ASIATIC CHOLERA
_A TREATISE_
ON ITS
_ORIGIN, PATHOLOGY, TREATMENT,
AND CURE_.
BY
E. WHITNEY, M. D.,
AND
A. B. WHITNEY, A. M., M. D.,
LATE PHYSICIAN AND SURGEON
To Diseases of Women in the North-Western Dispensary,
Visiting Physician, Etc.
NEW YORK:
M. W. DODD, PUBLISHER,
NO. 506 BROADWAY.
1866.
Entered according to Act of Congress, in the year 1866, by
A. B. WHITNEY, A. M., M. D.,
In the Clerk's Office of the District Court of the United States,
for the Southern District of New York.
E. O. JENKINS, STEREOTYPER AND PRINTER,
20 NORTH WILLIAM ST., N. Y.
DEDICATION.
TO PROFESSORS POST, VAN BUREN, METCALF, AND BEDFORD.
For those lucid Clinic illustrations and faithful instructions during
a three-years' course in the New York Medical University, particularly
the critical Pathological knowledge there inculcated, and consequent
professional success, the youthful author is indebted.
Knowing they will agree with him, that his appreciation of their valued
services, and his gratitude for the same, can be best acknowledged
in his attempt to benefit suffering humanity, he would here publicly
acknowledge the pleasure and benefit received from their instructions
during his College course, and beg their acceptance of his sincerest
gratitude and affection.
TO THESE ABLE INSTRUCTORS THIS VOLUME IS CORDIALLY DEDICATED BY THE
JUNIOR AUTHOR.
A. B. WHITNEY, M. D.
PREFACE.
The following pages are the result of investigations and the collection
of facts and arguments from a great variety of sources, originally made
and presented in aid of the discussions on the subject during the past
six or eight months.
The most eminent and reliable authorities for nearly half a century,
that is, from 1832 to 1865, including the late reports from India,
have been carefully examined, and such late discoveries, facts, and
arguments collected, as seemed to throw light upon the subject, or in
any degree to indicate or direct to a general principle of practice.
The various experiments instituted for the cure of the disease have
been carefully investigated, and the principle evolved explained
whenever any advantage was derived from the same.
In all these we have diligently searched for the cause of the failure
of "remedial agents," so uniformly admitted, and have endeavored to
present the results clearly and fully in the body of the work.
Our statistics are collected from reliable sources, are very brief,
and introduced in aid of the main object,--the establishment of a
general principle of practice.
The different modes of practice are from the most distinguished authors
of the different Schools of Medicine, and non-professional gentlemen;
condensed and exhibited mainly in their own language, to show their
conformity or non-conformity to the Pathology of the disease.
In all we have kept constantly in view the pathology of the disease,
whose "dictates" have governed us in the exhibition and establishment
of a general principle of rational practice, confirmed by observation
and experience, which, if accepted and carried out by the profession,
we hope and trust will save a very large proportion of those attacked
by "this most acute of acute diseases."
AUTHORS.
CONTENTS.
CHAPTER I.
SEC. I. ORIGIN AND DEVELOPMENT. 7
SEC. II. PROGRESS AND FATALITY. 20
SEC. III. CAUSES--PROPAGATION. 34
CHAPTER II.
SEC. I. PATHOLOGY. 45
SEC. II. PHENOMENA, OR SYMPTOMS. 55
CHAPTER III.
SEC. I. UNSUCCESSFUL MODES OF TREATMENT.--VENOUS
TRANSFUSION EXPLAINED. 64
SEC. II. PHYSIOLOGICAL CONDITION OF THE BLOOD, ITS
NON-AERATION, OR NON-OXYDATION.
MAXIMS OF RATIONAL PRACTICE SUGGESTED. 91
SEC. III. DIFFERENT MODES OF TREATMENT. 130
SEC. IV. STATISTICS. PERCENTAGE OF LOSS. VARIABLE
RESULTS--THEIR CAUSE. 166
CHAPTER IV.
SEC. I. GENERAL PRINCIPLE OF RATIONAL PRACTICE,
DICTATED BY THE PATHOLOGY OF THE DISEASE,
CONFIRMED BY OBSERVATION AND EXPERIENCE. 178
SEC. II. REMEDIES, RECIPES, ETC. 188
SEC. III. PROPHYLAXIS, OR MEANS OF PREVENTION. 203
SEC. IV. FORMULÆ--PREPARATIONS, ETC. 213
ASIATIC CHOLERA.
CHAPTER I.
SECTION I.--ORIGIN AND DEVELOPMENT.
Epidemics have occasionally prevailed in all ages. Sometimes they
have been circumscribed in their influence, and limited to particular
localities; while at other periods they have taken a wider range and
extended over larger sections, inflicting the most lamentable results,
and augmenting the bills of mortality to an incredible degree.
The earlier writers have given some account of these diseases, which
have occasionally prevailed as very fatal and devastating epidemics;
surpassing all other diseases in their mysterious origin, in their
rapid extension, and in the duration of their prevalence. In the
East,--in Egypt, and on the eastern border of the Mediterranean,
fearful epidemics have prevailed from time immemorial. They have often
proved very destructive, especially in the Middle Ages, and as late
as the sixteenth and seventeenth centuries. During the prevalence of
the "Pestis," which raged throughout Europe between the years 1347
and 1350, according to computation, a fourth part of the inhabitants
of this part of the globe was carried off. The estimates of the vast
numbers swept away by its repeated occurrence and prevalence appear
quite incredible.
During the time it raged at Marseilles in 1720, it is reported that in
the Charity Hospital there were admitted from October 3d to February
28th, 1,013 patients, of whom 585 died; and during the same period, in
another hospital, there were admitted from October to July 3d, 1,512
patients, of whom 820 died. The population of Marseilles previous to
the occurrence of the disease was estimated at about 90,000, of whom
40,000 died; leaving only about 10,000 of the whole population who had
not been attacked or in any way affected; so that the record shows the
appalling mortality of fifty per cent. of those who were attacked.
