advocate, and which any one may understand and bring into use on an emergency, was not only PREFACE. V 111 unifoiraly successful in his own immediate practice, comprising several hundred cases in the two former epidemics, but was the means of signally arresting the fatality of the disease far more extensively in a neighboring republic. So much said may serve to explain, if indeed any explanation were needed in a matter of such deep import to the general weal, why he has consented to the solicitations of his patients generally, as well as of many others, both in his own profession and out of it, immediately to prepare for the press, to do what good it might, this little treatise, which for many months has been lying by him partly written, in anticipation of the epidemic which has now come. His only regret is that all the leisure he could possibly command was so much less than he could have desired for such a purpose, that he fears that the truth which he wishes to promulgate may suffer from the want of that careful revision and proper arrangement which he can hardly expect of himself, especially when the hourly and engrossing cares of his profession have obliged him to find time generally after midnight to accomplish the otherwise light task which he has imposed upon himself in the preparation of these pages. THE EPIDEMIC. The terrible mortality marking the pathway of the pestilence, which has wasted the human family since its recent origin at Jessore, near Calcutta, in the year 1817, as well as the utter uncertainty of its treatment, both in result and principle, which has been exhibited by the generality of writers, renders the attempt to clear up the mystery of its pathology and treatment a very discouraging undertaking. Unless it can be proved that errors, capable of correction, exist in the impressions which are entertained of its nature, or that the practitioner can be furnished with rules of practice more in accordance with a true pathology than has hitherto been done, little advantage can be derived from further labors, however an author may benefit his reputation for learning or impress his reader with his ingenuity or ability. But the unspeakable importance of the subject to human life would suggest, that without the purer and higher motive of doinggood by explaining the character of the disease and adding information on the subject of its treatment, by correcting an error or promoting a useful investigation, it is hardly justifiable to add another to the many essays Avith which the profession of medicine and the public have been already furnished. It is the design of this communication to give the impressions derived from a careful observation of two epidemics, to state the author's views of the nature and treatment of the disease, and 2 to endeavor to correct certain errors which prevail, both in regard to its pathology and therapeutics. If his views should be charged with novelty, they are, perhaps, not the less true ; and he is entirely confident that he is actuated by no vain desire of signalizing any supposed originality, but simply of promoting truth on a subject of immense interest to his fellow men, because he sincerely believes that the principles he defends are intrinsically right, and of deep importance to the cause of humanity and medical science. Confining these remarks, then, principally to positive observation, it must be premised that little actual light has been derived from the voluminous publications with which the medical press has teemed on this subject, and that the diligent student is forced to the conclusion that the disorder is not clearly understood, and the treatment is generally, therefore, to a great extent, uncertain and empirical. If these observations are correct, they at once furnish a reason for the astonishing mortality of the epidemic, and an apology for attempting to supply a pathological and therapeutical view more conformed to rational principles than has been attempted, and more adapted to the necessities of human nature, suffering under the most deadly scourge of pestilence. It was in August, 1822, during a residence in a hospital in Philadelphia, that the writer first heard from a surgeon in the American navy, a description of this terrible disease as he had observed it in India. His account agreed exactly with those which have since been before the public in every medical journal, pamphlet, lecture, or daily paper throughout the country and the world. He described the attack as instantaneous. The patient being in usual previous health, in one moment was prostrated with vomiting and purging, not of the common contents of the stomach and bowels, but of a substance like rice water, attended with immense prostration and fainting — the face becoming discolored with lividness, the surface 3 cold as ice, the voice hoarse, the eyes sunk, the features contracted, the expression of countenance cadaverous and horrid, the whole body collapsed, and the fingers corrugated as if soaked in water or parboiled, the urine deficient, with an entire absence of bile.; while the patient, feeling like ice to others, complained of excessive heat and intense and burning thirst. During these rapid changes violent cramps of all the muscles came on, adding unutterable torture to the wretched patient, death in a very few hours being his only relief. In respect to the treatment he declared that it was all useless, and acknowledged that in the cases of recovery it was impossible to say whether this happy result was the effect of treatment, or whether it happened in spite of it, and as a rare occurrence attributable to the constitution of the patient, or some peculiarity in the nature of his attack. He declared that to be seized with the disease was usually to be destroyed by it. He described it as a cholera morbus, but more severe and very different in intensity from the most violent form of our indigenous disease. The gentleman who gave this account of the disease won from his audience, consisting of some eight or ten medical men, the character of an exaggerating traveller. His story was not believed, and could not be realized by those who had never seen in a vast multitude of diseases, which in that Institution came under their notice, anything at all resembling so strange a complaint. It was like Bruce the traveller's account of the Giraffe to his countrymen, or Sir Walter Raleigh's story of Eldorado, previous to the recent golden discoveries in California. How much truth was contained in the story, and how frequently are the first discoverers rewarded with incredulity, if not with contempt and persecution for the very veracity with which they state the facts of which they are the sole witnesses ! 4 THE DIARRHOEA, ABSURDLY CALLED " PREMONITORY SYMPTOMS." In every medical journal since, the unvarying testimony of all writers corroborates this account of an attack of Cholera ; and up to the year 1832 no author had taken any adequate notice of the diarrhoea, which is now known to precede these symptoms, until the attention of the profession and the public was called to it by Dr. Kirk, a Scottish physician of great respectability, who, in his excellent essay, designated this particular feature of the disease as " the premonitory symptoms." So inveterately fixed at that time upon the public and professional mind was the idea of the sudden and mysterious onset of the disease, that if Dr. Kirk had used a more correct designation than he did, it is more than probable he would not have been listened to at all. The immediate effect of his pamphlet on the Asiatic Cholera was to induce attention to that symptom, and this was a great point gained in the observation of the disease. But it requires only a moment's reflection to see that this name is unphilosophical and incorrect. Conveying an idea more true than the view it superseded, it has yet contributed in no small degree to confuse the mind and retard its progress in the investigation of the nature and treatment of the epidemic. In a measure, indeed, it has perpetuated the very error which then prevailed on the subject. For if a symptom be present, that symptom, being a deviation from health, is disease. The disease is therefore present, and the symptom is not premonitory. To reflect a moment, then, no greater contradiction in language can exist than a " premonitory symptom." If it is a symptom, where is the premonition ? It is the disease itself in its first symptom. The patient by this misnomer is induced, however, to think that he is not laboring under the epidemic, but that he has about him some manifestation of approaching danger — a premonition, a sort of physical prophecy of coming disease, but not the disease r> itself. This expression of the strongest possible conviction of the true state of the fact should not be regarded as a caricature of the opinions of one whom a sense of respect as a public benefactor should protect from an unseemly and rude assault. Properly understood, however, it cannot be thus regarded. The great difficulty of investigating such a subject as the nature of an epidemic, is frankly confessed. There is a feeling of panic pervading the public mind. The general impression with every one is, that he may be the very next victim. The prominent subject before his mind is not one easily subjected to cool and scientific inquiry : it is shrouded in mystery. The observer is more struck with astonishment at the apparent impossibility of what he sees, than with the points of analogy. If such men as Hunter and Cooper, Abernethy and Liston, could permit the deformity of club-foot to go from infancy to age, without attempting relief by the extremely simple and palpable means by which that deformity is now known universally to be cured, is it strange that in the moment of fearful terror of the pestilence, men should fail to observe facts as palpable and apparent in the pathology of the changes which it is destined to effect in the system of its victim ? Again, Dr. Kirk himself was laboring under the malign influence of a bad nomenclature, and although people sometimes contend that there is not much in a name, so that principles and facts are admitted, it is certainly true that nothing so completely clouds the understanding in the investigation of natural science, as the use of false names, while on the other hand, the greatest advantage is gained to the study of truth by a lucid and correct use of words. The false employment of a name had obscured the fact of the diarrhoea. Dr. Kirk has the great merit of establishing the fact, even if his designation of it was somewhat defective. It is, therefore, with no feeling of severity or spirit of censure, that the attempt is made thus strongly to draw the line between error and truth. To conclude, then, what is most unphilosophically called 6 the " premonitory symptom," is truly the first symptom of the disease ; and it will be found to be the ruling symptom, or, in other words, the disease itself. In support of this view, let us refer to the cases which happened on board of the vessel from Havre, which, during the last autumn, introduced the disease into New Orleans. The cases were thought to be a dysentery or diarrhcea, and were treated as such, but the patients uniformly perished under the use of a dose of purgative medicine. So with the account of Captain Nye, of the " New York," the vessel which brought emigrants from the same city in France. They sickened off the northern part of our own coast. Every one of the sick was treated with calomel and ipecacuanha, and every one of them died — purged to death. These accounts, when the parties giving them had no preconceived idea of the disease, in both instances, represented the case as a bowel complaint ; in other words, taking the view of Dr. Kirk, they were the " premonitory symptoms ;" but in fact, the whole disease, including what this writer calls the " premonitory symptoms," — really the incipient stage of the disorder, — and the subsequent or dying symptoms, usually called the " cholera," taken together, are truly the epidemic which has now again reached our shores. There is certainly not so much reason to regard the last violent, extraordinary, and incurable symptoms, usually called " cholera," as the disease produced by this epidemic, as there would be to consider the simple purging alone, and of itself, as that disease ; for if the purging always either precedes or accompanies the other and more horrible symptoms, then it is the disease as much as any other attending symptom. But in truth the disease consists of all its symptoms. It then follows that the purging is a symptom of the disorder, and not a mere premonition of it. In the end, however, to use a repetition, it is the grand and ruling symptom, upon the character and treatment of which depends not only every succeeding symptom, but also the final result. 7 THE DISEASE IS REALLY A DIARRHOEA. The word chosen to designate the epidemic is also a misnomer. It is derived from two Greek words signifying, the one, " to flow" and the other, " bile," and means, therefore, a discharge of bile. This disease, which, for a time, was thought to have been unknown even in India, previous to its late appearance in 1817, has since been found to have prevailed several times in that country in the last century. Different epidemics have been recorded "by Bontius in 1642, and Dillon in 1685. The histories of the epidemics of 1756, 1759, 1781, and 1782, have been given by Father Jean Baptiste, a Jesuit, and by two Bengalese physicians, Messrs. Wise and Corbyn." Vide Scouttetten, p. 7. The description of Bontius seems more like the real Cholera which is indigenous in our own country — a bilious disease ; but the others give a description which cannot be mistaken, being identical with the present epidemic. Somewhere it is stated that this disease prevailed at Pondicherry in Southern India, early in the last century, while that country was under the French. Their name was mort de chien, a much better designation than that which we have adopted from the British in India. The French regarded the symptoms now universally called Cholera, as the death symptoms — a dog's death — mort de chien ; and truly the great mistake of the British physicians in India has been to omit absolutely to notice the disease proper — the diarrhoea — and to describe the symptoms of death as the true disease. The name of the French shows conclusively that they never regarded it as a cholera. THE INDIGENOUS DISEASE OF OUR COUNTRY IS TRULY DESIGNATED CHOLERA. It happens in this case, unlike that of our indigenous cholera, that 8 there is a striking" deficiency instead of a redundance of bile in the discharges. In the common cholera of this country there is found a case of real flowing of bile. The disease affects the liver as well as the stomach. The latter organ is disturbed with excessive and perverted action, by Avhich its contents are thrown up with terrible violence, Avhile the liver displays the excitement to which it is subjected by an immense augmentation of its secretion — the bile. The common cholera of our country commences in the stomach, with malaise at the epigastrium, pain, and nausea, which precede a violent vomiting. Then come on copious dejections from the bowels, first of the usual faecal matters, then of bile — immense discharges of that secretion. In addition to these symptoms, violent agony in the stomach and small intestines exists. TRUE CHOLERA CONTRASTED WITH THE EPIDEMIC DIARRIKEA. Not so in the Asiatic disease, most commonly called by the same name. This disease commences in the intestines, as is proved by its history. Nausea, which indicates disturbance of the stomach, is not the first symptom in a case of the Asiatic cholera, strongly pronounced ; neither is pain. It is true, nausea and pain may both be, by accident, present, but they are not essential to the existence of the disease, and generally they are not the earlier symptoms of it even as accidents. The patient is first attacked with a looseness, unaccompanied with pain, which he therefore disregards. The first discharges are of the usual faecal matters : these are soon followed by thinner dejections, then large fluid passages succeed. In a longer or shorter time, pure fluid, of a light straw color, containing