A report, &c. on cholera morbus
Chawner, Darwin
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ON CHOLERA MORBUS, BY DARWIN CHAWNER, M.D* NEWARK: PRINTED AND PUBLISHED BY S. AND C. RIDGE. SOLD BY SIMPKIN & MARSHALL, LONDON ; AND ALL OTHER BOOKSELLERS. MDCCCXXXII. fiJSTCfftCAL iicDiCAL TO THE MEMBERS OF THE BOARD OF HEALTH, IN NEWARK, THIS REPORT, READ AT THEIR MEETING, AND PUBLISHED BY THEIR UNANIMOUS REQUEST, IS INSCRIBED, WITH EVERY FEELING OF OBLIGATION, BY THEIR VERY OBEDIENT SERVANT, THE AUTHOR. Newark, January 21, 1832, In giving a larger puhlicity to a report^ hastily ivritten, of my observations on Clioleray while 1 acknowledge the kindness displayed by those individuals who heard it read, and who, in the handsomest manner, requested its publication , I feel the more sensible of its deficiencies. To each of my readers, general and professional, I xvould address the observation, in the same spirit in which I feel its force: — Si quid iiovisti rectiiis, candidus iniperti ; Si non, liis iitcre meciim. nc * ." ’'‘“'k ■' “i® ■- Y' , i t /: S’A,\ ’v- r * ’ *■ .‘Hi {'Ite.'vS^V', iSVv.,' *'k ,t’ ^ ’ f-kiT rvki'itti.Y*-* ■• JiK'/ni;' )i' ’'^ .^: T - ** • -■- . *- -^T ;4ff. ;| >^/i;1^|f ' - df »n^U ; \ • : ‘ •;.. 'f' t ■ Vi^:' . .. biMfl/ "" ‘ ’ * ^'Is. ’.W w .wirnir IP j*# '•.« ||gte )»-m , *-] -> .M(liMAm[V«*,K- 1)PM|^ .J^ ■■’* <ak)[ .j,. ^. •^, Sr ^ '■ ^ ■ If '' 0' t ,• I ir-.w ,2^. * .% REPorrr, &c. IN offering to the Board of Health the result of my recent visit to Newcastle and Gateshead, I beg at the outset to avow my determination to confine myself entirely to those facts which came under my own notice ; or which were communicated to me from unquestionable authorities residing on the spot. Instead of advocating one or other of the hypotheses which have been set forth rela- tive to the nature of the disease, my principal object was, from personal observation, to de- tect the erroneous and false information which, I feared, was generally disseminated by the public press ; as well as to inform myself of that rational way of treatment, which being the result of experience, is the only safeguard against the dangers of Empiricism. And I was the more inclined to adopt this resolution, A 8 from observing the conflicting’ opinions vvliich pervade the iViedical profession, both as regard the nature of the disease, and the period of its first appearance in England. In my own private opinion 1 may adv^o- cate a particular view of the nature of the disease, but I am anxious that this paper, which I have the honour to lay before you, should simply contain the result of personal investigation; leaving it to every Medical man to form his own opinion, and only claiming for myself that privilege of judging, which 1 am most willing to concede to others. I trust my communication will be received with that indulgence, for which the haste in which it has been arranged, furnishes iny apology ; but, I confess, I felt anxious not to defer laying it before this Board, at the earliest opportunity. Although mv visit to the District of the Disease was verv short, yet wdien I inform vou of the opportunities of observation which I enjoyed ; and when 1 say, that during the time I w^as at Newcastle, 1 was permitted to accompany different Physicians, who usually visited their private patients every 9 tliree or four hours, it will he seen tluit I had ample opportunities of‘ becoming' accpuilnted with the peculiarities of the disease. Four Cholera Hospitals were open to me ; the pri- vate patients of the several Medical men, (particularly selected to superintend the Cholera cases in their respective parishes) were at all times accessible to me, and I was invited to otter any suggestions that might strike me; an offer, of which, in some instances, 1 availed myself. Whilst I was at Newcastle and Gateshead, I saw considerably more than Otie Hundred' patients ; the result, of course, marked by various success. These cases presented the varied symptoms incidental to the disease occurring’ in all the different combinations, which they assume in each particular stage ; and I hesitate not to express my firm opinion (though in declaring it, 1 am subjecting myself to the remarks of those who consider personal investigation useless) that Personal IxNVESTiGATiON, and it alone, has afforded satisfaction to my own mind : for I am free to confess that many of the opinions which I had formed, from reading and report, were not borne out by my experience on the spot. 10 When first I arrived at Newcastle I expressed regret that I had deferred my visit until the Epidemic had, in some degree, subsided, and that I did not see the disease at its height. This regret, however, was imme- diately removed by the very sensible and judicious observation of a Medical friend : that when first the disease appeared, an unusual excitement pervaded the profession ; but that now, while the fatal cases were happily of rarer occurrence, they were still ‘^Too frequent: and in place of the crude suggestions, and necessarily empirical treat- ‘^ment, resorted to on its invasion, the most violent cases were now treated in that syste- matic and practical manner, which, if it too often failed in curing, yet was generally more successful; and, at least, possessed the ‘^advantage of being dictated by reason, and regulated by experience.’’ The cases which came under my own notice justified the propriety of my friend’s observation, and their treatment reflected tho highest credit upon the Medical skill displayed by those members of the faculty, who were particularly called upon to treat the disease. From the official reports, while I am 11 happy to find a great mitigation of the disease, I see additional reason to congratulate myself upon the time I selected to visit Newcastle. I hope that some advantage will accrue from my visit to Newcastle, should the disease, in its progress, reach this neighbourhood, my experience would enable me, I trust, more successfully to combat it ; (or which is most ardently to be desired) should we be exempt from its attack, some unfounded apprehensions may have been allayed. I venture to make this observation, suggested, in the first instance, by the kindness of personal friends, who have expressed themselves to me in these terms, and I trust my report, when generally known, may produce the same effect upon all who read it. The propriety of the term CHOLERA, as applied to the disease, it is not my province to question. With the derivation of the word, all my Medical hearers are familiar. To enter into a vindication of the term, would be to involve myself in hypothesis, which would be foreign to the ultimate object of this report. 12 Cholera Morbus, like diseases in general, has its STAGES, VARIETIES, and DEGREES, and according to these circumstances, must the treatment be regulated. In the majority of cases which came under my notice at New- castle and Gateshead, THREE stages of the disease might be distinctly marked : (and I again repeat, that my observations are intended to apply solely to that form of the disease which came more immediately within the range of my own inspection). The three stages are as follows : — 1st, The Premonitory Stage ; 2dly, The stage of Collapse, or Blue State; and 3dly, The Consecutive Stage. I adopt these terms, as they appear to me to be quite appropriate, and also as being in very general use amongst the Medical men of the district. The stages vary in degree and in duration. (1). The first stage will sometimes be prolonged for a week, or even for a longer period. In many instances it continues only for a few hours, when the Blue State or Collapse supervenes : and too constantly, the attack is so rapid and violent, that cvei\ 13 the stag-e is with difficulty distinguished. The Premonitory class of symptoms consist of a disordered state of the stomach and bowels, in many instances so slight as not to have attracted attention until strictly enquired into ; but when particularly questioned it will be found that the patient has experienced slight affections in his bowels for a few days, of wliich he took no notice, having suffered no pain ; his appetite remained good, and he continued his usual employment, until these slight symptoms became so urgent, as to com- pel him to have recourse to medical assistance. This stage commonly begins in the night or early in the morning. At this time the patient suffers from pain in the stomach and bowels, accompanied with diarrhoea, his spirits are much depressed, and his evacuations are sometimes dark and offensive : they become watery and mingled with unhealthy faeces : they shortly assume the appearance of rice GRUEL. In some instances 1 have seen this peculiarity at the commencement, attended with occasional vomitings of the same kind of matter. Cramp accompanies these symptoms, and becomes gradually more violent and fre- quent. The cramp and vomiting curiously commence and recur together. The pulse in 14 the patients I saw, in this stage, was not unusually quick, but unusually ; though in some cases, I am informed, it has been observed to be full and hard, with symp- toms of increased action, approaching to fever. The skin is cool and moist; the fea- tures arc relaxed ; the tongue is sometimes loaded at the root, with a red tip ; and at other times altogether red ; or presenting a natural appearance. The disease, with judi- cious treatment, and occasionally without any medical treatment, has been known to cease at this stage, and not to run into the second. Examples of the degree of Cholera I have just described, were those ranked by Dr. Daun, when the disease first appeared in Sunderland, under the head of Diarrhcea : he afterwards altered this plan, and reported all cases under the term Cholera : for he observed that precisely the same symptoms would, if