The bills of mortality in 1770 and 1771 were as appalling as any
arising from epidemics of a later day. A very extended notice of
the "Pestis" as it raged in Moscow in the year 1771 is given by M.
Gerardin, who, quoting from the published statistics, observes: "In
April, the deaths were 744; May, 851; June, 1,099; July, 1,708; August,
7,268; September, 21,401; October, 17,561; November, 5,235; December,
805"; making a total in nine months of 56,672, which is considerably
less than the estimate given by De Mertens, who thinks the whole
number carried off by this pestilence, from the city alone, cannot
be less than 80,000. These statistics bear a striking resemblance to
those of the Epidemic Cholera, whose fatality is materially varied by
the seasons of the year; the greatest being usually at the close of
Summer or the beginning of Autumn. There are, in short, many points of
resemblance in this and former epidemics to that of the Cholera, which
naturally lead to the supposition that all have had a common origin,
if, indeed, they be in many respects dissimilar.
Their pestilential character, their extended influence, and their great
fatality, rendered their appearance and progress a special terror to
physicians, and melancholy apprehension to the people. They seem to
have been regarded as the manifestation of an invisible power, which
directed and guided "the pestilence that walketh in darkness" and "the
destruction that wasteth at noon-day;" a visitation or chastisement
over which human ingenuity and medical skill had little control. Under
these impressions, the earlier physicians labored and endeavored to
satisfy the great mass of mind that these occasional and special
developments of disease arose from natural causes, and were subject to
certain natural laws. They ascribed their origin to the commingling of
some specific poison in the food, and drink, and air, which, through
these "media," was received into the system.
Subsequently, they seem to have made some advance on this theory, and
considered the extreme Summer heat--especially the intense heat of the
sun in a dry season--the emanations from stagnant waters, and the miasm
exhaled from the soil, and from putrid bodies of animals, as the chief
causes of all epidemics. These views prevailed for a very long period,
and have undergone no very remarkable change from the observations and
discoveries of centuries.
Modern and quite recent writers have advanced nearly the
same doctrines, embracing, however, the principal sources of
insalubrity--the malarious and miasmatic influences; and have assigned
as the cause of epidemics, especially that of Cholera, a peculiar
constitution of the atmosphere, and certain predisposing causes
combining with each other, so that an association or union of these two
independent and individual causes are necessary and essential to the
production of the disease.
Eminent scholars and pathologists have, during the century last past,
patiently searched for its final cause, without arriving at any better,
wiser, or more satisfactory conclusion than the earlier writers, who
regarded it a poison, commingled with the food they ate, the water they
drank, and the air they breathed. The modern writers, according to the
more popular views, almost universally adopt the hypothesis that the
remote or final cause of the Cholera is a specific poison; for at no
period has a person in good health in this or any other country been
known in a few minutes to be shriveled up, his face and extremities to
turn purple, his whole body to become of an icy coldness, and with or
without vomiting a peculiar fluid, like rice-water, to die in a few
hours, except under the influence of poison. That this disease, so
appalling and destructive in its effects, and so mysterious in its
wanderings, should spread over countries in respect to climate, soil,
geological formations, and as to the moral and physical habits of the
population, so utterly opposite to those where it first originated, is
only explicable on the hypothesis of its propagation on the principle
of a specific disease-poison.
How and in what manner it travels has not been satisfactorily
determined. Whether independent of any and all human agency, or
absolutely dependent on ordinary communication and intercourse of
tribes, and peoples, and nations, is as yet unsettled. It is, however,
a matter not of so much consequence as the fact that, in all its
nomadic life, it retains unchanged its youthful disposition, vigor and
energy. It seldom shows any inclination to associate, or coalesce, or
even adopt the milder habits and manners of others.
Perhaps some idea of its character may be obtained from a microscopic
view of its birthplace and its surroundings. Whether the locality
of its irruption in 1629, or that of 1817, whence it spread over the
greater part of the globe, be entitled to the unenviable distinction
of fostering its gestation, concealing and protecting its birth, and
nursing its infancy, is immaterial;--since the similarity of these
localities strikingly illustrates its cause and ultimate development.
On the north side of the island of Java, about 6° S. lat. and 107° E.
long., near the mouth of the river Jacatra, is situated Batavia, in
the midst of swamps and marshes, surrounded by trees and jungle, which
prevent the exhalations from being carried off by a free circulation
of the air, and render the town peculiarly obnoxious to marsh
miasmata. Besides this, all the principal streets are traversed by
canals, planted on each side with rows of trees, over which there are
bridges at the end of almost every street. These canals are the common
receptacles for all the filth of the town. In the dry season their
stagnant and diminished waters emit a most intolerable stench, while
in the wet season they overflow their banks and leave a quantity of
offensive slime. From these united causes, it is not surprising that
Batavia has been considered the most unhealthy spot in the world, and
has been designated the store-house of disease. According to Raynal,
the number of sailors and soldiers alone who died in the hospitals
averaged 1,400 annually for sixty years, and the total amount of deaths
in twenty-two years exceeded a million of souls. The city was inclosed
by a wall of coral rock, with a stream of water on each side within
and without. Few Europeans, however, sleep within the town, as the
night air is considered very baneful. The inhabitants, possibly, as
an antidote against the noxious effluvia arising from the swamps and
canals, continually burn aromatic woods and resins, and scatter about
a profusion of odoriferous flowers, of which there are great abundance
and variety. During the prosperity of the Dutch East India Company,
Batavia obtained the title of Queen of the East, as the resources of
all other districts were sacrificed to its exclusive commerce. Here,
in this noted locality, was the Cholera bred and reared in 1629, under
circumstances of great significance, admirably adapted to convey some
idea of its cause and character.
A learned professor, speaking of the diseases of India, observes:
"CHOLERA is the most acute of acute diseases. It seems to have existed
in Batavia as far back as 1629; and it has been known to prevail as an
occasional epidemic in India at different years and places from 1774
to 1817. Since then it has been endemic, and is a disease whose germs
are essentially maintained in, or upon the soil. It annually recurs at
many of our large stations, commencing generally at the beginning of
the hot season, but sometimes occurring in the rainy and cold season.