flakes of floating mucus, the secretion of the muciparous glandulse of the intestines, is discharged in large quantities, with surging violence. Sometimes a gallon passes away at once. Still there is often no nausea. The strong dissimilarity of the first symptoms of these two 9 diseases seems to establish the want of identity. They are surely different diseases. Hence many ephemeral works, which have given accounts of different epidemics of " cholera morbus," have served only to mislead and confuse the inquiry into this most important subject. TRUE CHARACTER OF THE EPIDEMIC. Having endeavored to show that the epidemic is not a " cholera," and that its first symptoms are not premonitory, but present, let us proceed to establish its true character by arguments derived from known and incontestable facts — a point which could not have been approached successfully until it was first shown that the disease is badly named, and that its primary symptoms should no more be regarded as " premonitory" than the first symptoms of any other disease are entitled to be considered as no part of that disease, but only premonitory of it. Scouttetten, in his " Medical and Topographical History of the Cholera Morbus," &c, page 23 (Boston Edition), describes the disease in these words : " The symptoms are as folloAvs : a lively heat in the region of the stomach — vomitings and dejections of bilious, greenish, and greyish matters, or of a liquid resembling rice water ; sometimes this fluid, is green or dark, like an infusion of tea, and always has an acid smell — at the same time very violent and excruciating pains in the region of the epigastrium and in the abdomen, which is tense, and very painful on pressure — violent pains in the head — the pulse is small, feeble, quick, frequent, and often scarcely perceptible — depression of mind, stupor — the countenance is haggard — the eyes are first brilliant, sunken, then moist and injected, sometimes covered with a thick serum resembling a pellicle. The surface of the tongue is red ; there is a burning thirst. With these formidable phenomena, the limbs contract — the cramps of the fingers and toes ad- 1* 10 vance gradually from the extremities to the trunk, and there is frequently delirium and convulsions — the urine is scanty and turbid, and when the disease is violent it is generally suppressed. " The most violent symptoms continue to afflict the patient, until his strength fails. -In the latter period of the disease the vomitings and spasms cease, from the complete exhaustion of the physical powers. The patient, however, often experiences great relief, and may live a long time in this state ; his mind continues vigorous, while all the functions of the body are suspended. "In the most severe cases, and in weak and badly nourished subjects, death supervenes without any spasms, and without any derangement of the mental faculties ; but the patient is astonishingly indifferent in regard to himself. In vigorous subjects, on the contrary, the spasms are extremely violent — some patients have required six men to hold them. " The cholera sometimes supervenes suddenly, without any precursory symptoms. More frequently, however, it shows itself after the subject has complained for one or two days of disgust for food, bitterness in the mouth, and thirst. To an experienced physician, the countenance often announces a proximate attack before the patient is sensible of any change in his appearance or feelings. His countenance appears unusually fatigued, and his whole external appearance is that of anxiety. The disease most frequently commences in the night, between two and five o'clock. "The duration of the cholera is from one or more hours to one or more days. It rarely continues longer than the seventh. "When, the disease is arrested, the pulse improves, there is a desire for sleep, the patient becomes calm, and is completely well in a few days. "In some subjects, however, debilitated by a previous disease, the convalescence is often long and tedious." This quotation of the whole description of the disease by this author is made with the remark that he begins at a period long after its commencement, as is easily proved by reference to the fact of his 11 description of the discharges of a fluid "resembling rice water." Now it is manifestly impossible that " rice water discharges " can occur until considerable evacuations have preceded them, sufficient to wash away and entirely cleanse the intestines of their usual feculent contents. For suppose the " rice water discharges " to begin, is it not evident that as long as the natural contents of the bowels are present, they, too, will be discharged ? It is apparent, then, that this author, like many others, has disregarded in his description the primary symptoms. Hence he says :" at the same time very violent and excruciating pains in the region of the epigastrium and the abdomen come on ;" and goes on to associate all the symptoms together, without much respect to the order of sequence, insomuch that one is obliged to regard his information as second-hand, and to suppose that he does not really describe the case from his own observation. CHARACTER OF THE FORMER EPIDEMICS IN NEW YORK. During the prevalence of the disease in 1832 and 1834 in this city, both in the public hospitals and in private practice, there was nothing to enable the observer to recognise the accuracy of description which is expected from so learned and eminent a writer. Let us now enumerate the symptoms as they occurred in those epidemics. Usually a diarrhoea, unaccompanied with pain, and hence often unnoticed, or rather disregarded, came on, varying in its duration, according to its activity, from a few hours to several days, until it had entirely cleansed the intestines of their usual faecal contents, when the " rice water passages " were observed. At this time the fluid discharged became more profuse. The debility of the patient was greater, but often, even after the loss of a gallon of this fluid, the patient seemed indifferent and fearless of results, not having experienced the least pain. It is true that at this moment he was in reality on the verge of collapse. But he would entertain no appre- 12 hension of danger, and as his experience seemed so entirely different from the symptoms he had heard as characterizing the disease, he could not persuade himself that he was in danger. Here we may see the evil of making the fatal distinction between " premonitory symptoms " and the disease itself. Under such circumstances, he would naturally conclude " that he had not the cholera. He neither vomits nor feels pain, he feels well, and, at any rate, has only the ' premonitory symptoms.' " In a short time another discharge happen — it is larger and more violent — it passes with a furious effort — it is irresistible — he feels less vigorous, makes an effort to assure his strength — determines that he will not give vp — but soon a slight nausea, and an attempt to vomit, take, place — sometimes the quantity is small — it may be what he has taken into his stomach last — ov it may be pure water — or else a very copious discharge of the same clear fluid as passes from the bowels. Cramps now suddenly develop themselves. His eye sinks rapidly into its orbit. It would seem that the whole mass of fat in which that organ is imbedded had by magic been removed. The ball itself has lost its lustre. It appears no longer to be an orb of brilliant beauty, full of energy, life, and intelligence ; it is revealed as a sack not filled with fluid — its lustre and expression fly. The eye seems, in fact, as if sunk into the orbit, so that the orbit looks like an auger-hole in the head. The alse nasi are compressed together. The nose is pinched — the lips are contracte — the hue of the face is first leaden, then livid, then of a dark, deep bluish color. The skin looks soaked, or sodden, or parboiled. The abdomen contracts, and almost disappears ; the abdominal muscles seem to cling to the spine and posterior walls of their cavity, as if they had no contents, so that, in some instances, the diameter of the abdomen in the direction from before backward, seems to be not more than two inches. The skin of the finger ends is corrugated, as if long soaked in hot water, like that of a washerwoman. The surface of the body is cold. The pulse becomes frequent and small, and Ultimately stops beating, The respiration continues with effort, and 13 the ribs heave. The cramps subside, but the heart stops its action entirely, so that no pulsation can be heard, even by the ear closely pressed to the chest of the patient ; yet respiration continues laborious, and the breath is icy cold. Deep coma comes on, and, in children, the eyes are turned up, and in them strabismus and symptoms like phrenitis are observed. At any rate, at this period there is generally in their cases considerable cerebral disturbance. The patient is tormented with thirst, and complains of burning heat of his surface, while that surface feels like ice to his nurse. The pupils of the eyes are usually contracted to the minutest point. Death is the next symptom. In all this series of symptoms, it is impossible to recognise anything but the act of dying as the consequence of the terrible depletion produced by previous discharges from the bowels. THE DISCHARGES CONSIST OF THE FLUID PART OF THE BLOOD. In order to render intelligible the very peculiar occurrences of this form of disease, it is essential to keep in mind that the original symptom is nothing more than a discharge of fluid in immense quantities from the bowels. In fact, it is a copious haemorrhage of the fluid parts of the circulating mass. That this discharge is derived from the blood-vessels of the intestines is indisputable, when we reflect that the bodies of those who have died of cholera, and have had no partial relief from treatment and drinks, present the extraordinary peculiarity of being without fluid ; nothing remains in the small vessels but the thick parts of the blood. Frequently, mere clots or coagula in the larger vessels, and dark grumous blood in the smaller ones. 14 COLLAPSE. Collapse is a word whose etymology proclaims its specific and mechanical signification. It is familiarly used in reference to steam apparatus. Where the vapor of water is suddenly condensed by cold, the vessel, whether boiler or pipe, which contains it, is said to undergo collapse. The meaning of this is simply that the steam being condensed, as there would be a vacuum in the cavity of the vessel but for the pressure of the atmosphere, which instantly compresses its sides together, so this falling together, or collapse of the sides of the vessel, takes place immediately on the condensation of the vapor within. Perhaps this explanation may not be generally necessary, but there are undoubtedly some readers, of intelligence too, whose views would be indistinct without a clear understanding of the origin and use of the word as it is applied in other departments than medicine. Collapse in Cholera may be regarded by some as a mere figure of s])eech, but it is literally true that the vessels do positively collapse from loss of their fluid parts, precisely as in mechanics a tube exhausted of air undergoes the same process. The collapse of innumerable small vessels, which compose the human form, occasions what is called collapse of the soft parts of the whole person. Certainly this is the best chosen word in the whole vocabulary of the Epidemic. The French phrase, " mort de chien," signifies just what we mean by collapse. It is the dying stage. The disease proper has passed and the process of death has commenced. A diarrhoea has existed and it has accomplished its direct work ; it has carried away the water of the circulation. The body has become a living mummy. It is exsiccated. Nothing is left but the solid parts which cannot flow off. 15 Collapse is a word introduced by the Anglo-Indian physicians after the adoption of the word Cholera. This seems to indicate their own sense of the necessity of another word to convey a true idea of the disease. If the case had been a real Cholera, or vomiting and purging of bile, there would have been no occasion of adding another word to the nomenclature of the epidemic. The fact is, they had left the diarrhoea eiftirely unnoticed, and,- therefore, the adoption of the term collapse is in effect the substitution of another, and a correct designation of the last symptoms of the disease which they had most erroneously called Cholera. Collapse is recognised by the shrivelled and cold skin, cold tongue, cold breath, blue surface, icy sweats, coma and contraction of the pupils, suppression of bile, of urine, and of all. secretion of animal heat. Nature has set up certain actions, as if to restore the natural operations which have ceased. She contracts all the tubes and organs which formerly contained the now lost fluid, as if it were possible, by diminishing the container, to suit its capacity to the contents. The muscular system aids the contractile efforts by convulsive actions, and sometimes these operations are so successful that if only a little fluid remain, the circulation returns. So that a number of recoveries have taken jilace, even from the coffin and the bier, which shows the gross impropriety of hurrying the body to the grave before there is positive proof of death. The test proposed of applying scalding water to the skin, in small patches, and observing whether a blister, or blush, or other sign of life exists, is therefore worthy of trial, but not to the exclusion of the much better one of waiting a little time. Time, which is often in other cases the best test of truth, is here also to be preferred, and humanity shudders at the horrible catastrophe of a living sepulture. No disease is more likely to have recoveries after apparent death than this, and the bodies of the dead can easily and safely be kept a day or two, even in hot weather, owing to the great cleanliness of 16 the corpse as well as to the dryness of tlie whole body. Decomposition is in no other case so tardy in its approach. When collapse commences it is ushered in with nausea, for the intestinal tube has become irritated through its Avhole extent, and the stomach begins to sympathize completely ; then the respiration ceases to produce warmth, the skin changes its color, and the symptoms of approaching death are present. The diarrhoea which precedes the collapse, and the collapse which succeeds the diarrhoea, thus appear to constitute the whole disease. How useless, then, are the terms " jjremonitory symptoms" and " cholera" to express the true idea of the different periods of this epidemic. The whole disease is comprehended in these words, diarrhoea and collapse ! TWO STAGES OF COLLAPSE. Collapse may be properly regarded as consisting of two stages. The first stage continues from the earliest appearance of the symptoms which describe it, until the blood has had time to coagulate. During this time, although the collapse may be complete, yet there exists a possibility of the patient's recovery. In fact cases often recover. The second stage comes on with the formation of coagula, and in addition to the symptoms described in the first stage, it is marked by a peculiar, imperfect, and feeble action of the heart, and by the gradual cessation of pulsation in the minute arteries of the head and extremities. This absence of pulsation extends towards the heart, until that organ also ceases all motion. In the second stage of collapse recovery is impossible because of the existence of the clot. Respiration still continues. Nor is the heart's inaction positive evidence of coagulation, for cases of rapid recovery have taken place after this event, a circumstance which forbids the idea of the blood having coagulated. 