in- creased beyond a certain point, rapidly progress till this most dreadful malady arrived at its height. On enquiry, I found that those persons most experienced in the disease, were unable to distinguish, at this stage, whether the case would terminate here, or run throu2:h its most fatal form : this depending upon the strength of the secret morbific cause, and the 15 power of resistance in the constitution of the patient. However dissimilar the forms of the disease may appear, no generic difference has been observed between them. This want of distinction was commonly admitted in India, and even the cases marked by bilious vomiting and purging, instead of the rice gruel form of evacuations were still ranked among the milder forms of Cholera. It is worthy of observation, that such deviations became more frequent as the epidemic declined. The Premonitory symptoms having been noticed, I have now to speak of the second stage, viz. that of Collapse or, as it is expres- sively termed by some, the Blue State. This stage more particularly characterizes the malady. Under its violence, in a few hours, the most vigorous frame will be prostrated, in spite of every human effort ; for the gripe of the disease seems to have fastened upon each vital power. The first patient I saw was in this stage, and I did not hesitate to declare it was, to me, a new disease. In fact, no malady is more fatal in result, or more dreadful in aspect. B 16 The Cramp, in most instances, thoiigli not invariably, becomes more violent and fre- quent ; vertigo often ensues ; the surface of the body cold ; the pulse is scarcely percepti- ble ; the countenance blue, anxious and pecu- liarly resembling* old age ; this symptom is so remarkable, even in the early period of this stage, that when once seen it cannot be easily forgotten; the vomiting incessant; the secre- tion of urine entirely suppressed ; and all the vital functions wane. These symptoms are succeeded by a sinking eye, surrounded by a dark areola ; a nose pale and compressed ; lips livid ; tongue cold ; and the breath issuing forth from the mouth like a chilling curi’ent of air. The pulse is entirely lost ; the voice changes into a shrill whisper, and appeared to me to be formed only in the throat. This pecu- liarity is such as to have acquired the term Vox Cholerica. The hands, previously cold, become withered, and the nails livid. — - The mind of the patient is strongly impressed with an apprehension of death ; in many cases there is a continued moaning, interrupted only by hiccough ; a sensation of oppression on the heart is felt; the weight of the bed clothes becomes oppressive ; a change of position is constantly required, though instant danger 17 attends the slightest exertion. The cry of the patient is, “ 1 am burning to death, give me cold water.” The body meanwhile is ex- tremely cold. The scene now is about to terminate ; the eye becomes still more shrunk, glassy and half closed ; the eyelids often loaded with a mucous discharge ; the features more haggard and covered with a cold sweat : indeed the patient from whose case I drew this description, more resembled a mummy, than a living being. One remarkable feature attends this malady, viz. the retaining the intellectual faculties almost to the last ex- tremity. In India it was observed, that those cases in which the symptoms of retching, spasms, &c. .had been more than usually violent, and which by a common observer might be considered hopeless, became tractable : and in the most fatal cases the same symptoms were slight and quickly ceased, nay, even were not observed. Should the strength of the constitution and the natural powers retain sufficient energy to enable it to throw off this stage of collapse : or should medical skill have been successfully employed, the patient has 18 still to encounter the clangers of the third or consecutive stap'e : for it has been observed, and the remark is most just, that every reco- vered patient is twice saved. A very different class of symptoms is exhibited in this stage of re-action to those which have been pre- sented in either of the preceding. The vital powers having recovered from the pressure of the collapse, in turn require moderating. The first symptoms of re-action may be thus described. Nature gradually reviving, begins to develope a degree of animal heat. The features and hands become less blue, the pulse returning at intervals, ulti- mately is found quick and hard, the vomiting and purging having for some time gradually ceased — the excretions ( which it is most impor- tant to observe ) become changed in their appearance, often assuming a greenish or dark cast favourable in prognosis : — the secretion of urine, before so totally suppressed, is re- stored ; the face becomes flushed ; the tunics of the eye much suffused ; the tongue dry, red, and cracked ; there is generally pain on pressure in the region of the