Its greatest proclivity to propagation is amongst populations living
in low, damp, crowded, and ill-ventilated situations, especially if
the water supply is impure. Nearly all the diseases fatal in India are
accompanied by profuse discharges, with which the air, water, linen,
bedding, closets, walls of hospitals, and barracks become more or less
infected; so that the 'Materies Morbi' come into contact with all the
inmates of buildings where the disease prevails."
Its origin, or reappearance in 1817, is not in any respect essentially
different from its earlier development on the Jacatra. The River
Ganges, in India, like the Nile in Egypt, flows for a long distance
through a low, level country, which it annually inundates. Dividing its
waters about 200 miles from the sea, the Delta of the Ganges commences
and continues its variegated and checkered surface, till, approaching
the borders of the sea, it presents a peculiar aspect, being composed
of a labyrinth of creeks and rivers, called "The Sunderbunds," with
numerous islands, covered with the profuse and rank vegetation called
"jungle," affording haunts to numerous tigers and other beasts of prey.
This large river, "a Deity of the Hindoo," is subject to an annual
freshet, often rising to the height of 32 feet in the month of July;
when all the lower parts of the country adjoining the Ganges, as
well as the Burrumpooter, are overflowed for a width of one hundred
miles; nothing appearing but villages, trees, and sites of some places
that have been deserted. Here in this vast pest-house, where every
conceivable vegetable and animal substance is left upon the soil by
the retiring inundation, exposed to the heat and dews of a tropical
climate--where, too, noisome and infectious diseases have prevailed for
centuries, the Epidemic Cholera is said to have arisen and acquired its
strength and full development. A fit origin for a fatal and devastating
pestilence.
To this low, insalubrious, and festering locality, this vast
pest-house, where so many noxious and noisome diseases are generated,
and where so many epidemics have arisen and so often swept over the
surrounding regions with most fatal and desolating effects, is ascribed
the birthplace of the Epidemic Cholera of 1817. Here it is said to have
first made its appearance at Jessore--a populous town in the centre of
the Delta of the Ganges; whence attaining its growth and power, it has
extended its influence as from a common centre, and marked its progress
with hecatombs of victims in the direction of almost every point of the
compass.
Here we may remark, that it is not our intention to travel over the
whole ground embraced by the subject under consideration; but, on
the contrary, to present in this treatise only a cursory view of a
few prominent features which may interest and aid in the important
object of deducing from the pathology and the varied phenomena of the
Cholera some general principle of practice. For this, and to this,
our labor and our investigations are directed. Availing ourselves of
every source of information within our reach, and relying in part on
the observations and experience of others, we shall aim to present
such facts and arguments as will shed light upon the subject, and aid
in the accomplishment of this desirable object. However difficult this
may appear, it is nevertheless believed to be within the province of
science and unbiased reason.
SECTION II.--PROGRESS AND FATALITY.
The disease in 1817 appeared on the Delta of the Ganges, and gradually
extending its influence, swept over various countries with terrible
severity. Having here acquired its full development, and manifesting
an indomitable determination to itinerate, it starts upon its lethean
errand, and soon shows a capacity and power to overcome every obstacle
opposed to its progress, and to pursue its course unchecked and even
unretarded by any natural or artificial barrier. It soon traversed
India, and in the succeeding season spread over adjacent countries,
visiting in 1818 the Indian Peninsula, the Burmese Empire, the Kingdom
of Aracan, and the Peninsula of Malacca. In 1819 it reached Sumatra,
Singapore, and various other islands situated along the coast on either
border of this vast peninsula.
During the year 1820, pursuing steadily its progress eastward, it
reached Tonquin, Southern China, Canton, the Philippine, and numerous
other places and islands in that direction. In 1821 it visited
Java--the place of its earlier nativity--Madura, Borneo, and many other
places in the Indian Archipelago. During the years 1822, 1823 and 1824,
it continued to spread over the vast and populous regions of Central
and Northern China and the numerous islands upon the coast, and in 1827
prevailed in Chinese Tartary, leaving few places in all these different
countries on the continent, or even on the islands bordering on the
eastern coast, unscathed by its terrible ravages and depopulating
influence.
During the same period, its progress westward has been uninterrupted,
and attended with results no less remarkable. It has baffled all
attempts to check or even retard its onward course, or mitigate its
appalling effects. In July, 1821, it had reached Muscat in Arabia, and
thence extended its influence to the populous cities and villages along
the Persian Gulf. During the same season it appeared in Persia, and
continued to ravage the principal cities and towns of that empire for
four successive years. At Bassorah and Bagdad it broke out in July,
1821, and thence extended its desolating influence westward to the Red
and Mediterranean Seas, carrying off vast numbers of the inhabitants of
the populous cities of Mesopotamia, Syria, and Judea.
In 1822 it prevailed among the nomadic and Tartar tribes in Central
Asia and in the northern Persian Provinces, and in 1823 broke out on
the Georgian frontiers of Russia, at Orenburg on the River Ural, and
at Astrachan on the Volga. Here its western course was apparently
interrupted. There was, for a short period, an interval of complete
immunity from its presence. Along the border of the Russian Provinces
the disease had entirely disappeared, and seemed inclined to retrace
its course and return to the home of its birth. But the fond
anticipations of Europeans were disappointed; the destroyer was not to
be arrested and turned back in his progress over the earth; his march
was onward, his demands imperative.
Hence, in the month of June, 1830, the disease reappeared in a Persian
province on the southern shore of the Caspian, and again at Astrachan,
on the Volga, in July, where it prevailed with such unwonted violence
that, before the close of August, more than 4,000 persons had died
of it in the city, and 21,270 in the province. From its interval of
repose, it would seem to have recuperated its strength and vigor for
the lethean work awaiting its progress. Ascending the Volga, it reached
Moscow, became prevalent there in September, and continued with great
severity till February, 1831. Here it attacked, in the city, about
9,000 persons, of whom more than one-half died. Continuing its advance,
it reached Riga about the middle of May, and St. Petersburg on the 26th
June.