17 COLLAPSE WITHOUT DIARRHCEA. Some cases, indeed, are confidently reported as not having been preceded with a diarrhoea. The writer has met with several of this sort. One, in which he was in consultation with Dr. Cockie, a gentleman in Lexington Avenue, was stated to have had no diarrhoea. This statement was made by a sister, a respectable and highly intelligent lady, who was positively sure and is still certain that in the case in question there was neither "premonitory symptom nor diarrhoea." Yet, she admits that on Friday she knows the patient had been troubled with a great looseness of the bowels on three different occasions ; and further, that from eight on Saturday evening until half-past three on Sunday morning, the passages of rice-water " were incessant." Here the incongruity exists only in the mind of the witness. In another case visited by the writer on the first of this month, he was confidently assui-ed by a clergyman in the family, who " had paid great attention to Cholera in 1832," that the patient, also a lady, had never been aware of any diarrhoea whatever. This gentleman was sure that such occurrences were frequent, and referred to certain cases in Bagdad, of which the writer of course had no personal knowledge, but the evidence of which he insisted we are bound to receive. On visiting the patient and prescribing for her, the question was asked, and the assurance given that no diarrhcea had preceded the other symptoms. But on more diligent inquiry the lady admitted that the day before she had been most freely and repeatedly purged, but that she had not regarded the pure water that passed from her on that day as a diarrhcea. It was fair to assume that the cases in Bagdad might have been preceded in like manner the day before with purging, and the 18 very day of the inquiry accompanied with watery dejections, which the party might have considered as no evidence of a diarrhoea. Dr. Southworth, of Avenue C, a friend of the writer, has just communicated to him the particulars of a case, in which death occurred with well marked symptoms of collapse and no discharge of ricewater passages. In the possession of persons ignorant of the subject and incapable of prosecuting a correct inquiry, this case would have been confidently appealed to, as proving the possibility of collapse unpreceded by the discharge of the watery parts of the blood. The patient must have passed the faecal contents of the bowels, because, on inspection after death, there were none present. Yet he was not aware of having had a diarrhoea. This shows only the insidiousness of the first symptoms, and it proves nothing else ; for if the contents of the bowels can be discharged entirely without looseness, it is certainly a fact more unaccountable than the supposition that the patient may not have noticed a slight and painless diarrhcea. Indeed this latter is an exceedingly common occurrence. But the bowels in this case were found to contain from six quarts to two gallons of " rice-water," or in other words, of the water of the blood, while the abdomen was unusually prominent. The whole system was collapsed ; that is, there remained in the heart and arteries no fluid whatever. Let those who insist on collapse without diarrhoea explain, if they can, in what manner the vessels can collapse when they are distended with fluid ; or else, if the fluid is absent from the vessels, let them say how and where it has escaped. In all cases of collapse, then, the fluid has at least passed from the vessels into the intestines, or collapse is impossible, nay absurd. That in a few cases no discharge of it may have taken place from the bowels, because of an extraordinary vigor of the sphincter ani, the muscle that closes the last intestine, is certain. But these singular exceptions prove the rule, not in the common acceptation of the phrase only, but they establish the pathology of 1 9 the epidemic in a more striking manner than ordinary cases ; for they prove the discharge from the blood-vessels to have taken place, and that the depletion is therefore as real as if the fluid had passed into a vessel and had been subject to actual measurement. It is very important to strip the disease of the mystery with which many people seem determined to involve it at this point. So long as the least reliance is placed in stories so absurd and impossible, there can be no rational idea entertained £>f the nature of this epidemic, the fatal consequences of which cannot be doubted by any one who witnesses, on the one hand, the dismay in which mystery enshrouds it, and on the other, the salutary and delightful results which follow a perfect conviction of its true character in this respect. There is no hazard whatever, then, in the assertion that the disease is a diarrhoea, and from its earlier stages always consists of the fluid part of the blood. THE DISCOLORATION. It is the discharge of the fluid of the blood which furnishes the true explanation of the disease, and accounts for every symptom in the most satisfactory manner. In the first place, the exhaustion is entirely similar to what constantly follows the loss of large quantities of blood by disease or accident, with the exception merely of the difference in the color of the skin. When the red blood is lost the patient becomes pale ; but when the water of the blood only is discharged, a leaden or blue tinge is imparted to the surface, in consequence of the stagnation of the remaining blood, from the loss of its fluidity. NAUSEA. Another symptom common to both is the nausea or vomiting. It is also a common attendant on ordinary haemorrhage. 20 Cramps. Cramps, likewise, attend both of these haemorrhages. "Whet large discharges from any cause take place in the circulating fluid of an animal, the natural contractility of the whole system immediately manifests itself, aided by the external compression of the atmosphere, which every one kfeows is fifteen pounds to the square inch of the surface, both internal and external. By this process the blood-vessels are enabled to contract to the diminished bulk of their contents, and thus the discontinuance of the circulation is prevented, which must otherwise of necessity happen. In aid of the general tendency of the vascular system to contract as the fluids are diminished in their cavities, the nervous and muscular systems co-operate, and this produces the phenomenon of cramps. Cramps are, therefore, a necessary and constant attendant on all haemorrhages, and often occur to persons of feeble and emaciated forms, in other cases in which they are not caused by profuse discharges, and are often called nervous, for the simple reason that their true pathology is not understood. Animals bled to death in slaughter uniformly die with cramps or spasms perfectly resembling those occasioned by the loss of the fluid of the blood in Asiatic Cholera. Persons who are bled for pleurisy or other inflammatory diseases, until fainting takes place, are likewise usually affected with cramps. These facts show that the loss of the fluid of the blood in Cholera should be regarded as the true cause of the spasms or cramps. CONTRACTION AND SHRIVELLING. The sudden reduction of the bulk of the body is to be referred also to the fact of the abstraction of its fluid particles. In like 21 manner, in cases of recovery, the rapidity of the restoration of the embonpoint of the patient is perfectly astonishing, and is to be accounted for by the amount of fluid quickly returned to the system in drinks, which are demanded in immense amount by the craving thirst of the convalescent. COLDNESS. The coldness of the whole body, internally and externally, is owing to the same cause. For as the circulation of the blood in the lungs conveys to the air-vessels of those organs the carbon of the system, which, uniting with a portion of the oxygen of the air, is discharged in respiration in the form of carbonic acid gas, and as this is the known process by which animal heat is produced, constituting a true but slow combustion, it is evident that the loss of the fluid particles of the circulation must at once arrest this process, since, by the loss of its fluidity, the blood can no longer convey its carbon to the air-vessels of the lungs. Coldness of the body comes on, then, the moment that a certain amount of loss of fluid occurs. In vain warm applications are made to the external surface. They only annoy the patient, who is tormented Avith a sense of burning heat, in exact proportion to the diminution of his temperature. These applications are then worse than useless, for it is impossible that anything but the return of the water to the blood can afford warmth to the body. The true remedy consists in arresting first the discharge from the bowels, and then supplying fluid to the blood. Ice, or cold water, or chicken tea, whichever is most agreeable to the patient, at once allays the thirst, settles the stomach, and affords the means of circulation, efficient respiration, and consequent secretion of animal heat. The patient's own feelings should be permitted to regulate his amount of covering. 22 SENSATION OF BURNING HEAT. The burning heat of which the patient complains, while the body feels icy cold to the touch of his attendant, seems at first mysterious, but it is perfectly natural, when we reflect that the sensible temperature is attributable to the increase of external heat, in comparison with the temperature of the body. For instance, in a state of health, the body is at 98° of Fahrenheit. When the external air becomes heated to near that point, so that the continual secretion of animal heat cannot easily be thrown off, we complain of the temperature. "When, then, the heat of the body is, by the loss of circulation and healthy respiration in Cholera, reduced many degrees below that of the external air, it is evident that the external air must convey the sensation of heat to the surface. When we feel heat or cold, then, it is not the actual temperature of the body itself, but the relation it bears to the external temperature which furnishes the criterion of judgment. Hence what at first seems a mystery, by a little reflection, appears a simple and reasonable occurrence. Dr. Liebig has said that " the lungs are the fire-place of the body." But the fuel must be furnished, or the fire-place will not warm the house. In like manner, the carbon of the blood must be brought in contact with the atmospheric air in the lungs, or combustion and the production of heat cannot take place. This is a most interesting fact, and really seems so apparent, that it would not have been surprising if its occurrence had been generally anticipated, from the mere loss of the fluid of the blood, without the aid of the universal experience we have in regard to it. DIMINUTION OF THE BULK OF THE BODY. The collapse of the whole body, the sinking of the eye, the shrivelling of the fingers, and the pinched appearance of the features, all bear testimony to the great fact that the blood-vessels have lost their fluid contents. Many persons not acquainted with the relative proportions 23 of the fluid to the solid parts of the body, would suppose that the amount lost could not be in proportion to the diminished bulk of the body. But we have only to reflect that the largest muscle, the glutens maximus, when dried, becomes as thin as brown pajDer. Nineteen-twentieths of the soft parts are fluid, and to this fact is attributable the softness and mobility of the muscles of the whole body. To it likewise must we look for the explanation of the frightful loss of bulk produced by the discharges of the Asiatic Cholera. DEFICIENCY OF BILE No bile whatever is usually present in the discharges of a patient laboring under Cholera. The simple explanation consists in the great fact, already employed to explain the preceding phenomena, viz. — there being no fluidity to the blood, there can be no supply furnished to the liver, which cannot therefore secrete a particle of bile. No greater misapprehension of the true nature of this disease can be made, than the supposition that the deficiency of the biliary discharge is owing to any primary disorder of the liver. This idea is at once disproved by the universal fact that the liver instantly acts with vigor on the arrest of the diarrhoea and the restitution of the fluid to the blood by the abundant supply of drinks which the demands of the system manifest in the thirst of the patient. This prompt action of the liver is as marked and decided where no calomel has been employed, as it can possibly be where that medicine has been used. DEFICIENCY OF URINE. The urine also is deficient. This likewise is in perfect consistency with the other facts of the disease. As no blood passes to the kidneys, it is impossible for them to secrete the urine. 24 CONTRACTION OF THE PUPIL. It is this suspension of the action of the kidneys to which we must look for an explanation of the contraction of the pupils which sooner or later is observed in collapse. Very soon after the occurrence of watery passages this symptom is present. It takes place with suddenness. It is an important indication in reference to the prognosis. If it has not happened the patient may be promptly cured. If it has, there is reason to think the case more difficult to manage, because it proves it further advanced. The loss of the fluid has in this case suspended the functions of the kidneys, and they arc unable to separate from the circulating mass the several salts, and particularly urea, which are usually contained in their secretion. The brain is, therefore, directly stimulated by the presence of these urinous particles, as soon as the organs adapted to their removal cease to act. As the existence of this symptom denotes a certain stage of advancement in the disorder, so the promptitude or delay with which, when the patient is relieved, it disappears, serves as a kind of criterion of the intensity or advanced stage of the case. Thus, from the presence of a chemical agent, a morbid result is produced perfectly similar to what occurs from mechanical injury of the brain, as is familiar to surgeons in concussion. The contraction of the pupil, then, is another, though indirect effect of the loss of the fluid particles of the blood. HOARSENESS. One other symptom remains to be explained, viz. the hoarseness which characterizes the voice in this disease. It is a well known fact in the physiology of the voice, that the increased width of the 25 aperture of the larynx called the glottis, causes hoarseness. Now, the lining membrane of this organ is composed of blood-vessels and small mucous crypts, or glandulse, which . by the loss of their fluid blood collapse, and greatly enlarge the glottis, or aperture of the larynx. Thus the loss of fluid again affords a satisfactory solution of another phenomenon of this disease. COMA. The coma and contraction of the pupils which immediately precede death in this epidemic, are often regarded by unmedical persons as the effect of opiates and stimulants, to which they are indeed almost universally attributed with entire honesty and deep conviction. But that such is not the cause is evident from the occurrence of the same symptoms at the same period of collapse in other patients, who have had no stimulants or opiates, and have even been without any treatment whatever, while persons who are treated successfully with large doses of these agents are not at all affected with these symptoms. Yet the resemblance of the case to that of narcosis is very striking, and it is well to understand its cause. This is to be looked for chiefly in the presence of the urinous particles retained in the blood, as before explained. PRINCIPLES OF TREATMENT. As, therefore, the discharge of the water of the blood explains the pathology of Cholera, it at once furnishes the true clue to the treatment of it. This has been unfortunately conducted, hitherto, on principles of necessity purely empirical, but if we retain in mind the nature of the disease, our practice will be no longer uncertain, and there can be 26 no doubt that human life as well as science will reap the benefit. The first indication is to economize tl c vital energy of the system, impaired by the epidemic cause. During the prevalence of the disorder, all persons feel more or less its enervating influences. A baker informs the writer that he supplies but little more than half the usual quantity of bread to his customers, and that others in his business make the same remark. This proves the universal effect of the epidemic in impairing the appetite and depressing the powers of life. In 1832, a builder remarked to the writer, that in order to complete a contract in the required time, it was necessary for him to employ nearly twice the usual number of