stomach ; head- ache is complained of ; a state of coma super- venes with restlessness ; impatience of distur- 19 bance is exhibited ; when roused the patient will answer questions ; in fact, this stage fully established, resembles a degree and variety of typhus fever, sometimes termi- nating fatally ; at others in a rapid conva- lescence, and the same remedies commonly used in that disease have been very success- fully administered in this stage of Cholera. I may here be permitted to observe, that although great variety may mark the symptoms of this disease in other countries ; the disease still maintains its identity. Other si^ns of 4/ O the disease, unfrequent and anomalous, might have been detailed : these I have intentionally avoided. Aware that my paper claims only to be a report, and does not profess to be a treatise, I have only mentioned those symp- toms which will, I trust, enable any person to recognize the disease. I am conscious, however, that both in description and in detail, I have omitted much which might beneficially have been remarked. I have now finished my description of Cholera Morbus : it remains for me to speak of the treatment — would that I could say the cure of the disease. 20 Every remedy that ingenuity can suggest appears to have been tried, but we are still looking for a specific. I am sorry to declare it to be my firm opinion that the research is hopeless. By specifics must be understood such remedies as infallibly produce given salutary effects, under every circumstance of the disease to which they are applied : — acting by some unknown or occult power, as bark, mercury, sulphur, &c. on the disorders for which they are respectively prescribed — these and such like are the boasted remedies of empirics. In general, however, as the knowledge of sound science has increased, these vaunted specifics have disappeared, and systematic treatment is regularly adopted according to the indications of the disease. It is to be lamented as producing no beneficial result, that some members of the profession, far removed from the disease, continually busy themselves with not only suggesting to the public, through the medium of the press, supposed specifics, but also trouble those who are obliged to encounter the 21 dii^^order, with their fancied remedies. Notliing’, indeed, appears to me in theory, and I have observed it in practice, more calculated to retard a patient investigation into the syste- matic treatment of Cholera, than the mania for specifics. Indeed universal experience of disease, while it has proved the non-existence of specifics, might have suggested the hopelessness of any such being discovered for Cholera. I may here advert to what have been termed Cholera doses: the exhibition of which, we know, to be common in India, (with Asiatic Cholera I have nothing to do) for during the prevalence of the Epidemic, few people were without them: the consequence of which was their frequent malappropriation, for whatever symptoms of disease presented themselves the Cholera dose was invariably resorted to. — This practice prevailed to a degree in Sunder- land : for I was informed by a Physician, deputed from a Board of Health to investigate the disorder, that great difficulty was expe- rienced in distinguishing between the appear- ances of original disease and the effects of the administration of Cholera doses ; patients 22 being* constantly found under the full influ- ence of the narcotic powers of opium. And the same physician gave it as his decided opinion — the propriety of which must be admitted — that these effects of opium fre- quently accelerated the fatal termination of a case, which under other treatment might happily have recovered. In a subsequent page a few directions are given relative to the most advantageous plan of treating incipient symptoms. When I state that the following catalogues of remedies, with many others, have been applied, and the most opposite under the same circumstances, having their advocates, it will be admitted that no specific can be selected from among them. Bleeding, the exhi- bition of Cayenne pepper, phosphorus, turpen- tine, ammonia, emetics, calomel, opium, hot- baths, brandy, the inhalation of oxygen ; the exhibition of injections, whether of infusion of tobacco, or simply of warm-water, the appli- cation of mustard plasters, blisters, boiling- water, and even the actual cautery, have been in frequent use. I proceed to state the remedies usually resorted to in each stage ; and although I shall detail one or two cases, yet I prefer 23 rather giving the result of wliat T saw, in the form of deductions, than swelling out my report by a multiplication of examples. I shall mention some remedies separately, and afterwards shall lay down a summary plan of treatment for each stage. Bleeding has been used in every stage. In the first stage when the pulse is found full, and the strength of