From Astrachan it also directed its course towards the northern coast
of the Black Sea, and thence along the course of the rivers into
the central parts of Russia. It reached Poland in January, 1831,
accompanied the Russian army in its various marches and encampments
during the subjugation of that country, and proved very destructive
in Warsaw and many other places during April and May. It appeared at
Dantzic in May, and in June at Lemburg, Cracow, and various other
places and sections of country, extending through Gallicia, Hungary,
and reaching Berlin and Hamburg in August and September, and Vienna
about the same time.
Smyrna was visited in September, and Constantinople soon afterwards. It
is reported that the pestilence was conveyed by a caravan from Mecca
to Cairo in August, 1831, some thousands having died on the road;
and, by the middle of September, 10,400 Mohammedans, besides Jews and
Christians, had died of it in this latter city.
Passing from the western coast of the continent, on nearly the same
parallels of latitude, it found its way over the Northern Sea to the
British Isles, and made a lodgment, first, on the northeastern coast
of England, in October, 1831, at Sunderland, situated in latitude
55° north, whence it prevailed and extended its influence over this
section, evincing the same malignant and lethean character it had
manifested in its progress over the continent. Its course thus far has
been marked with unparalleled fatality.
It made its first appearance in Scotland, at Haddington, in December,
1831, and at Edinburgh in January. In these and various other places it
prevailed for some months, and, as warm weather came on, increased in
severity, and carried off a large percentage of those attacked. After
spreading thus over the northern section, and rioting for months in the
more populous cities and towns, it made its appearance in London on
the 14th February, 1832, where it found an abundance of material for
recuperating its strength and multiplying its forces, and soon after
spread over various other places in the United Kingdom, inflicting
the most appalling bills of mortality. In short, its progress over
this country has been attended with the same destructive influence
and the same lamentable consequences as on the continent. No change,
modification, or softening of its disposition or character has arisen
from its passage over the Northern Sea, nor from the refreshing
influences of a purer atmosphere.
It appeared in Calais on the 12th, and at Paris on the 26th of March,
1832, where it continued in these and other cities and villages for
some months with its accustomed severity. During the season it raged
throughout the vast empire, and swept away an immense number of its
inhabitants. During the succeeding years, 1833 and 1834, it traversed
Spain, and proved very destructive in many of its larger cities and
villages.
In the mean time, continuing its course from the British Isles
westward, unchecked by the prevailing western winds and the broad
expanse of the Atlantic Ocean, over which it passes a distance of
nearly three thousand miles, and makes its first appearance on the
American continent at Quebec, Lower Canada, on the 8th June, 1832, and
reaches Montreal on the 10th of the same month. From these cities it
rapidly spread in all directions, prevailing in the towns and villages
on the St. Lawrence and its tributaries, and soon extended along the
chain of lakes, dividing the Provinces from the United States, visiting
the principal ports on either shore. It exhibited in all these places
its peculiar epidemic character, and proved excessively violent and
fatal wherever it appeared.
Its first irruption in New York was on the 24th June, 1832, sixteen
days after its appearance at Quebec, and at Albany, midway between
the two former cities, on the 3d July. From New York it extended its
influence to Flatbush and Gravesend, Long Island, where it appeared on
the 5th July, and on the same day and date at the city of Philadelphia.
It broke out at Rochester on the 12th and at Buffalo--July.
Thus, while it was making its way westward along the great chain of
lakes, towards the arteries of the Great West, it was, at the same
time, steadily pursuing its uninterrupted course along the coast,
visiting the main cities, and spreading from these as from common
centres over the intermediate towns and villages. In its progress it
reached Baltimore on the 22d August, and the City of Washington on the
28th of the same month.
Thence it continued its course to Richmond, Norfolk, Edenton, and
various other cities along the Atlantic and Gulf coast.
It appeared at New Orleans in the Autumn of 1832, during the existence
of a severe epidemic of yellow fever, and apparently subsided on the
disappearance of the fever. Sporadic cases, however, occurred during
the Winter, and in the opening of Spring it broke out with unwonted
vigor and severity, and thence spread, according to its accustomed
laws of itineracy, along the rivers into the interior of the States
bordering upon the Mississippi and the Gulf coast, and raged throughout
Louisiana and Texas with unusual violence and fatality.
In 1832, 1833, and 1834 it prevailed throughout the Mississippi Valley
with great fatality, especially in the principal cities, villages and
towns situated upon its navigable waters. Here, after intervals of
entire immunity from its presence, it occasionally reappeared in some
of the larger cities with renewed vigor and power, and swept off vast
numbers of the inhabitants. In no section of the States have greater
numbers, compared with the whole population, fallen victims to it than
in the fertile and sparsely settled prairies of the South and West.
Thus, from the North, and at a later date from the South, extending
its influence along the principal rivers into the interior, it swept
over the States, prevailing in some places in the Valley of the
Mississippi as late as 1836. In short, it reappeared in 1834 in many
cities and places where it had before prevailed, and again spread over
a considerable portion of the country with unprecedented fatality.
In 1833, the disease appeared at Havana and Matanzas, and prevailed on
the island for several months with great fatality, especially among
the colored people. During the same season it appeared in August
at Tampico, Campeachy, Vera Cruz, and the city of Mexico, proving
especially violent and destructive in these and other cities of the
Republic. In Central America it is said to have attacked the army, and
in a very short period to have swept away a very large proportion of
its officers and men.
Thus, it appears that the epidemic or Asiatic Cholera, from its first
irruption on the northern coast, spread over the greater part of the
North American Continent in the space of two years, and has several
times reappeared in different sections in its peculiar malignant
character, spreading on each occasion over a greater or less extent
of territory with the same uniform and destructive influence. Neither
time, nor science, nor professional skill has thus far appeared to
soften its character, or mitigate its severity.
When the disease had fully assumed its epidemic or malignant type in
India, in 1817, its rate of mortality was everywhere in that vast
territory excessively high.