men, and he called attention to the fact, that in using a hammer on the parlor floor which they were nailing, they uniformly rested between the strokes. This sufficiently indicates the general sensation of feebleness that attends the epidemic. PERFECT REPOSE IN THE HORIZONTAL POSTURE. To attain this important end, — the necessity of restoring the strength, — all that is requisite is first that the patient, as soon as he is attacked, should confine himself to the horizontal position on a bed or couch, and preserve perfect repose. So important is this direction, that it deserves to be somewhat enforced and dwelt on. Exhausting labor, fatigue from walking, marching under arms, or running up and down stairs, are some of the most common and serious exciting causes of Cholera. Cleanliness of person, however desirable, is less important than rest during the presence of the epidemic cause. All labor, in a degree, exhausts vitality, and demands the return of repose, in exact proportion to its extent. As the loss of strength after labor disqiialifies the muscles of volition from further toil, so it enfeebles the mouths of the 27 exhalant arteries which open on the mucous surface of the bowels. They thus lose the tone necessary to retain their contents, and a passive discharge of fluid takes place in consequence, while from the very minute size of these capillaries, the larger and red particles are retained. The posture, too, is far from being unimportant. When we are erect, the hydrostatic pressure of the blood undoubtedly promotes the morbid tendency already induced by the epidemic cause, to pour out the fluid of the blood into the bowels ; while it prevents a full supply of blood to the brain, which is essential to that organ to supply all parts of the system, through its nervous connexions with the peculiar energy which we suppose it destined to secrete. Hence, during sleep, the horizontal posture is demanded, in order that the brain may effect its peculiar changes on the whole system, which it vivifies by its mysterious agency, and that it may convey through the nerves its inscrutable product to every organ and structure in the body. Doubly important, then, is the injunction that, during cholera, all persons should spare their energies as much as possible. But that this direction may not appear purely theoretical, it is onl}' necessary to remark, that the number of victims in every class is usually proportioned to the amount of fatigue required of them; thus, " in India, persons exposed to great bodily fatigue, confined to poor or scanty fare, or leading irregular lives, were usually the victims of this dreadful disease. The Europeans were usually less subject to it than the natives ; and the higher classes of the latter were more exempt from it than the lower. Females suffered more rarely than men, and children in a less degree than either. Of all the circumstances predisposing to an attack, great fatigue of travelling and hard labor in the open air were found the most powerful ; thus, troops on a march, and people whose occupations exposed them to the weather, as laborers, fishermen, gardeners, grass-cutters, washermen, palanquin-bearers, were extremely subject to the 28 disease." — History of British India, v. iii. p. 275, Harpers' 1 Family Library. It is stated that, in the British army, the mortality was confined principally to the soldiers, whose wives were less affected, and their officers scarcely ever ; while the ladies of the officers, whose habits were very quiet, were absolutely exempt. Thus, the importance of repose in averting an attack of Cholera is confirmed by experience, as well as by a consideration of the principles of the animal economy. Humanity requires, therefore, that the usual parades and exposures of soldiers should be generally omitted. Many lives will be uselessly sacrificed on the 4th of July, unless the celebration common to that day be avoided. It is to be hoped that this subject may be brought before our cit}' councils.* ARRESTING THE DIARRHCEA. The next object is immediately to arrest the purging. This may be attempted by the administration of medicines by the mouth. Usually, this is the method adopted. But it may be justly questioned whether this is the treatment best adapted to the case. If the discharge commences in the intestines, it is certain that * This suggestion, which in the former edition was made in the very words still retained in this, was acted out by our authorities, in consequence no doubt of the judicious recommendation of the Sanitary Committee, and the usual parade of the military was dispensed with. It is still to be lamented that the different societies feel themselves obliged to follow their deceased members to the grave so frequently as death removes a member under the presence of the epidemic. Nothing can possibly operate more powerfully as an exciting cause of diarrhoea than this very practice. Respect for the dead is the just and powerful inducement, but it is matter of regret that under circumstances like the present this honorable feeling should be permitted to occ ision to survivors exposure to such fatal danger. 29 the medicine is not so directly applied to its seat in tins way, as by using enemata and suppositories. The same remark is eminently applicable to the treatment of dysentery, and is familiarly acted on in practice. A dose of medicine of the same amount will do more good, in cases of intestinal disorder to which it is adapted, by applying it directly to the intestines, than by giving it by the mouth. But the intestines will bear three times the quantity, as a general rule, which we can commit to the stomach. This remark is especially true of the narcotics. A dose of opium which we would think proper to administer to the stomach, may be, and usually is, trebled when given in enema. This medicine generally affects unfavorably the digestive functions, the action of the heart, and the operations of the brain more powerfully when administered in the former manner, from the propinquity of those organs to the stomach ; while its immediate effect on the bowels, from its remoteness, when given by the mouth, is less distinct and powerful. From these palpable principles it follows, that opium, if it is intended to act as an astringent and anodyne to the intestinal vessels excited by the mysterious agency of the miasm to discharge from their minute mouths the fluid parts of the blood, must be more efficient if immediately applied to them by suppositories and injections, than if given by the mouth ; for, in the latter mode, they enter the stomach, and are thus, anatomically considered, applied at a distance of six times the length of the body from the organ on which they are designed to act, while it is impossible to give them in doses of more than one third the amount in which it is safe to administer them by the other method. Injections are, therefore, for this purpose, of much greater efficacy, while they are more harmless, as they disturb less the functions of the brain, lungs, heart, and stomach. While this is true in reference to those medicines which are designed to act on the bowels, yet in the administration of cordials and stimulants, such as ammonia, ether, camphor, capsicum, and brandy, the design of which is to act on the brain, by increasing the 30 energy of the nervous system, the preferable method is undoubtedly, for similar reasons, to administer them by the mouth. INJECTIONS. From two to four drachms of laudanum, in a little water, should be employed as an enema. It will not do to temporize in respect to quantity after watery passages have happened. The disease is rapid, — the treatment must be prompt and efficient. If the dose should come away, it must be immediately repeated. If it be in sufficient quantity, it will probably arrest the disease, so that there may be nothing discharged from the bowels for three or four days. The patient is then safe. It is not pretended that so large a dose is in every case necessary. But when watery discharges are present in an adult, less than the quantity named will not be found efficient. In another place, a suppository containing one grain of opium is recommended. This, in the case for which it is ordered, that is, in an incipient diarrhoea, with rest, is sufficient ; but as the disease advances, its tendency to profuse evacuations becomes greatly increased, and like the law of falling bodies in natural philosophy, it augments in geometrical ratio, and hurries its victim to the grave with corresponding rapidity. To candid minds, the difference between one grain of opium — the exact equivalent of thirty drops of laudanum — for the first appearance of the diarrhoea, and a tablespoonful of laudanum, which is directed for a much later period, viz. that of the occurrence of the rice-water discharge, shows a sufficient recognition of the different degrees of exigency which exist in the different stages of the disorder. To reduce it to a mathematical criterion, the dose of laudanum is about three hundred drops, being ten times the amount recommended for the first appearance of the discharge. In the inter 31 mediate stages, it is manifest that the judgment of the physician must be relied on to graduate the amount necessary between these extremes. It was thought sufficient to state the extremes alone, and it may be well to observe in this place, that the writer has been obliged to augment this quantity, in one case, to a tablespoonful and a half, and this not remaining, it was succeeded by a scruple of tannin before the tremendous discharges of fluid could be arrested, and he is happy to be able to add, that these large doses were attended with complete success, and that they undoubtedly saved the patient's life ; but what was more remarkable, they produced none of the usual effects of laudanum given under common circumstances. There was no narcosis brought on. The patient did not even appear disposed to sleep. The pupils were not more contracted than before, neither coma nor drowsiness occurred, and the medicine seemed to have exhausted its power simply in the arrest of the discharge and the relief of the cramps and abdominal distress. This singular absence of the usual bad effects of opiates, has been particularly and habitually observed. It is a most interesting and gratifying fact, and wherever strong coma or deep stupor is induced by its use, it only proves that the prescriber has not acquired the proper tact in the administration of the remedy, and that he has given too much for the demands of the case. Yet there can be no doubt that as a general rule it is safer to give rather too large a quantity of the drug, than by insufficiency in the dose to permit the disease to go on to its certain and awful results, unchecked by an adequate amount of the medicine which, in judicious hands, is as safe as it is undoubtedly salutary and certain. ICE. If the discharge has produced thirst, ice is at once grateful am. useful in restoring the fluid which has been lost. The restoration of fluid to the blood is a most important indication. In addition tt 32 this remedy a prescription at once cordial, astringent, and anodyne, should be employed, and administered by the mouth. The chalk mixture, with astringents, &c, may be used, as in common diarrhoea ; but a better prescription will be found by substituting lime-water for the prepared chalk and pure water. DRINKS. After the first excessive thirst is abated, a drink of chicken or mutton tea should be used, until the fulness of the countenance is restored, and the desire for drink is entirely allayed. Food of a light but nutritious and astringent kind should be employed as soon as the appetite permits, such as boiled rice instead of potatoes, with broiled chicken, beef, or lamb. Veal and fresh pork should not be used at all, during the epidemic, by any one. COUNTER-IRRITANTS. But little or no benefit is derived from sinapisms or other counterirritants, and they would probably never have been resorted to if the nature of the disease had been understood. By this remark it is not intended to proscribe altogether their use under special circumstances which may seem to require them, but merely to condemn them as reliances for cure. They have no effect whatever in arresting the disease. They have been promiscuously and empirically used ; and they, as well as hot bottles, are a source of great suffering to the patient. The writer in 1832 had the mortification to see a patient, to whom he had been unable to come when first sent for, being absent, covered from head to foot with a composition of mercurial ointment, camphor, and cayenne pepper, io strong that the gentleman was in more agony from the action of the last ingredient than from all the cramps and distress of his disease. By this 33 absurd and cruel treatment in his last moments (for he died) he was horribly tortured without benefit. And yet such empiricism would have been regarded as enlightened practice if in spite of it he had recovered. For a definite and appropriate end, counter-irritants may be employed with propriety in this as in other diseases, but an empirical confidence in them should be discouraged. BLOOD-LETTING. It will be manifest that venesection and purgatives are both highly injurious under common circumstances. My friend Dr. D. D. Marvin has had the kindness to furnish me with a case m which the folly of blood-letting in this epidemic is strongly exhibited. What is evidently required to restore health to a patient deprived of a great portion of his blood is nourishment and drink. But the error of direct depletion, manifest in the very nature of the case, is rendered striking by the result and the intelligent history of it which Dr. Marvin has furnished. If a patient loses red blood from a wounded vessel or from spontaneous haemorrhage, as in epistaxis, every one knows that beef tea and brandy, or milk-punch, would be the proper restorative. The man would be accounted mad who would, in such a case, recommend or employ the lancet. Much more, when not only the actual loss of fluid debilitates the system, but when every drop of the water of the circulation lost, as Dr. Marvin truly remarks, serves to deteriorate the remaining mass of circulating fluid, much more is it folly and error to attempt to rectify the injury done by depressing still further the powers of life by the direct abstraction of blood. The letter of Dr. Marvin contains all that need be said in reference to venesection. 2* 34 No. 151 Tenth St., New York, July 20th, 1849. My dear Sir :—: — I cheerfully comply with your request, to furnish you with the particulars of a case illustrative of the evil effects of blood-letting in the epidemic now prevailing, and I take the opportunity to bear my testimony to the fact of your having taught and practised, as early as the year 1832, on the principles which you have lately given to the public in your treatise on the Pathology and Treatment of Cholera (so called). My experience in 1834, and during the present epidemic, has fully established in my mind the soundness and truth of your pathology, while the success which I have derived from your principles in practice furnishes me with the best possible test of their value. Indeed, the more I see of the disease, and the more I reflect on its nature and symptoms, the more confident and satisfied I am of the truth and reality of your theory — a theory which seems to have grown naturally and of necessity from the contemplation of the known facts of the case, rather than from the ingenuity and contrivance of the author. The case which I have drawn up for you is that of Henry Deri', of Clarkson street, a man of strong constitution and temperate habits, a native of Pennsylvania, aged 34 years, who had diarrhoea during the preceding week, and was seized on the afternoon of Sunday, July 1 5th, with vomiting and copious purging, cramps, coldness, and lividness of the extremities, with the peculiar corrugated appearance of the fingers present only in this disease. Cordials, stimulants, and opiates, together with a laudanum enema, were administered. Under the use of these remedies the purging and vomiting ceased, the cramps subsided, the pulse rose at the wrist, the natural warmth began to return, and the patient fell into slumber with free and warm perspiration. It was late in the evening when he was left in this condition, with directions to give him rennet whey and other diluents freely, as soon as he awaked, in order that the blood-vessels drained of their fluid by the profuse discharges, might be replenished. 