the patient is deemed capable of bearing the loss of blood, this remedy has been so strongly recommended, as even, by some, to be thought a specific. I shall P'ive the details of a case as far as O circumstances permitted me to remark them, D. W. aged 50, a stout and powerful man, a spirit drinker, was seized on the 29th of Dec. last with purging, which continued all night. No vomiting; violent cramps in his limbs; pulse hard and small ; bled from a large orifice to about 30 ounces ; blood coagulated firmly, shewing the usual appearances ; a little faint after the bleeding; voice restored, though before whispering; vomiting followed the bleeding; free from pain; tongue white and moist; an emetic of common salt was admi- nistered, after which calomel in doses of 10 grains were repeated six times at intervals. c 24 Dec. 31st, no cramps ; feculent stools; pulse feeble and morbidly slow; hand shrivelled; blue fingers ; no urine; tongue dry ; calomel and opium continued in moderate doses until January 4th, when the typhoid state super- vened, with frequent bilious stools ; urine became copious ; but the patient died comatose on the 9th. Though the details in this case are very imperfect, yet they prove that bleeding is no specific, though tried to a full extent, and under favourable circumstances. Another case in which I recommended the use of the lancet, may be not inappro- priately introduced. J. C. aged 30, was attacked about 4 o’clock on the morning of January 9th with bowel complaint.. He was a very stout man. He was visited at 9 ; took a dose of 15 grains of calomel and 2 of opium ; and warm water injections were repeated hourly; at 2 o'clock, P.M. he was found with purging and vomiting of the rice-gruel matter ; eye sunk, surrounded with blue areola ; cold tongue and breath ; blue lips and whispering voice ; in- tellect quite clear ; hands cold, and fingers slightly livid ; pulse scarcely perceptible ; cramps slight ; the left arm was tied up to be bled, the veins looked very full and dark ; a 25 large opening was made and about 3 ounces of‘ blood were immediately obtained, after wliicli not a single drop could be made to How, thong'll every means were tried ; the blood presented a very thick appearance, resembling thin treacle. Exposure to the air produced a very slight change in the colour; no serum separated ; the coagulation was imperfect ; the symptoms remained the same after the loss of blood. Five grains of calomel and 07ie of opium, were ordered to be given every hour, till visited again ; with injections of warm, water. Twelve o'clock, p. M. no pulse; vomit- ing, purging, and cramps remain ; still the countenance rather improved. A mustard plaster applied to the pit of the stomach for 20 minutes, at the end of which time it was removed, owing to the desire of the patient ? the pulse had returned ; four other plasters were applied in succession to different parts of the lower extremities. Tuesday, 4, a.m. left the patient much better, pulse steady, and the animal heat considerably returned. To continue the calomel and opium in half the quantities with the use of the warm water injec- tions. Three^ p.M. Evacuations green; pulse still more improved ; vomiting ceased. It was the opinion of all the medical men, who saw this 26 case ill its earliest stage, that it was hopeless. On Tuesday night, he had lost the symptoms peculiar to the blue state, and was considered in a fair way of recovery. In this case no stimulants were administered, even in the blue stage, though a very slight loss of blood had taken place. Bleeding, under some modifications of Cholera, may be highly useful ; but I had few further opportunities of judging of its effects than these two cases afforded me. The use of stimulants (as phosphorous, turpentine, Cayenne pepper. See.) has been prescribed to the greatest extent in the stage of collapse; and although attended with little, if any, benefit, their use appears strongly indicated. The result of two cases, both in the blue stage, placed in opposition to each other, forcibly proves the inefficiency of these remedies. In the one case, six ounces of undiluted spirit of turpentine were administered in two lioiirs without any perceptible efteds; the 27 actual cautery was applied down the whole length of the spine, and the patient shortly died. The other patient was bled in this stage ; took no stimulants, and yet ultimately recovered. The following case was treated on a somewhat stimulating plan, in a Cholera hospital ; and I subjoin the details furnished by the surgeon of the Institution : — M. A. admitted January Sih, 1832, aged 20. This patient came from Corbridge, (a small town 16 miles west of Gateshead), where no Cholera had yet appeared, he was perfectly well when he reached Gateshead on the 6th ; he went to a lodging house situated in Pipe- well-gate, a low, dirty, narrow street, in which the very outcasts of society