According to the most reliable reports, the cases occurring in the
earlier period of an irruption were generally fatal, few only surviving
the attack; while of those occurring when the disease was on the
decline, a greater proportion recovered. We read of numerous instances
where one-third, one-half, two-thirds, and even nine-tenths of those
seized with Cholera perished, and again of some places where one-fifth,
one-fourth, and in some instances one-third of entire populations were
cut off in a very short period by this disease. But without attempting
to give the statistics of cholera in this part of the world, or even in
Europe or America, we may present a few instances of mortality, going
to show the great percentage of loss by this singular disease during
its ravages from 1817 to 1837.
In Siam, it is said 20,000 persons fell victims to it in twelve days.
The inhabitants are remarkable for their uncleanly habits, and crowded,
ill-ventilated tenements.
In Sicily, 16,000 died of cholera in 1832, at Catania; in Palermo,
40,000. These cities are represented as being filthy in the extreme,
and the personal habits of the people so uncleanly, and the houses so
crowded, that it is a matter of surprise the mortality was not greater.
In Bassorah and Bagdad, situated in low, unhealthy localities, and
exposed to a damp, insalubrious atmosphere, which, in the warmer
season, is often essentially impregnated with miasmata and offensive
exhalations from animal and vegetable decomposition, both within and
without their inclosures, it is affirmed that more than one-third of
their entire populations were carried off in less than one month.
In the Province of Caucasus, out of 16,000 attacked by the disease,
10,000 died. In Russia, out of 54,000 attacked in 1830, it is said more
than 31,000 died.
In Hungary, it is reported that the whole number affected by the
disease was about 400,000, of whom more than one-half died.
It is officially stated that the total number--the military
excepted--of those affected with cholera in France, from its first
appearance at Calais, March 15, 1832, to January 1st, 1833, is 230,000,
and the deaths 95,000.
In England, the whole number of cases of Cholera is reported to be
49,594, and the number of deaths 14,807. In London there were 11,020
cases, of which 5,274 were fatal. In Wales there were 1,436 cases, of
which 498 proved fatal. In Ireland, from its first irruption in 1832
to March, 1833, there had occurred 54,552 cases of cholera, of which
21,171 were fatal.
In Quebec, from June 9th to September 2d, 1832, there had occurred in
that city alone no less than 5,783 cases of cholera, of which 2,218
were fatal. In Montreal, from June 10th to September 21st, there were
4,440 cases, and 1,904 deaths reported.
In New York, from July 4th to August 28th, in 1832, there had occurred
5,814 cases of cholera, and 2,935 deaths by the same disease. In
Philadelphia, from July 4th to August 28th, 1832, there were reported
2,314 cases of cholera, of which 935 were fatal.
In many of our Southern and Western cities and villages the percentage
of loss from the prevalence of cholera is considerably higher than the
general average, compared with the data given above. The mortality
varies materially in different localities, and, indeed, becomes very
much augmented by the prevalence of those influences which particularly
favor the vegetation, and are especially concerned in the production of
zymotic diseases, whether in the lower or higher latitudes.
SECTION III.--CAUSES--PROPAGATION.
The remote or final cause is essentially of miasmatic origin, developed
under certain atmospheric and terrestrial local conditions, not well
defined or fully understood. In its nature and essence, it constitutes
a peculiar disease-poison, which is now generally admitted to be, in
one way or another, absorbed, and infects the blood, inducing a primary
disease of this vital fluid, and directly depressing and deranging
the ganglionic system of nerves. To its general character, and the
circumstances under which it is generated and in which it operates in
producing the disease, we have alluded in speaking of its origin.
The predisposing causes are as numerous as the varied influences
which operate to depress the general health. The insalubrity of the
atmosphere may be regarded as a general, and, perhaps, the most
extensive predisposing cause. In this state, its vital element becomes
diminished or impaired to such an extent as to render it incapable of
sustaining the normal and healthy functions of the system in their
most vigorous condition. Hence, the foul and noisome air of close,
ill-ventilated apartments becomes very depressing and baneful; a direct
and effective element, often, in constant operation in generating and
producing the cholera, typhoid fever, or other deadly maladies. This
is not unfrequently the case on board some of our emigrant ships,
when hundreds of human beings are stowed away between decks without
the means of efficient ventilation, disinfection, or other mode of
expelling the noxious principle. Though the germ of disease may be
ever on board, it does not vegetate and come forth and rapidly acquire
its activity, vigor and power, unless the localizing influence vivify,
foster and nurture its development. This is fully confirmed by the
recent arrival of two steamers with cholera on board.
The _England_, and a few days later the _Virginia_, with crews and
passengers all in perfect health, departing from a healthy port where
no cases of cholera were known to exist, and after being out at sea six
or eight days under the influence of a cool, invigorating atmosphere,
were surprised by the sudden irruption of cholera on board. It breaks
out among the steerage passengers who are crowded and packed together
between decks like sheep for the slaughter, in a confined atmosphere,
daily becoming more noisome, without the means of ventilation or
disinfection. Can any sane man say the disease--the cholera--was not
here, on board these ships, generated and produced?
This is also confirmed by the occurrence of an isolated case on
Ninety-third Street, near Third Avenue, the first case in this city
this season. Though the cholera exists at Quarantine, the patient had
not been in any way exposed to the disease, except to the exhalations
from the overflowing and drainage of a privy and the foul atmosphere
arising from the cellar of her own tenement. On Monday, it is said,
she partook of her dinner, feeling a little indisposed; at 4 P.M. she
called in her physician, and died the next morning, May 1st, at 11
A.M., in a state of collapse.
Take another instance: the second case in this city occurred in one
of the tenement dwellings of the Sixth Ward, No. 117 Mulberry Street.
The patient was a woman about thirty years of age, who had not
been exposed, except to the noisome atmosphere of her own dwelling
and its surroundings, which must be regarded, under the peculiar
circumstances, as a true, genuine cholera atmosphere. In these cases
the evidence is conclusive that the disease was generated and produced
within, and on these premises.