35 Being engaged with other and distant cases during the night 1 could not see Mr. Derr again until break of day. During thi interval a benevolent old gentleman had kindly introduced another physician, who sadly thwarted all my plans, by taking " half a pint" of blood from his arm ! It would have gratified me exceedingly to have had an opportunity of abstracting from the doctor's arm twice that quantity of blood and transferring it into the veins which he had deprived of the last drops of life. The result of course was fatal in a short time, and the " strong man" soon breathed his last. This case illustrates the folly of taking blood to cure what is a haemorrhage in fact, and a haemorrhage more fatal than the loss of the red blood would be, since every ounce of the epidemic haemorrhage, by leaving behind in the circulation its share of fibrine, deteriorates the circulating mass which remains. With sentiments of affectionate and deep regard, I am your friend and former pupil, D. D, Marvin. PURGATIVES. The only purgatives which are usually employed are rhubarb and calomel. They are both highly objectionable. Their use, uncombined with other agents, would be uniformly fatal. Some practitioners continue to support the use of calomel, however, in the treatment of cholera, relying on its known alterative powers in other diseases. This is very natural ; for the power of association is often greater over us than we apprehend, and exerts an influence upon the judgment entirely unsuspected. This infirmity of the mind exhibits itself in its most vulgar form among people who, having seen some medicine or prescription act favorably, immediately repose in it implicit reliance in all cases. Their impression is that it is good. because it has done good ; and without the power to distinguish the circumstances and principles upon which its success depends, they 36 recommend it as a nostrum with entire and unsuspecting confidence. Such infirmity of mind is less likely to prevail among physicians well educated and accustomed to employ their powers of observation with precision, and whose judgment has become mature from exercise. Nevertheless, whole classes of men sometimes fall into the very errors which they condemn and despise in the vulgar. Who can now deny that the practice of our forefathers in fevers, of proscribing the employment of cold water, was an error of the gravest importance derived from the very source in question ? And it is equally certain that their habit of salivating, almost in every case of disease, was likewise the result of error in judgment maintained by the force of authority to the injury of their patients, and in a great degree to the sacrifice of the confidence of a community disposed implicitly to follow their prescriptions and reverence their opinions. They produced salivation, because they regarded that symptom as a test of the constitution being affected. Even now this doctrine is occasionally maintained by some men of professional respectability ; but nothingis more certain than that salivation from mercurials is the result of ulcers in the mouth, produced by the medicine, which can be almost instantly cured by a proper application of nitrate of silver. It is, therefore, no test whatever of the constitution being affected by it. Almost every opinion sustained merely by dogmatism is erroneous, and every one having no better foundation is at least to be suspected. This very notion of mercurials affecting the constitution, vague and inaccurate as it appears, is the foundation for the confidence which is so generally reposed in its power of cure in the epidemic diarrhoea we are considering. At any rate, all experience in other diseases teaches us that this constitutional action is quite too slow to produce any result whatever in so rapid a disease as this. Mr. Hunter, in the treatment of another disease, recommended a pill of one grain, night and morning, for ten days, before any constitutional effect was to be expected. Without quoting this high authority 37 with any confidence in the practice itself, as it must be regarded as a deliberate surrender of the patient for ten days to the undisputed ravages of disease, it is still in point to establish the great length oi time necessary to influence the constitution by the drug. The time necessary to accomplish this object, then, is itself an insuperable obstacle to its successful employment for this end, in a case of only a few hours' ordinary duration. But it will be contended that larger doses will attain the end in view in quicker time. This is true ; but then large doses are sure to operate as purgatives, an effect to be deprecated in this malignant diarrhoea. If employed with opiates, these latter must be administered in quantities sufficient to counteract the purgative tendency. Still the fact remains that the purgative tendency exists ; and, therefore, just so far as it exerts its natural power in this respect, the medicine is objectionable, and we have with our other remedies to contend with two powers, both disposing to purgation, the one the epidemic cause, the other the calomel. Here, then, we manifestly lose ground by the use of this purgative. But the employment of calomel in Cholera cannot be defended successfully without first establishing the necessity for the alterative action which is attributed to it in arresting the disease. Its friends are bound to prove that it cannot be cured without it, or at least that it cannot be as well cured. This they have absolutely failed to do. On the other hand, multitudes of cases are on record of undoubted cures of the disease by other means, without a particle of any mercurial, and without any apparent necessity for the employment of such a remedy at all. Occasionally in cases where calomel has been given, a fine black powder has been distinctly observed in the discharges. This, without doubt, is the black oxide of mercury of which the calomel is formed — the muriatic acid or chlorine, the other constituent having united with the lime, which abounds in the fluid parts of the blood, for which it exerts a most powerful affinity. It might be thought 38 that the calomel passing off thus decomposed, could have done no harm ; but this is not the fact, as the black oxide is itself purgative. Calomel, then, cannot act as an alterative in the brief period of the existence of this disease. Its power to effect a salutary alteration in the case is not established, and the idea is probably the effect of its known good properties in a variety of other diseases, and that principle of association and generalization which often exerts a pernicious influence in medical practice in other diseases. Nor is it proved that any such necessity whatever exists in the case for alterative action. The real alterative effect required in this diarrhoea, is simply to astringe the mouths of the exhalants of the bowels. It is known to exert an influence undeniably evil, so far as it is a purgative, and this effect is alterative precisely in the wrong direction, and all other alterative power is purely imaginary ; while its advocates themselves attempt to obviate this power by combination with opium, a procedure which virtually implies its evil influence in requiring to be thus modified. The argument derived from supposing the liver to be primarily deranged in Cholera, needs but a few words. It has been established before, that the cessation of all supply of blood to the liver, in consequence of the loss of the water of that fluid, furnishes a sufficient reason for the absence of the biliary secretion. If there were any just foundation for this theory, it would then be impossible to cure without some such direct means of acting on the liver. A thousand recoveries without mercury prove that the organization of the liver is absolutely untouched, and that the functions of the organ are only suspended — not depraved. Much more ground exists for charging the disease on the kidneys, since in the first place their secretion is also entirely deficient, and there can be no doubt that urea, and all the salts usually separated from the blood by the agency of these organs, must remain in it ; and 39 it is not to be denied that the contraction of the pupils, coma, and other evidences of cerebral irritation, are the direct effect of the presence of these urinous particles in the blood. If the argument is good to prove the liver the offending organ then, it is much stronger as applied to the kidneys. But both theories are defective, because they are both founded on partial consideration of the facts. The theory of primary defect in the liver fails to notice the undeniable deficiency in the action of the kidneys, and vice versa. They are both manifestly not causes, but effects of the disease. We require a theory in explanation of the cause of Cholera, that acknowledges all the facts, and this is what is defended in the present argument, viz. the undeniable loss of fluidity in the blood. The same obvious objection exists to the doctrine that the blood itself is primarily, or originally, the seat of morbid action. If such were the case, no recovery would take place at all by infusion, as In case No. 4, and as has occurred to other practitioners, very frequently, from the same means. The mere supply of water could not by any possibility restore the blood if it were primarily diseased. These views sustain the objection to all reliance on purgatives in the treatment of Cholera, and direct our attention to the means of arresting the discharges from the bowels by which collapse and ultimate disorganization of the blood itself are induced, as the only rational measure by which a cure can be accomplished. A further support to the opinion of the injurious effects of calomel, employed in the treatment of the present epidemic, is derived from observing the greater fatality which prevails in those parts of our own country in which this drug has become, both in professional and popular practice, the only remedy in every variety of disease. The west and southwest are proverbial for the copious employment of calomel. Where has Cholera had so many victims ? In the cases of the New York, from Havre, Captain Nye reported n every instance that he gave calomel and ipecacuanha. The operation 40 of the medicine was immediately followed by collapse and death ; and in the only case in which the writer was called in 1832, before collapse had been fully established, and which proved fatal, the patient had of his own accord taken fifteen grains of calomel, and as much jalap, to the operation of which alone is attributable the impossibility of arresting the purging. No purgative whatever should be employed. Calomel, salts, oil, rhubarb, seidlitz powders, in common with all other purgatives, should be forbidden. There is no danger in immediately arresting the diarrhoea, and there is no safety until it is arrested. THE INSERTION OF FLUID INTO THE VEINS BY DIRECT INFUSION. In case too much discharge has existed to enable the practitioner to relieve the patient by the use of ice and drinks, not a moment's delay should be permitted in resorting to the use of infusion. Twenty or thirty ounces of water, containing a drachm of carbonate of soda, and ten grains of common salt, to the quart, at the temperature of 98° Fahrenheit, should be most carefully introduced into the vein at the usual place of performing venesection. This always affords relief, and would generally effect a cure ; but because of its being usually deferred until after the thick parts of the blood have had time to coagulate, when the remedy is too late. In illustration of the advantage of this practice the reader's attention is directed to the fourth case on page 50. AFTER TREATMENT. In the course of two or three days, supposing the case to recover, the discharges from the bowels take place ; they are then hard and entirely without bile, or else they consist of black bile alone ; or sometimes they are perfectly natural. This is supposed by some, 41 very erroneously, to be evidence that the liver is the primary seat of the disease. But it is natural that that organ, having had its secretion entirely suspended, should at first perform its functions irregularly. It is then very much in the condition of the liver of a new-born child, the first discharges from which are perfectly black. But in Cholera, we know that as soon as the liver resumes its action the bile is prepared from blood unusually loaded with carbon, which may be an additional cause of this peculiarity. A small dose of calomel may sometimes be necessaiy at the conclusion of the treatment, especially when there is a manifest deficiency in the biliary secretion, but never to arrest the disease or when the bile is in excess. To give calomel when the liver is discharging bile freely, and even with morbid copiousness, is a course of practice for which authority enough can be quoted, but it is a practice as unsound as it is unsuccessful, and part of that system which has caused an ungovernable aversion of people even to its proper use. In such a case the liver is doing its duty, and is in no need of stimulants, requiring time only to effect all necessary changes. In many cases, at the very commencement of the diarrhoea, a pill of opium, from one to three grains, introduced into the rectum, will, of itself, arrest the disease. CORROBORATION OF THE PRACTICE. Under this plan of treatment the writer has seen several hundred cases recover, and, in 1333, when it prevailed in the city of Mexico, he had the satisfaction to learn that a gentleman, a connexion of his, following the prescription and advice of a letter, succeeded in curing more than a hundred cases without losing one. Mr. St. John, of the firm of St. John and Tousy, of this city, was then there, and united with this gentleman in the treatment of those cases. He confirms the account, and they both state that the letter of direc* 42 tions, which had been designed only for the use of the party to whom it was addressed, was translated into Spanish and circulated in every state of the confederacy, by order of the government ; and further confirmation is afforded by a gentleman who was at Matamoras, of the fact of the treatment having been followed with success in that place also. He stated that the accidental remark in the letter, that common tea being an astringent was an excellent drink in Cholera, caused such an increased consumption of it at a time of comparative scarcity of the article, as to raise its price so that to get as much as one could hold in the palm of his hand cost one dollar. These confirmations of the writer's experience are not only gratifying, but useful as testimonials from persons whose whole skill was derived from the principles of treatment so informally communicated to them, and it is hoped that this reference to them may be considered pardonable, particularly as one of the principal objects in publishing these remarks is to set the writer's own patients at rest, and to furnish them with such hints as they require in case of attack before they can see their physician. In order to illustrate the treatment here recommended, several cases, some of which have happened during the present epidemic, will be related. Case Ist. — On Saturday the 12th of May, 1849, a gentleman and his wife who had just arrived at the house of his father in this city, from a journey from Burlington, lowa, and had been exposed to the Cholera in the West, were troubled with looseness of the bowels, of which they had complained on the journey for three or four days previously. They had been in company with a medical gentleman on his way to the examination of the cadets at West Point, who had prescribed for them efficiently at the early part of their journey, and had parted company with them afterwards, and by his advice they took laudanum and brandy, which had the effect of helping them, although it did not arrest their disease. Or the contrary the discharges, 43 which were excessively prostrating, continued, and on Friday night there were as many as six or eight of pure water uncolored by any faecal matter whatever. They were both very feeble. The lady when I saw her said that the rice water discharges had then continued with her for thirty-six houi's. Her eyes were sunk, her face thin, her countenance of a leaden hue, the fingers slightly corrugated, and she was nauseated and occasionally vomited small quantities of water. There were, however, neither cramps nor any very unusual coldness. But from the presence of the great pathognomonic sign of the disease, viz. the rice water passages, from the general expression of the face, the color of the skin, and above all from the extent of the evacuations which had taken place, there was no doubt that the lady especially would, unless relieved, become incurably collapsed in a very short time. An enema of laudanum was prescribed for the lady, of three teaspoonfuls ; for the gentleman one containing four. She complained of burning and unquenchable thirst, for which she was ordered ice ad libitum. An astringent mixture containing laudanum was directed, and the discharges from the bowels were completely arrested. The thirst and vomiting continued for twentyfour hours, but no passage was had from the bowels, in either case, for more than three days. After the ice ceased to be strongly desired, chicken tea was substituted, and the recovery was rapid. On •the sixth day after the first prescription the lady had entirely recovered her embonpoint, and declared that she felt better than before the attack. They have been both scrupulous in preserving the horizontal position, and have been in entire repose. The gentleman too has recovered. In these cases, especially that of the lady, the use of calomel, salts, or any purgative whatever instead of the judicious prescription of laudanum and brandy, would in all probability have precipitated a rapid collapse and certain death. 