reside, and in which upwards of thirty persons had died of Cholera since the 25th of December. None had been attacked with the disease in the house in which the patient went to reside, nor had he, to his own knowledge, ever been where the disease had existed. Seventh, 8 o'clock, A.M. His bowels were regular, but at that hour he was attacked with violent purging, whi ch continued all day ; during the night of 28 the 7th, he was attacked with severe pain in the stomach and bowels, and immediately after vomiting; stools watery. Eighth, 1 o'clock, A.M. Cramps in legs and thighs ; I was called to him about 9 o’clock, and found him in a state of collapse; no pulse; slight lividity of fingers, and underneath the eyes; cold tongue; cold nose; cold breath; cold surface. Al- though, from the first moment I saw him, I considered it a hopeless case, I immediately had him conveyed to the hospital. Patient much depressed ; a conviction of approaching death; still no pulse. Took 13 grains of calomel and two and a half of opium. Had an injection of three pounds of warm water, with a drachm and a half of laudanum. — Twenty riiinutes to 1 o'clock, P.M. No pulse ; (used dry cupping for 1 hour on first entering the hospital.) Took a draught with 10 grains of the carbonate of ammonia, and 30 drops of spirits of camphor. One o'clock, p.m. Had an injection with an ounce of rectified spirits of wine in a pint of gruel. Five minutes past 1 o'clock. Took a draught with 10 grains of the carbonate of ammonia, and 30 drops of spirits of camphor. Ten minutes past one o'clock, p.m. No pulse in right arm, but perceptible in left; surface warmer ; pain in sides diminished. — 29 Eighteen minntes past 1 o'clock. Expressed him- self as feeling easy, but burning hot voice sinking. Tiventy minutes past 1 o'clock^ P.M. Took a draught with 10 grains of the carbonate of ammonia, and 30 drops of spirits of cam- phor. Twenty-two minutes past one o'clock, P.M. Pulse the same in both arms ; tongue warmer. Had an injection with an ounce of rectified spirits of wine in a pint of gruel ; dejected immediately. Fifteen minutes before 2 o'clock, P.M. Still easy ; pulse 100, small in left arm, scarcely perceptible in right ; tongue still warm. Two o'clock. Pulse 100 in both arms. Fifteen minutes past 2. Pain in stomach ; pulse again lost in right arm; tongue cold. Took an ounce of brandy in warm water ; had the injection repeated, and 5 grains of calomel. Twenty minutes past 3 o'clock, P.M. No pulse ; tongue cold ; surface a little warmer. The in- jection to be repeated with two drachms of laudanum every hour. Four o'clock, v.M., No pulse ; surface cold ; cramps returned in feet. The stimulants repeated. Half-past four o'clock, P.M. Pulse again perceptible in right arm. Five o'clock, P.M. Had an injection with an ounce of rectified spirits of wine in a pint of gruel : dejected immediately. Half- past 5, No pulse ; great thirst ; surface cold ; 30 tongue cold ; countenance sunk ; lias not had a secretion of urine since taken unwell. Six o'clock, p.M. Patient is restless; complains of sickness ; pain at the pit of the stomach. Ten minutes to 7, P.M. No pulse ; evidently sink- ing-; annoyed if spoken to; lividity extend- ing-; surface cold and damp; tongue cold and dry ; great thirst. Eight o'clock, P.M. No pulse; surface cold and dry. Nine o'clock, P.M. Death. The inhalation of oxygen has been re- commended, with the most sanguine expect- ations ; and its failure caused great disappoint- ment to its advocates. Every person is acquainted with the peculiar change effected in the appearance of the blood by the inspiration of atmospheric air into the lungs. It was consequently hoped that the blue stage would be removed, and animal heat restored by applying oxygen in a concentrated form. This expectation was founded on false reasoning; for when we reflect that the inhala- tion of pure oxygen can only be endured for a short time, and that its supply is required to be 31 permanent and diluted ; the defect evidently lies in the system, not in the default of oxygen, but in the inability of the patient to appro- priate to himself that supply which nature affords. The same kind of reasoning is applicable to the use of hot baths of all kinds. They are intended to re-establish animal heat — but are found inefficient permanently to accomplish this, unable as they are to restore the healthy action of those vital functions necessary to the formation of this heat. I found their use at Newcastle and Gateshead almost entirely laid aside ; and Dr. Barry and others, have declared them to be xvorse than useless. It was generally observed that vomiting (during the first stage) though very constant was very generally insufficient to evacuate the contents of the stomach. It was therefore suggested to administer mild emetics, not only to remove the load that might be oppress- ing the stomach but to rouse the sinking