The exhalations from low, moist, and marshy localities, from
the offensive cesspools, water-closets, sinks, sewers, and the
decomposition of animal and vegetable substances, from the refuse or
garbage which so often befouls the sidewalks and gutters of streets,
are all effective, predisposing causes, that directly facilitate the
production of the cholera. Whatever tends to depress the vital powers,
impair normal action, or relax in any degree the tone of the nervous
system, favors the operation of the final cause. So, too, the low,
underground, damp, unventilated apartments, the crowded and uncleanly
tenement houses, in which multitudes of the poorer class live, in a
confined, foul, and noisome atmosphere, not only favor, but actually
invite, the active operation of the infecting agent.
Habits of intemperance, profligacy, impurity, and late hours, have a
powerful influence to depress and prepare the system for an invasion
of the disease in its most malignant form. In a neighborhood of this
description, when the cholera in 1832 was raging in the adjacent city,
from which it was separated by a very small creek, the uncleanly
multitude escaped entirely, not a case occurring there at that time;
but when, after an interval of several weeks, all danger seemed to have
passed, and the people were rejoicing and congratulating themselves
on their good fortune, the fearful disease suddenly appeared in their
midst with greatly intensified effect, and in a very few days swept the
place so clean that few were left to tell the sad story of its ravages.
There are some other predisposing causes of no inconsiderable
influence, which not only favor the operation of the infecting agent in
the production of the disease, but even awaken its latent power, and
stimulate its activity and development in the system, once exposed to
its invasion. Among these, excessive fear of an attack, great anxiety
and depression of mind, constitutional debility, deranged condition
of the digestive organs, accompanied with a relaxed state of the
bowels, exhaustion arising from fatigue or disease, semi-starvation
and unwholesome diet, neglect of personal and domestic cleanliness,
irregular habits, and excesses of every description, are all direct
incentives and stimulating agents in the production of the cholera. Any
one of these may be sufficient to induce an attack; but when a number
unite and act conjointly the danger is vastly greater, as the infecting
agent or disease-poison becomes thereby more intensified.
When the cholera first appeared in Europe and in this country in
its epidemic form, the majority of medical men, as well as the
people, believed it to be contagious, and to be propagated solely
on this principle. But when the disease appeared in 1848 a decided
change of opinion occurred, which led to a full discussion of the
subject, without any definite result; and the great question as to
its contagious character and its mode of propagation remains still
unsettled. The higher authorities, says an eminent author, concurred in
the opinion of the Board of Health, "that the disease was not in any
way contagious, and that no danger was incurred by attendance on the
sick."
A large body of evidence, however, has been exhibited, going to show
that human intercourse has, at least, a share in the propagation of the
disease, and that it, under some circumstances, is the most important,
if not the sole means of effecting its diffusion. On the other hand, it
is affirmed that though it may be communicated, in some cases, by the
agency of human intercourse, it does not follow that the material cause
spreads by true contagion, that is, by reproducing itself in the bodies
of men, and there only.
The disease may be carried by healthy persons in their clothing,
in their ships, and in their caravans. That instances of this kind
have occurred there can be no question, for numerous records present
some undoubted instances of the occasional communication of the
cholera-poison through human intercourse; still it is no less certain
that its general extension over the world cannot be accounted for on
this principle alone. "Its propagation by this means seems to be the
rare exception, its spread over the earth from other causes being the
common rule."
Dr. Hamlin, writing from Constantinople, in reference to the recent
irruption and prevalence of the cholera in that city, observes, "The
idea of contagion should be abandoned. All the missionaries who have
been most with the most malignant cases, day after day, are fully
convinced of the non-contagiousness of the cholera. The incipient
attacks which all have suffered from are to be attributed to great
fatigue, making the constitution liable to an attack."
It is a very singular fact, that the medical profession in India,
the birthplace and home of the cholera, almost universally reject
the doctrine of contagion. If those most observant and familiar
with its history, its prevalence, and its annual recurrence as an
endemic disease, which they are called to treat in all its varied
phases, have discovered no contagious character by which it can be
propagated, it may be safely inferred that it is not contagious in the
common acceptation of the term, and that its extension over the earth
is governed by some other principle, and that the predisposing and
localized causes which are always in operation in India exercise no
small share in its diffusion, in directing its course, aggravating its
severity, increasing or diminishing its fatality, and determining the
duration of its prevalence in particular localities. When its infecting
germs have gained a lodgment in any city, section, or country, they may
be stimulated and become exceedingly active in the production of the
disease through these influences.
As to its introduction into different countries, it is quite evident
that the germ, or latent principle of the cholera-poison, exists in
such a state as to be capable of transportation, and may in this way
be diffused to almost any extent when the localizing influences are
sufficient to develop its energies.
In this, as in all other zymotic diseases, some persons are more
susceptible of an impression and more liable to an attack than others.
Though no class can be considered exempt, yet there are some whose
organization, or innate protective principle, seems to render them
impervious to its influence. The cholera, however, is no respecter of
persons, or rank, or condition. The anæmic and cowardly in all ranks
and conditions are peculiarly liable, and are the most defenceless and
unresisting when invaded. In Europe, the probable numbers attacked in
that part of the world appear from statistics to be, in France, as 1
in 300; Russia, as 1 in 20; Austria, as 1 in 30; Poland, as 1 in 32;
Holland, as 1 in 144; Germany, as 1 in 700. "The circumstance of one
attack by no means protected the individual from a second in the same,
or any subsequent year; still a repetition of the disease in the same
person in the same year was rare."
CHAPTER II.
SECTION I.--PATHOLOGY.
The doctrine now universally accepted and prevailing regarding its
Pathology is, that a poison, virulent, subtle, and unknown, has been
absorbed, and primarily infects the blood, so that, after a longer or
a shorter time, a primary disease of this vital fluid is produced, and
that the poison undergoes an enormous process of multiplication in
the living body of the cholera patient, as the direct result of this
morbific process so established, and that changes are induced in the
function of respiration directly consequent on this alteration of the
blood.