44 It may be observed, too, that while travelling and therefore undergoing some fatigue, and depending on the use of brandy and laudanum by the mouth, although the patients were much benefited, their discharges were not arrested. But when, in addition to positive repose on their backs, a sufficient enema of laudanum was given, the purging was promptly and permanently arrested. We may from these cases draw the conclusion, first, of the advantage of using cordials, as brandy and camphor, in this disease, characterized as it is by the presence of a marked debility of the whole muscular as well as the nervous system, in which the orifices of the exhalants of the large intestines seem to participate in a degree more striking than the rest of the system ; and second, that the administration of laudanum by the mouth did not act as well as when applied by the rectum, both because in the latter method a more direct employment of it was made to the seat of the disease, and because a much more efficient dose was given. Case Id. — Since those cases another has occurred near the city, on our beautiful bay, within ten miles of the ferry, on the Long Island side. The residence of the patient was one of the most delightful which the neighborhood affords. He was a gentleman of the highest respectability, and possessed of every blessing which affluent circumstances and an accomplished and affectionate family could afford him in the hour of sickness. He had diarrhoea on the 23d and 24th of May, for which he did nothing, and on the morning of the 25th partook of some fresh broiled fish, and afterwards drank milk. During the whole time of its existence, he continued about his usual avocations, giving himself no particular rest. On the morning of the 25th, which was the third day of the disease, the family physician was called, and gave him brandy and laudanum in doses which checked the diarrhoea ; but pursuing the course of practice originally indicated by the British physicians in India, he added a dose of calomel in the quantity of twelve grains. This, however, did not for some time seem to produce 45 its usual purgative effect. It was not until the next day that the evacuations were renewed. These were not bilious, but consisted of the usual discharges of this disorder, viz. rice water. Since the third day of this disease the evacuations had been all of this character, presenting the strongest evidence of the nature of the case. Severe cramps came on, accompanied with violent vomiting. The former after a few hours ceased, but the latter continued with unabated severity. The skin became slightly blue, the eyes were not much sunk nor the nose much contracted, the hands were cold and the urine suppressed. No bile was discharged and the voice was little affected, although a slight hoarseness was observed. The pupils were contracted excessively, and the patient slept with stertorous breathing. This latter symptom occasioned less alarm, however, because he was said to snore habitually in sleep, and his appearance was in that respect declared to be perfectly natural. At twelve o'clock at night on the 2*7 th, which was the fourth day of the disease, the writer first saw him. Collapse had already taken place, but it was not as fully marked as usual. Although comatose, he could be aroused. The contracted pupils and cerebral symptoms, resembling in their external phenomena very strikingly those of congestion of the brain, gave a bad augury, and the frequently repeated watery passages, which had returned, manifested the great danger of his case. The prognosis was unfavorable, especially as purgative medicine had been given, and a corresponding opinion was expressed. However much the vaunted powers of calomel are relied on to produce discharges of bilious matter in this disease, here it had no other effect than to reproduce the watery discharges, which were renewed before morning. Under the use of laudanum and brandy these ' had ceased, when the calomel was given and the rice-water passages were renewed. Opiates, astringents, cordials, ice, all were in vain to resist the incessant passages from the bowels. In consultation with the excellent physician who was his usual attendant, on 46 the night of the fifth day, it was determined to give a solution of nitrate of silver and to use also an injection of the same material. This was at eight in the evening. At midnight a discharge of bilious matter took place and vomiting ceased. Some small hopes of recovery were now entertained, but in twenty-four hours the watery discharges recurred, and though bilious passages repeatedly took place, the cerebral symptoms became more and more urgent, and on the sixth day an attempt to open the temporal artery revealed the fact that no pulsation could be found there or in any other small vessel in the head, though pulsation was felt in the carotid. The pulse had varied from 100 to 80, and had improved during the treatment, so that if the bowels could have been sooner quieted, recovery might have taken place. No blood could be obtained at the temples. In the morning infusion was resorted to, but without relief, and the patient died comatose on the eighth day. These symptoms resemble congestion, but are alwaj^s present in collapse after a certain duration. The contraction of the pupil and other cerebral disturbances, the absence of arterial action of the smaller vessels, and the fact that the evident absorption of drink afforded no relief to the cerebral symptoms, established the direful conclusion of the coagulation of the blood and the hopelessness of the case. The sphincter ani was so relaxed during the whole period after the fourth day that the thumb could have been introduced without difficulty at any time, a circumstance showing the relaxation of the muscular fibre produced by the disease, if not aggravated by the use of calomel. Had this case been as early treated with opiate injections as the two former, it is not improbable that a different result might have occurred. As it is it presents as strong evidence of the value of the opiate and cordial, and the evil of the purgative practice, as the two cases before described, or as the thirty-five cases on board the New York treated with calomel and ipecac. It is more than probable that on the fourth day of the case collapse 47 had so far done its work that the fibrine had coagulated in the heart and large vessels. Every symptom confirms this idea. From that time forward the pupils of the eyes were contracted to the extremest point, and though the occasional arrest of the purging and the use of drinks had evidently restored the fluid of the blood to a considerable extent — a fact indicated by the increased fulness of the pulse^ the return of the natural color of the face, the warmth of the body, and in some degree the functions of the brain — yet there was a gradual diminution of the force of the circulation — the pulse ceasing at the parts remotest from the heart, and the heart itself ceasing its action and yielding to death, a result which it is pretty certain must always occur as soon as a coagulum is formed at the centre of the circulation. The occurrence of this cause of death is the great event to be avoided. Then, no restoration of the fluid or any other favorable change can avail. All apparent improvements in the condition of the patient are, after it has taken place, of no possible benefit. It is, however, very surprising to see how near this point patients may approach and yet be saved. The uncertainty as to this fatal occurrence having taken place should then stimulate the physician to exertion under the most unfavorable appearances. Case 3d. — In 1832, a gentleman, a clerk in an auction store, was engaged with another young man in packing goods until two o'clock in the morning. They both found themselves attacked with the diarrhoea, but were not deterred from returning to the store on the next day. Towards afternoon they both left their employments from alarm at the continuance of the complaint. One took a warm bath at a public bathing establishment and collapsed before coming out of the water. He was taken home and died. The other walked a distance of two miles to his home. Having arrived there, his mother insisted on his not leaving the chamber on occasion of an evacuation., He had a very large discharge of water, certainly above two quarts, and his physician arrived immediately afterwards. No cramps 48 or other bad symptoms had exhibited themselves. A tablespoonful of laudanum by injection, and rest in the horizontal position, stayed his discharges, and nothing passed his bowels for five days. A dose of calomel and mild purgative enemata were then used, when dark bile passed off from the bowels, and, with the exception of large draughts of chicken water as a drink, he recovered without further treatment. IMPORTANCE OF DRINKS Many cases of recovery have taken place with no other treatment than that of copious draughts of water. Several very curious cases are related, which are instructive and worth repeating for the support they give to the pathological views which it is the object of the writer to sustain, as it cannot but be remarked, that the restoration of the fluid is the principal and evident cause of recovery in all these cases, and should be regarded as the principal indication in the treatment after arresting the alvine discharges. CASES FROM SCOUTTETTEN. " Case Ist. — Velly Chetty, the interpreter of the Comptroller, a powerful and robust man, was attacked in the morning very violently ; vomitings, dejections, spasms, and cold sweats, appeared at the same time. Rassendren visited the patient at this time, and immediately gave him several glasses of water, which had been set away to cool ; one hour after, all the symptoms had ceased, he slept quietly, and in the evening he arose, feeling only a slight lassitude, which disappeared the next day. Case 2d. — A man of property was seventeen hours insensible, and ,his comrades thought him dead. Eassendren was called in, and finding neither warmth nor pulse, he applied, for his own satisfaction, fifteen leeches to the epigastrium. M. Gravier was immediately sent 49 for, and having seen him, lost all hope. He however rilled his mouth with cold water, and ordered his arms and legs to be rubbed with a piece of camel's hair ; the sick man having spit out the water in his mouth, they gave him more ; he put his hand to his stomach, to remove the linen with which he was covered. The leeches were now filled and dropped off, the blood was permitted to flow, the body became warmer, the extremities alone remained cold, the frictions were continued, and also water in small quantities. Two hours after, the temperature of the body was uniform. Notwithstanding the frequency and the smallness of the pulse, the anxiety of the countenance and the derangement of the ideas announced a violent irritation of the mucous membrane of the stomach. Repeated eructations were followed with vomitings, and with violent nervous phenomena. Water then being insufficient, thirty leeches were applied to the epigastrium. In the night there was remission. The next day gum water was administered, the third day sweetened rice water ; from this day to the sixth, chicken water. The sick man was up on the seventh day, saying that he was not very weak, and, in fact, his actions proved it. He was cured. Case 3d. — The Indian domestic of M. Delarche, Captain of Cipahis (usually written Sepoys), was attacked with epidemic cholera. Laudanum, ether, and an infusion of ginger were administered, but they were ejected by vomiting. An Indian physician was called in, and made a paste of lemon juice, alum, and oxide of iron, and rubbed his eyes with it. The pain it produced vexed and enraged the sick man, and he attempted to strike those around him ; the vomitings became more frequent, his attendants fled to avoid his blows ; he pursued them : passing by a reservoir of water, which served for the purposes of the garden, he plunged into it and drank with avidity for several moments. They surrounded him, but he remained tranquil in the water. The enormous quantity of liquid he drank, was followed by fainting. He was then removed from the reservoir and put to bed ; he slept quietly for eleven hours. When 3 50 he awoke, the vomitings and dejections had ceased, but he was blind. This fact is known by all the inhabitants of Pondicherry." Case 4th. — In the Crosby Street Hospital, in 1832, a woman was brought in in deep collapse, at the hour in which the physicians had gone to their dinner. A young physician, a Frenchman, only remained. The writer had entered at the moment, and on examining the patient she was found to be cold, blue, and without pulsation at her heart. Twenty -four ounces of water at 98° Fahrenheit, containing a little soda and salt, were infused into her veins. Immediately her color changed, her whole physiognomy was restored to a natural expression, her eyes became prominent instead of sunken, her circulation returned, and her pulse numbered 132 in the minute. She spoke. Her first words were " where am I?" She supposed herself to have been dead, and said that she believed her existence had been renewed in another state. Her warmth of body returned and she was covered up in bed. The medical gentleman having charge of the hospital returned, and exhibited to her a dose of medicine consisting of a scruple of calomel and two grains of opium. The latter ingredient was not in sufficient quantity to prevent the purgative operation of the calomel, and she was again before night freely purged. This was followed immediately by a return of the collapse. The infusion of a larger quantity of water was again resorted to, and she again recovered. No more purgatives were employed, but it is not known what other or if any treatment was used. The patient finally recovered, and my friend, the late Dr. Downs, informed me in 1837 that he had seen the woman at the wash-tub a short time before, so that she was alive five years after. In this case the restoration of the fluid to the blood was the instant means of restoring life. How many minutes' more delay would have been requisite for her blood to have clotted at the heart ? Could anything, too, more strongly illustrate the evil effect of purging ? 