power of the s vs tern. •/ The kind of emetics commonly used were either composed of flour of mustard or D 32 common salt. Both were tried in the first stage constantly, and with the greatest advan- tage. The effect of the emetic was most frequently to tranquillize the stomach for two or three hours, and to induce, in place of nervous irritability, a comparatively healthy excitation. During this time (perhaps the most important period for the administering remedies) calomel properly apportioned with opium must be given. Considerable caution is requisite here, for if the emetic be too power- ful, exhaustion will reduce the patient, and thus irreparable mischief ensues. A tea- spoonful of flour of mustard, or a table- spoonful of common salt in warm-water is the usual dose, to be repeated every ten minutes, until the desired effect is produced. The effect of emetics is, to clear the way for the favourable exhibition of the niost valuable combi- nation of remedies (systematically used) in this disease, viz. calomel and opium. An effective dose, of these remedies combined, should be administered as soon after the emetic has operated, as the state of the stomach wnll allow ; and smaller doses should be hourly repeated, particularly taking care that the patient does not suffer from the narcotic effects of opium, for although opium is most valuable 33 as a remedy, yet when too largely administer- ed the effects are highly injurious. ' These remedies should be then continued till some effect is evident ; and unless some different action, after their use, is evinced, the case generally terminates unfavourably. In con- junction with these remedies, the continual application of injections affords the greatest I’elief. So much so, that the hourly adminis- tration of warm-water, with a dram or more of laudanum was scarcely ever omitted. The injection of the infusion of tobacco has been used, and its efficacy has been mentioned in the public prints. From what I saw and learnt, although, in one solitary instance after its application the patient escaped, yet experience too soon evinced its dangerous, nay, directly fatal effects. Of the external class of remedies, mustard plasters are the best form of counter-irritation, and it appeared to me, when applied in succession, decidedly beneficial; blisters and boiling water have been applied with apparent benefit. The actual cautery has been once or twice resorted to in this country, but all who witnessed its application, regretted that it had 34 been tried, vvliatever may Lave been the report, froni the continent. The most beneficial mode of treatment appears to me to be as follows : — 'The disease in its first stage, should be encountered by a mild emetic, succeeded as before directed, by proper doses of calomel and opium. Combined applications of external warmth, to the extre- mities by means of bags containing heated sand, with warm^water injections afford great relief. Should the second stage supervene, the doses of calomel and opium must be con- tinued; which, in fact, are the only remedies that have been tried with any thing like systematic success, for violent stimulants, &c. have generally failed; in truth, no one can say what has more particularly succeeded in this stage. The third stage in its re-action, is so similar to some other diseases, particularly to those of the typhoid kind, and with which all medical men are so familiar, that I can only say it will be best met by such remedies as have been found advantageous in this type of disorders. I may be permitted to observe that almost every thing depends upon the early and 35 proper application of remedies in the Jirst stacre. In the second, or blue stage, when all the vital organs seem paralysed, no certain effect can be anticipated from the exhibition of ANY medicine. The difficulty to medical men, is to refrain from attempting* too MUCH. That natural desire, which at all times prompts us, to afford every relief which medicine can suggest, in the extreme state of cholera, dictates the application of those powerful remedies which the distressing appearance of the patient seems to demand ; but which experience has proved to be, if not decidedly injurious, at least useless. The report, as it was read by me to the Board of Health, is now finished and with the exception of a few verbal alterations, and the addition of one or two cases, which I considered perfectly useless to detail to unprofessional auditors, but which become greatly important in the way of confirmation, when submitted to the medical as well as general reader. In this report it will be seen that I studiously avoided, as much as possible, the introduction of all matters of opinion ; my own view of Cholera I give in an appendix. APPENDIX. At the request of several Medical friends, I publish this Appendix, containing my views of Cholera Morbus. My pathological opinions appeared to them clearly