This altered condition and rapid change in the life-sustaining
principle of the blood, the loss of nerve-power, the impaired
circulation and tendency to congestion, are the proper and
distinguishing features of the disease; and the term "Algide," first
used by the French Pathologists, very happily describes one of the
most remarkable and constant symptoms, namely, the diminution of animal
heat. The loss of temperature and its consequent effects upon the
circulation, depressing and prostrating the nervous power, impairing
and paralyzing the respiratory organs, suspending the functions of the
liver and kidneys, enfeebling the action of the heart, and causing
the capillary vessels of the mucous tissues to expand and pour off
the serous fluid from the blood and every muscle and tissue of the
system, with great rapidity, essentially constitute the phenomena of
the Cholera. The constantly increasing augmentation of the poison and
its intensified effects measure the malignity, the violence, and the
rapidity of the disease.
It is this multiplication, and the disturbance which attaches to it,
that in each case constitutes the disease and destroys life. Of this
fact the circumstantial evidence is abundant and conclusive, and may
account in part for the violence of the disease in its first irruption
in any particular locality. The vomiting, purging, and cramps are now
generally considered as secondary and non-essential phenomena, for
numerous cases of cholera have occurred in every section where it has
prevailed in its more violent and malignant form without exhibiting
these symptoms. The poison was so potent, and its progress so rapid,
that life was extinguished in a very short time. In its first irruption
at Muscat, cases are reported in which only ten minutes elapsed from
the first apparent seizure before life was extinct. Dr. Milroy,
speaking of the violence and rapidity of the disease as it occurred in
1817, and again in 1845 and '6, at Kurrachee, observes, that "within
little more than five minutes hale and hearty men were seized, cramped,
collapsed, and dead." Instances of death taking place in two or three
hours are extremely common. When it broke out at Teheran, in May, 1846,
Dr. Milroy observes, that "those who were attacked dropped suddenly
down in a state of lethargy, and at the end of two or three hours
expired, without any convulsions or vomitings, but from a complete
stagnation of the blood." In many places during its prevalence in
1832, and subsequently in 1834, and in 1848 and '9, the rapid fatal
character of the earlier cases was observed and reported as the most
severe and hopeless. In various cities and villages in our own country,
cases of this description were not unfrequent. In all these the
destructive nature and rapid process of the disease was so depressing
and overwhelming as to prevent any effort of the "vis naturæ" to resist
its progress.
Hence, from the autopsy of those who have fallen victims to its baneful
influence in the first stage, or within forty-eight hours of the
attack, no alteration of structure in any organ or tissue has been
discovered. But in those cases where death has occurred at a later
period, some lesions and slight changes in the appearance of some
tissues have been traced. The more important of these, illustrative
of the characteristic effects of the disease, are, in brief, the
following:
The follicular structure of the intestinal canal has been found
slightly swollen, and the intestine partially filled with a
turbid, inodorous, semi-diaphanous fluid, resembling thin starch,
or rice-water, and is supposed to be the remains of that peculiar
secretion which had taken place during life. This fluid is sometimes
acid, and sometimes alkaline. In the small intestines it is found in an
unmixed condition. It consists of two liquids of different consistency;
the one thick, the other thin. The latter constitutes the rice-water
stools, and may be passed off without admixture with the thicker
substance. The colon has been found generally much contracted, and the
mucous membrane and the sub-mucous cellular tissue of the digestive
canal presenting evident marks of congestion, in some cases approaching
to a sub-inflammatory state, generally in spots or patches of various
sizes, the color of these varying from a very dark congestion to a more
roseate hue. The glands of Brunner and Peyer, as well as the solitary
glands, are greatly enlarged. The stomach and bowels are frequently of
a paler color than natural, both in their inner and outer surfaces. The
liver, the spleen, and the kidneys have been found engorged with blood.
The urinary bladder is always contracted, and empty. The gall-ducts
are sometimes contracted, at other times not. The vena porta and all
the other abdominal veins are loaded with black blood, resembling tar
in its color and consistency. The membranes of the brain and cord are
generally found congested, and the substance of the brain more or less
dotted with small points or specks of blood than usual.
"The most common appearances in the lungs," says an eminent
pathologist, "are the presence of blood in the large vessels, chiefly
or solely; the collapse and the deficient crepitation arising from
the more or less complete absence of air and blood, and from the
approximation of the molecular parts of the pulmonary substance.
In other cases there is more blood in the minute structure, a
corresponding dark color of the lung, and a variable amount of frothy
serum. The right side of the heart and the pulmonary arteries were
generally filled, and in some cases distended with blood; the left side
and aorta were generally empty, or contained only a very small quantity
of dark blood; the left side evidently had received little or no blood,
but had continued to contract, in some cases even violently, on the
last drop of blood which had entered it."
Such are some of the prominent appearances which the body has presented
when the patient has died in the first, or pulseless stage of the
disease. But in other cases, where the premonitory stage has been
definitely marked, and attended with diarrhoea or other depressing
disorder affecting the alimentary canal, and where the patient has
continued under the influence of the disease for a longer period, and
has passed through the usual successive stages of it, other additional
appearances have been noticed, which are here omitted, as they are of
a secondary importance, and belong especially to the more protracted
cases.
The _post-mortem_ appearances, the phenomena of the disease, the
Algide, or diminished animal heat, and the loss of nervous power, all
tend to show an obstructed circulation and consequent embarrassment
of respiration resulting in the non-aeration and non-oxydation of the
blood, from which a long train of secondary and non-essential symptoms
arise. For it is affirmed that the mechanical part of respiration
remains in a good degree perfect, and that the heart evidently
continues to beat in many cases till stopped by the want of blood in
the left side and by its accumulation in the right side. Hence, for the
cause of this arrest of the circulation of the blood through the lungs,
we are forced to look to the condition of the blood itself, and the
deranged action of the ganglionic nerves.
Attempts have been made to trace out from analysis the exact chemical
changes in the order of their occurrence which attend the period of
transudation from the blood into the intestinal canal. "The most
prominent phenomena of cholera," says Dr. Aiken, "during this period
of transudation, consists in separation of the water and of the salts
of the intercellular fluid (of the blood) through the mucous membrane
of the intestinal canal, and the retention in the blood of an important
excess of albumen and of blood-cells, with apparently less, but in
reality with great diminution of the salts and fibrin."