51 This case proves analytically and synthetically that the disease ia h diarrhoea which discharges the water of the blood — that the symptom called collapse is the result of the loss of this water — that its restitution restored health — that purging produced relapse ; and lastly, it presents an instance of the most extraordinary and unexampled delay in the congelation of the fibrine of the blood which probably has ever been recorded, or indeed has ever happened. It deserves to be remarked that cases of recovery more seldom take place after collapse in persons of robust and vigorous constitutions than in those of feebler and more spare habits, because in the "ormer there is usually more fibrine, and a more rapid coagulation naturally occurs. Dr. Geo. Stewart Hawthorne, whose letters on the Cholera have recently been re-published in this city, declares that no corpulent person has ever recovered from collapse, and assigns the same reason "or it. This opinion requires, however, to be modified, as the result of case No. G sufficiently proves. Still there is no doubt that such recoveries are extremely rare. The practical use of these cases is to induce us to employ an energetic course to arrest the discharge, remembering that in this disease especially, " the time is short," and that it is of vital consequence to anticipate the fatal coagulation of the blood to which the diarrhoea rapidly urges the case. What effect, then, can bleeding and purgatives exert, but to accelerate the fatal end ? "When they have appeared to succeed, has it not been only in the very early stages of the case ? Or have they not been so combined with opiates, cordials, diluents, and astringents, that the recovery has been in spite, and not in consequence, of their employment ? In the writer's experience, "or rather observation, calomel has always hastened the final and fatal result. Case sth. — On Sunday the 3d of June, 1849, a gardener, set. 35 years, of temperate habits and spare person, walked to Bloomingdale 52 with a friend, the distance being about five miles. He had an insignificant diarrhoea, without pain or uneasiness. It was marked by no symptoms whatever, unless its insidiousness. There was no diarrhoea at all on either of the nights of Sunday or Monday — the effect doubtless of the horizontal posture. He drank some gingerpop on Sunday. On Monday morning his diarrhoea returned, and thinking it would be of service to him he took a glass of beer. The complaint continued. On Tuesday morning the diarrhoea returning, when he got up he administered to himself a dose of castor-oil and a few drops of laudanum. This operated profusely. Rice-water discharges came away without faeces, and he collapsed. He sent for a- doctor, who gave him twenty grains of calomel and two of opium, and called in a friend. The purging of rice-water was not arrested. On the afternoon of Tuesday the writer was called to him also in consultation. It was agreed to use opiates, cordials, astringents, and diluents. At this time he presented a fair case of collapse, and he had been in that state ten hours. The extremities were cold as well as the tongue, the countenance blue and pinched, the collapse and contraction of the body were complete, and the voice hoarse and sepulchral ; the urine was deficient, and the vomiting without being violent was constant. Ice being grateful to him was used. On Wednesday morning he was no worse, the alvine evacuations had rather subsided in the night, his vomiting had diminished, and he took his drinks freely. On Thursday the symptoms of collapse began to disappear. His countenance resumed its healthy and natural expression, and he was pronounced well by the gentlemen who had charge of him. On the morning of this day they informed the writer that they had given him forty grains of calomel, a practice which had not been agreed on, with some opium, to which they attributed his recovery. But it is probable that his " recovery," or more accurately his temporary relief, depended upon the other remedies and not on the calomel. On Thursday night watery passages recurred, evidently the effect of 53 the purgative, and on Friday he was at the point of death, and died before night. In this case it is certainly to be feared that the calomel did no good — that if he had finally recovered, the recovery would have been a result in spite of, and not in consequence of, the calomel. And that, at the same time, it would have been in consequence of the opiates, cordials, astringents, and diluent drinks, whose operation is directly to diminish and arrest discharges, and to restore the fluid. If such were the fact, it could not be in consequence of the use either of the oil or calomel, whose operation is almost as fatal as Brandreth's Pills, which have been signally injurious in inducing the disease and rendering it fatal where it had existed, according to the testimony of several persons, whose accuracy is entirely to be depended upon. By what principle of sound reason can one purgative be eulogized in this diarrhoea, and yet another condemned ? But the fatal coagulation of the blood had taken place on Tuesday, when the writer first saw him, he having then been in collapse ten hours, and the arrest of the discharges, previous to their recurrence on Thursday night (which recurrence is only attributable to the calomel), and the restoration of the fluid to the circulation, by which he seemed to be relieved and even cured on Thursday, were measures of relief rendered at quite too late a period. On Friday morning the vessels at the wrist and temples were pulseless. The circulation at the heart was laborious, feeble, and sloav. If a clot was in its cavity, that would exactly explain the condition of the circulation. In that case, the systole of the heart being imperfect, the presence of a coagulum effectually preventing its entire closure, the blood would be feebly propelled ; the extreme vessels would not feel the force of the heart's action ; their pulsations would be at first feeble, then gradually becoming weak, they would stop. The inaction of the vessels is the inevitable effect of the presence of a coagulum of blood in the heart and aorta, and that presence exhausts and fatigues the heart's action until death arrives. 54 This is a mode of death very different from that produced directly from collapse without reaction. In the latter case every evidence exists of the absence of the fluid blood — coldness, lividness, shrivel* ling, and contraction of the whole body. In the case of reaction occurring after the formation of the coagulum, there is evidence of the return of the fluid in the warmth and fulness of the vascular system. But a slowly increasing loss of power in the extreme blood-vessels comes on, with a gradual and final cessation of all action of the heart and arteries. Attending these symptoms in both cases, there exists disturbance in the brain, precisely like that which occurs in congestive fever, but owing to a cause very different in mere collapse, viz. the loss of the healthy stimulus of blood, and the absence of actual bulk in the contents of the vessels ; while in cases of reaction, there remain the consequences of the injury done the brain, by the first loss of fluid in collapse, which keeps up an unnatural state of that organ,- from the presence of urinous particles in its vessels, even after the restoration of fluid to the blood, the symptoms of which seem very much like congestion, yet they are certainly of a different character, since congestion cannot exist when the vessels are deficient in respect to their contents instead of being impacted with excess. In cases of recovery it is undoubtedly a fact that this cerebral disturbance is often succeeded by a true congestive and sometimes inflammatory disease, but this cannot possibly occur at a time when no fluid whatever is present in the blood-vessels, and the opinion, often dogmatically stated, deserves no more respect than philosophy usually yields to pedantry. Case 6 th. — W. A., Esq., a gentleman of 45 years of age, of robust and rather corpulent person, not more than five feet seven inches in height, and weighing about 160 pounds, sent for the writer on Wednesday the 18th of July last. He had on Tuesday, the day before, gone to the funeral of a son who had died on Monday in collapse from the present epidemic diarrhoea. Another son, just arrived at manhood, was then in collapse in the next room, who 55 died on the Thursday following.* Mr. A., on Monday night, had sat up with the corpse of his son although the day before, he had been troubled with a free diarrhoea himself, which he had temporarily checked with some popular mixture of opiate, astringent, and stimulant ingredients. During the funeral procession to the Greenwood cemetery, he suffered extremely from the motion of the carriage, the springs of which were not good, and he was subjected to constant jolting. At night he went to bed, complaining of severe pain in his bowels, some diarrhoea, and great depression of spirits. Grief for the loss of one son, and anxiety for the other, rendered his state of mind painful in the extreme, and served to aggravate the causes which were operating to prostrate his constitution under the epidemic influence which had proved already so severe a scourge to his house. When he was first seen by the writer, he was in bed, having, within half an hour, discharged from his bowels what he estimated at one gallon of fluid, of a straw color. His voice was husky or hoarse, his countenance contracted and blue, his hands shrivelled and corrugated, his respiration laborious and cold, and his tongue was cold. His urine had been suppressed all night, and of course, from the na - ture of his discharges, there was no bile. He had cramp in his lei' 1 , hand well marked, but it extended no further. The pupils were im movable, and contracted to the minutest point. His whole body wa, cold. In short, he was in collapse. He immediately took a tablespoonful of laudanum, as an enema, in an ounce of water. In less than ten minutes he said the violei:'. uneasiness of his stomach and bowels had disappeared. The cran^ was gone. He had not vomited, nor did he show any disposition t.< nausea. He drank several tumblerfuls of ice water with soi?i brandy, and became warm in proportion as he imbibed fluid. I. external applications whatever were resorted to. Sinapisms, whii ': under such circumstances are usually employed, were not used at ; * The writer had nothing to do with these cases, which were treated c. another system entirely than this. 56 at this time. Neither were frictions of cayenne pepper. Not even hot bottles were permitted. This point of practice had been previously so well settled, that the prescriber felt that there was no experiment in his committing the restoration of his patient's temperature entirely to the action of the lungs upon the circulation of the blood. His object was, therefore, to promote the use of drinks, which were sufficiently demanded by the sense of thirst of which he complained. In less than a quarter of an hour a manifest improvement had taken place. His surface was in a glow, and became red instead of blue. A warm perspiration took the place of an icy sweat. His fingers were less corrugated, and his skin had less plasticity, so that when it was folded and pressed it exhibited some elasticity, to which before it was a stranger. Under these favorable circumstances he was left to the care of his friends, with the direction to give him as much drink as he would take, and not to regard his vomiting, if that symptom should appear, so long as the action of the bowels was restrained. No more fatal error in treating this disease can be committed, than to regard the vomiting as the important symptom, to which all the energies of the treatment are to be directed. The noise and disturbance produced in the sick chamber by active emesis, the convulsiveness of the stomach's action, and the disgust felt at the perversion of its proper function, all conspire to clothe this symptom with an imjwrtance not due to it. These considerations pervert the judgment of the bystanders, who uniformly express their anxiety to have the vomiting allayed, and are more solicitous for the attainment of this object than to arrest the watery passages, which are at once the precursory symptom and the cause of the nausea and vomiting. Indeed, if vomiting be present, and even urgent, plenty of fluid renders it less painful to the patient, and its administration is altogether the best measure of treatment which can be pursued to quiet the stomach. At 2 p.m. on the next visit, the patient was found again going into collapse. The attendant declared that nothing had passed from the 57 bowels, and the collapse could not be laid to that account. Nc drink had been given him, however ; a fact which might have been owing to the grief and anxiety of the family. The ladies of the house were called to witness the effect of drinks in restoring temperature to hands, face, and feet, icy cold. One quart of ice water with a little brandy, again produced warm perspiration, and restored the temperature. The voice, countenance, and feeling of the patient promptly improved, and the effect on those who attended him was so convincing, that there was no deficiency afterwards in supplying him with as much drink as he would take. In the meantime it was found that the second collapse had been preceded by immense and unconscious discharges of fluid from the bowels. Thirty grains of tannic acid, in a little water, were employed as an enema. In half an hour it was discharged. Again used, it remained an hour. Both of these passages also were rice- Avater alone, but they were in small quantity compared with those which preceded them, and hope was entertained, though faint, of being able to check the diarrhoea altogether. At no time was there any fear entertained of coagulation having occurred, because the minute vessels of his head and extremities always continued to pulsate distinctly. During all this time the use of astringents by the mouth was not neglected. The chalk mixture was employed in the following form :—: — $ Cret. Prep § ss. Pulv. Gum. Arab. Sacch. Alb. aa.3ij. Tinct. Opii 3 ij. Tinct. Kino §j. Aq. Purae g v. M. At first a wine-glassful was given, and every hour after, a table spoonful. The last discharge of water was at 5 o'clock, P. M. 3* 58 At 7 P. M., at the suggestion of the patient himself, a consultation was held with Dr. Horace Green. The result was a trial of a grain of acetate of lead, and an eighth of a grain of opium every two hours. This prescription was used six times. But no return of the diarrhoea, whatever, took place after the discharge at 5 o'clock, except an insignificant moisture not amounting altogether to two ounces. During Wednesday night, Mr. James A. Purdy, an indefatigable student of his profession, and pupil of the writer, watched with him, and carried out the treatment directed, viz. the use of the astringents, cordials, and diluents. In the morning Mr. A. was better, but the pupils still remained contracted and insensible to light, the urine absent, and the skin slightly plastic and somewhat deficient in elasticity. No alvine evacuations had taken place, and he had no appetite for food. During all Thursday the same feebleness of circulation remained, and a prescription of super-sulphate of quinine was used, in grain doses, every hour, until fifteen grains were taken. The effect was most salutary. The vessels of the skin recovered tone, perfect elasticity returned, the color became permanently natural, the sweats were less copious, but still no change in the pupils was observed. Dr. Green saw him a second time on Thursday morning, and concurred fully in the general views of the case which had been taken. On the evening of Thursday the abdomen became tympanitic and painful. Some relief was afforded by the introduction of a tube into the intestines, but it was imperfect. Upon a careful examination of the abdomen, the region of the bladder was found on percussion to denote the presence of fluid, and as it was impossible for a discharge to be procured naturally, a catheter was used, and more than a pint was removed, to the great relief of the patient. It was with no slight interest that the condition of the pupils was now observed. The connexion of this secretion