borne out by received physiological facts. Interesting as it is to view the assemblage of symptoms peculiar to Cholera, yet to trace the order of their succession is equally curious. My attention has been a good deal invited to the subject ; and I have been induced to follow it in many of its ramifications. I profess now only to give a compressed outline of what I may subsequently fill up. A variety of opinions have been formed as to the primary and immediate seat of the disease. The one most constantly enter- tained is that the nervous system, in some of its relations, is the first to suffer : — that its epergies are not only depressed, but its influences are become abnormal. Appearances certainly authorize the opinion that the nervous system is directly affected ; I think such opinion too general in its bearings to be efficiently brought within the rules of practice. If, however, we can point out what part of the nervous system is more immediately the seat of the invasion of the disease, we shall be enabled to reconcile, and adapt our curative measures more effectually to our inductive opinions. It roust be evident from a review' of the symptoms, that the organs principally and most directly affected are the stomach, lungs, and heart. Each of these viscera has to discharge peculiar and vital functions ; at first view apparently unconnected, but, upon a closer inspection, they are^ found so essentially dependant on each other, as to be directly united by the pncumogastric nerve. No part of the body has been APPENDIX. woro ably submitted to investigation than this nerve. Anatomists have pointed out its remarkable structure and distribution, which alone prognosticate some important rcsidts ; and the experiments of physiologists have gone far to point out their nature. The par vagiim, or pneumogaslric nerve, as termed by the French, from its destination, derives its origin from the lateral parts of the medulla oblongata, passes through the foramen lacerum, is continued through the neck and chest into the abdomen, associating, as is w ell know’n, the larynx, the lungs, the heart, the stomach, and the upper part of the alimentary canal. Near the pharynx this nerve is seen to become enlarged, softer, and redder, so as to present the appearance of a ganglion. In its course it is joincid by several others, particularly the great sympathetic nerve, and consequently is indirectly connected with pai'ts of the utmost importance. Its fiual distribution we have seen to be to the stomach and upper part of the alimentary canal : its importance here has been ably investigated by Dr. Wilson Philip, Mr. Brodie, and others. (1) The object of a series of experiments w'liich they instituted, was to shew that the secretion of the gastric juice was dependant upon nervous influence. Dr. Philip found that upon the division of the piieumogastric nerve, after it had emerged fi’om the chest, digestion was suspended; and imagining this opera- tion to be accomplished by the action of the gastric juice, he concluded that the secretion was necessarily dependant upon nervous influence. This conclusion, apparently educed with such, simplicity and clear- nerss, met with opposition from physiologists of great authority. (2) M. Breschet and Mr. Edwards performed similar experiments in Paris, and obtained modified results. They attributed the diminished efl'ects of the action of the stomach, after the division of the nerve, to the paralysis induced upon its muscular fbres ; in consequence of W'hich the diflerent parts of the alimentary mass were not duly sub- mitted to the action of the gastric secretion. (3) These experiments were repeated in London by Mr. Cutler, under tho inspection of Dr. Philip and Mr. Brodie, and it w'as found that when a portion of (1) See the Quarterly Journal, v. vii. (2) See Archives Generales de Medicine for August, 1^23. (3) Medical Chirurgical Review, v. p. 5S9. APPENDIX. nerve was actually removed, or the divided ends folded back, the process of digestion was suspended in the manner described by (4) Dr, Philip. The simple division of the nerve, and even the retraction of the divided ends, for the space of one-fourth of an inch, were not sufficient to prevent the transmission of nervous influence ; therefore the 23recautions above-mentioned were adopted, and the original proposition of Dr. Philips was consequently established, that the functional properties of the stomach depend upon the influence of the pneumogastric nerve. Experiment also proves that the peculiar functional properties of the respiratory organs depend upon the influence of the same nerve. Mr. Brodie shews that animal, or vital heat, is produced by the nervous influence communicated to the lungs, and not by the chemical process as laid down by Dr. Crawford. (5) Brande states that the chemical doctrine of animal heat, is completely subverted by the researches of Mr. Brodie. (6) Dr. 