with their state is obvious, and the benefit to be derived from the re-establishment of the action of the kidneys is a matter certainly of much more importance 59 than the state of the liver. It is familiar to everybody that bile m be in excess and absorbed into the general system, as in jaundic without any immediate evil ; or it may be deficient for some tiir. without inducing any serious injury to the constitution. Not ; 'with the urine. The absorption of its particles into the system is ir. compatible with the healthy action of life. " Suppression of urii; leads sooner or later to very serious consequences, more particular! by producing a cerebral affection, which for the most part terminate fatally." — Macintosh's Pract. of Physic, vol. ii. p. 309. Again tlr same author says, loc. citat. : " For the most part this disease i speedily fatal, by producing diseased action in the brain, terminatin; in coma and death." Sir Henry Halford, in speaking of a case of suppression of urine said, " the patient sat up in bed and conversed as usual, complain ing of some nausea, but of nothing material in his own view ; and ! remember that his friends expressed their surprise that so much in portance should be attached to so little apparent illness. Th patient's pulse was somewhat slower than usual, and sometimes h< was heavy and oppressed. I ventured to state," continues Sir Henry " that if we should not succeed in making the kidneys act, the pr tient would soon become comatose, and would probably die the fo' lowing night ; for this was the course of the malady in every othx instance I had seen. It happened so ;he died in thirty hours aftx. ; this in a state of stupefaction." Multitudes of authorities can be obtained in substantiation of tl, principle that the cessation of the kidneys' action is the certain ai direct cause of coma and contraction of the pupil, under oth conditions of the system. In this epidemic, when the same resv/ takes place from the loss of the fluid particles of the blood, it i apparent that it furnishes sufficient explanation of the ultimate ai. unavoidable effects upon the brain, denoted by coma and contract^/; of the pupils. Physicians should be prepared on this point, lest th fall themselves into the error of attributing to the use of an opir. 60 enema what is truly the direct and infallible consequence of the disease itself. This error should not be permitted to prevent the prompt and efficient employment of the remedy, and the friends should be relieved in reference to it by some explanation, which will strengthen their confidence and prevent the unfortunate influence of busy and opinionated acquaintances. To return to the case. On Friday morning the same condition of the brain continued, but in less degree, as was denoted by a small but manifest improvement in the mobility of the iris. The urine was again removed on Friday by the catheter. On Saturday the pupils were better. On this day the patient himself was able to discharge the secretion of his kidneys voluntarily. The eyes still improved. On Sunday the catheter had to be used, and again on Monday, after which no more necessity for its employment remained. It was not till Monday that the pupils were restored to a healthy action. The exact correspondence of this state of the eye with the condition of the brain manifested by more or less tendency to coma, and the connexion of both these symptoms with the amount of vigor of the secretion of the kidneys, were strikingly manifest in this case ; and while the subject is one of great intrinsic interest as a mere question of curious pathology, it is also of no less importance in point of practical usefulness. From this time the patient rapidly recovered. His principal nourishment consisted of a tumblerful of boiled milk iced, with a tablespoonfnl of brandy. All his drinks were cold as long as the great pathognomonic symptom of the epidemic, viz. the watery discharges, remained ; and as soon as the vessels of the bowels began to secrete air, a usual occurrence in the course of recovery, it was thought proper to change them for warm drinks. The effect of the change was found to be salutary, and the same thing is observed in other cases. No evacuation took place from the bowels until Sunday night, which was at the beginning of the fifth day from the final arrest of the watery diarrhoea. On Saturday night in 61 order to induce a gentle action of the bowels lie took a wine-glassful of the following gentle aperient : $ Syrup. Rhei Tinct. Rhei aa. ... § ss. Tinct. Opii .... 3j. Magnes. Ust 3 ij. Aq. Menth. Vir. ... § iij. M. The dose consisted of a drachm and a half of syrup and as much of the tincture of rhubarb, twenty-five drops of laudanum, and forty grains of calcined magnesia. The operation of this medicine aided by a purgative enema occurred in twenty-four hours after its administration, and although the discharges were perfectly natural in respect of the secretion of bile, a tendency to fluidity and copiousness admonished his physician of the danger of the recurrence of fluid passages, and it was thought proper to check its action by the use of a wineglassful of the cretaceous mixture before employed, which contains laudanum and kino. This had the desired effect, and the discharges were restrained. Since then his convalescence has been rapid, and at this time, Friday night, being the tenth day, Mr. A. speaks of spending a few days at the sea shore in order to establish his convalescence and recruit his strength. This case has been related in more detail than perhaps may be considered desirable by the reader, but it is thought to be so suggestive and fraught with instruction that it is hoped the writer's prolixity will be pardoned. It has been noticed in the previous edition of this little work, that Dr. Geo. Stewart Hawthorne's observation in more than a thousand cases in India went to establish the fact that no corpulent person had ever recovered from collapse. It is of course a subject of great satisfaction that the case of Mr. W. A. is an exception. To what cause is this to be attributed ? If it will not be put down to the charge of vanity, the writer would attempt the explanation by reference to the 62 different methods adopted by Hawthorne and himself, in the treatment of the case. The latter applies the opiate and anodyne to the large intestines. The former gives by the mouth twelve grains of opium, as much camphor, capsicum, and kino. Now if the reasoning on this point heretofore employed be sound, it follows that twelve grains of opium cannot have less effect on the brain in that method of administration than thirty-six grains would exert when given by the rectum, and still it would be unable to produce as much effect on the disease, because, as before mentioned, it is applied at a distance from its actual seat, of six times the length of the body. Now thirty-six grains of opium equal one thousand drops of laudanum, while the enema of a tablespoonful is about three hundred drops. It follows that the dose of opiate given by Dr. Hawthorne is in effect equivalent in quantity to twice or thrice as large an amount as has been practised by the writer. If Dr. Hawthorne gave doses of opiates so much larger as to affect the brain more than three times as powerfully as is done by the method recommended in this treatise, is it not possible that the latter method, being an undoubted improvement, may be on that account solely more successful ? This is sufficient to satisfy all who doubt the safety of the practice here recommended, for abundant evidence exists of the great success of Dr. Hawthorne in England as well as India, and the writer is by no means certain that he himself has succeeded in suggesting the best doses or quantities, although he ventures to entertain the hope that his principles are incontestable. Indeed his best observation has induced him — in cases, too, which have been successful — to doubt if he would not better have given at first a still more powerful enema. In the case of Mr. W. A. it would, very probably, have been an improvement. Case Ith. — William Haswell, an Irishman, a shoemaker, in the employment of Mr. Raymond, No. 236 Third Avenue, sent for the writer at 6P. M., on the 10th of July. He was found in complete collapse from the epidemic diarrhoea. The disease had been constant, 63 and the discharge profuse on that day, and the two days preceding it, but without pain. It had produced no apprehension, and was not accompanied with the usual exhaustion and feebleness which so generally prevails, so that up to the last hour he had continued at his employment of shoemaking. Suddenly he became excessively thirsty, and complained of burning at the stomach -and in the bowels ; violent cramps attacked the extremities, and were universal. He was cold and blue. The case presented a perfect specimen of the most complete collapse. His eyes were sunk, the nose pinched, lips thin, cheeks membranous rather than flesh-like, the voice a hoarse whisper ; the urine had been absent all the afternoon ; the pupils were mere pinholes in size, and motionless to the light ; a corpse-like coldness pervaded his whole surface ; the tongue was perfectly cold, and the breath itself icy ; the pulse small, and about 100 in the minute. He had just discharged three quarts of pure water, and for the first time without going out, because he was unable to do so. He was vomiting a little water almost incessantly. An injection of half an ounce of laudanum, with some water, Avas given, and in thirty minutes he said his pain was relieved, and he never had another cramp. Cold water was given him in large quantity, and before nine o'clock he had drunk three quarts, and a little brandy. He took some camphor, laudanum, capsicum, and kino every hour, by the mouth. At nine at night he was again visited, and found to be comfortable and without thirst. The skin had changed color. The face was red, and a warm perspiration covered the whole body. It was impossible, except on testimony, to recognise him. He had already filled up, so that he was probably six pounds heavier, for indeed he had drunk six pounds of water, and had discharged none. In the evening he said he had slept well, and his pupils were perfectly natural. One visit the next day, and one the day after, during which he had drunk chicken tea and eaten some broiled chicken, with mustard, and drunk some brandy with ice-water, was all that 64 was thought necessary in the way of subsequent attention. During the whole time he faithfully kept his bed, and preserved the recumbent posture. He was entirely well, and on the fifth day resumed his usual employment. Case 8 th. — J. 11. C, a gentleman from Scotland, called at the writer's office at about 1 o'clock in the evening of June the 19th, and said that on the day but one before, he had dined out at a friend's house, and had imprudently indulged both in food and in taking several glasses of wine ; that the next day he was unwell, and had been affected with nausea, loss of appetite, and slight diarrhoea. During the next night he slept badly, and was disturbed with dreams. On the morning of the 19th his diarrhoea became profuse and watery, and his discharges grew thinner and larger, until the last passages were perfect rice water, and very copious. He had a burning thirst, and felt precisely as formerly in India, where on two different occasions he had been in collapse, and was not expected to live. He wished he was there then. He said that he had been treated as early in the case in India as he was at this time, and he knew from his sensations that in a few hours he would be in collapse. His physician at that time was his father, who is Surgeon General of the Hon. East India Company's army. In India he was treated with calomel and opium, and he seemed to regret that he could not be so treated here. Fearful of the loss of time he was not permitted to go home until something effectual was done. Taken into a back office, and directed to lie down on the sofa, an enema of laudanum of half an ounce and a little water was in course of preparation, when he had to retire, and on his return he declared that four pounds of fluid at the very least had passed. The injection was then used. He took the same stimulating anodyne and astringent mixture given to the last patient, and drank, in the course of three hours, as much as three quarts of ice water with brandy. His burning heat, thirst, and uneasiness left him, and he declared himself, in his own feelings, well. He was taken home in a carriage at 65 ten o'clock, slept well that night, drank chicken tea in large quantities, was seen twice the next day, and once the day after. The next day he was well enough to resume his usual avocations, and has remained well since. This case is valuable, as the patient had experienced in India, under the best administration of the old treatment, the consequences of the calomel practice, and had then not escaped collapse. He was sure of going into that state, and was a good judge both of his own condition and of the relative advantages of the different modes of treatment. Case 9th. — On Tuesday morning, a little after 4 o'clock, having been employed in his office, the writer was called in haste to the house of Mr. Thomas Whitlock, in Thompson Street, near Prince. Mr. W. had sent a carriage, which was rapidly driven, so that no time whatever was lost. Loss of time is loss of life at a particular juncture of this disease. He found a servant woman on the floor of the garret in perfect collapse. Notwithstanding the repetition it involves, he will again mention the symptoms. Violent and universal cramps — absolute bluenes — icy coldness of skin, breath, and tongue — vomiting and purging of rice-water — gastric and abdominal agony, and sense of burning — pinched and contracted features and form — no urine — minute contraction and perfect immobility of the pupils — feebleness of pulse, with the rapidity of one hundred in the minute. Her lips were thin, like membrane, and the skin seemed to hug the bones as if the flesh Avas gone. She had just discharged from her bowels what seemed to be all the water of the blood, and she seemed mummied and exsiccated. The injection of four drachms of laudanum, and the use of the mixture of astringent, anodyne, stimulant, and cordial remedies, were immediately used, with brandy and plenty of ice-water. She drank more than a quart on the spot. Like magic all her symptoms disappeared except the contraction of the pupils, which was gone the next day, when the secretion of the kidneys was restored. She had no more 66 cramps ; the pain of the abdomen vanished ; vomiting ceased ; heat rapidly returned ; and by forty minutes after leaving his own door, the writer was seated at the employment which had kept him up during the night. That evening she remained comfortable, and her thirst had entirely ceased. Chicken tea was ordered in place of ice-water, with a tumblerful of milk punch three or four times a day ; and a natural discharge from the bowels happened on the fourth day. She rapidly recovered. There was no irregularity in the bilious secretions whatever. On the eighth day she resumed her employment as cook. She was alone by force of command and threat of instantly leaving the house, kept in bed for three whole days, and to that, and the great promptness and kindness of her mistress, she owes her life. More cases of similar character, and a multitude of less severity, might be added, but they are deemed unnecessary. GENERAL REMARKS. Out of seventy cases which have, since the first instant (and this is the 27th of July), come under the writer's care, not one has yet died ; nor is he apprehensive of the death of any now under his treatment, except cases in consultation, for which his practice is of course not responsible. Much of this success is doubtless owing to having prepared his patients by a full explanation of the character of the disease, and to their own promptitude. He feels himself obliged, however, to acknowledge that, in general, the great respectability of the persons who come under his care, has given him unusual advantages; and in behalf of many gentlemen whose j^ractice, being among persons not able to make proper provision for their wants, or to obtain aid in nursing,