"The inorganic constituents," continues the same author, "if compared
to the water, are during the first four hours increased, because at
this time the water is passing off with great rapidity; afterwards, as
the salts pass off, the disproportion is lessened, and after eighteen
hours or so, the proportion of salts is greatly diminished, and, if
compared with the organic constituents, the diminution is enormous.
With respect to the individual salts, there is in the blood a relative
preponderance of phosphates over chlorides, and of potash salts over
soda salts. By the end of eighteen hours or so, the blood-corpuscles
are left in a most abnormal condition; the great loss of water and
of salts, especially of the chloride of potassium--a most important
constituent of the blood-cells--at once leads to the conclusion that
their functions must have been greatly impaired. Accordingly, Dr.
Schmidt found that the amount of oxygen contained in them was lessened
by one-half." Dr. Robertson affirms that the "fibrin of the blood is
usually in large amount and coagulable with great firmness;" while
Dr. Parkes, speaking of the same condition of the blood, and relying
on the accuracy of his analysis, observes, "The presence of fibrin
in the blood was not indicated by any coagulation either in or out
of the body; and whether coagulated or not, the blood has usually a
dark color; but it generally acquired an arterial tint when brought
into contact with the air in thin layers." * * * "When we remember
the great share taken by the blood-globules in the respiratory and
heat-furnishing processes, it is scarcely possible to avoid concluding
that their loss of salts is connected with the characteristic cyanosis
and lowered temperature in cholera." "The diarrhoea coincides with
the first chemical changes in the blood--the transudation of some of
the constituents of the serum." Hence the phenomena of the disease
may thus be traced from this process as the starting-point. All other
chemical changes in the blood, and the most marked symptoms, such as
the abnormal respiratory process, follow as a matter of course. Such
is the theory of the nature of cholera, now advanced and sustained by
the most eminent pathologists, which embraces the doctrine previously
advanced that the blood is the primary seat of the disease, and becomes
contaminated by the absorption of a specific poison.
SECTION II.--PHENOMENA, OR SYMPTOMS.
The attack of this fearful disease is most generally sudden, the
patient being at the time apparently unconscious of any depressing
influence, or derangement of the system. It is not unfrequent, however,
that some slight irregularity of the bowels, loss of animation
and general vigor, or other apparently trifling indisposition,
have preceded it. In some instances there are definite and decided
premonitory symptoms which continue for a longer or shorter time
prior to the attack, commencing usually with a pallor or collapse of
the countenance, depression of spirits, slight pain in the forehead,
noise in the ears, occasional or transient turns of vertigo, slight
nausea, heat and pain in the epigastrium, oppression at the chest,
with frequent sighing, nervous agitation, some loss of muscular power,
general uneasiness, flatulence, with slight diarrhoea, sickness at
the stomach, occasional twinges of the nerves, or cramps in the
extremities, oppressed, small, feeble, and sometimes intermitting
pulse, coldness, clamminess, or humidity of the surface, and general
lethargy. Such are some of the premonitory symptoms which more
frequently occur in the lower latitudes, where the general vigor
becomes depressed by the long-continued and excessive heat of the
climate. Their duration, whenever any of them do occur, varies
materially; sometimes one, two, or three days--sometimes longer but not
often.
According to the observations and descriptions given by those who have
had the best opportunities for becoming familiar with all its various
phases, the symptoms attending its invasion and general course are
too distinctly marked to be ever mistaken for any other disease. In
the minds of many who have been called to witness the developments of
cholera, they undoubtedly exist with such distinctness and vividness
as to render the most labored and accurate description tame. In this
treatise, however, a description of the leading and more prominent
phenomena will be given, and so far as a general principle of practice
is concerned, this might be very appropriately limited to its first or
cold stage.
The commencement of the disease is often so insidious as to pass
unnoticed till the system is fully prepared for the sudden and violent
attack. The slight, painless diarrhoea, depression of the nervous
power, and occasional vertigo may all pass unheeded, and the patient
be apparently in perfect health. He may retire to rest entirely
unconscious of approaching danger, and after enjoying a sound and
undisturbed sleep for hours, be, on awakening from his slumbers, seized
with a remarkable sickness, perhaps vomiting, accompanied with most
remarkable and profuse discharges from the bowels. These inordinate
evacuations are usually attended with severe pains, extending down the
thighs, and a sense of complete and almost perfect exhaustion. The
physical powers and vital energies are immediately prostrated. The
temperature rapidly sinks below the normal standard--the body becomes
benumbed with an icy coldness--the skin becomes shriveled up, and
almost insensible to hot and stimulating fomentations--the breath,
too, as it comes from the lungs, appears to partake of the same icy
coldness, indicating the rapid elimination of heat, or caloric, from
the body. The patient complains of being greatly oppressed, throws off
his clothing--calls for cold water, which he eagerly and copiously
drinks; though it afford no relief to his insatiate thirst, it ought
not to be withheld. This peculiar icy coldness and loss of temperature
is also further shown by the livid, blue, or purple appearance of
the hands and feet, extending sometimes over the greater part of the
body. The skin becomes, even in a few minutes after the seizure, not
only shriveled up, but often curiously wrinkled, as in extreme old
age. Severe spasms in the fingers, toes, legs, and abdomen, cause the
patient to groan and writhe under their influence, and to call on
his attendants, if fortunate enough to have any around him, for aid
and relief from his agonies. As the disease proceeds, there may be
noticed a peculiar, sharp and contracted state of the features, and
a wild and terrified expression of the countenance, arising from the
impression and fearful apprehension of rapidly approaching dissolution.
These important changes may all take place in a very few minutes. To
these most obvious and singular symptoms there is superadded constant
vomiting--incessant purging--low, feeble pulse, though occasionally
natural and sometimes rapid, yet in some instances, from the very
first moment of attack, cannot be discovered either in the large
superficial arteries or at the wrist. The voice is altered, becomes
low, feeble, unnatural in tone, or sinks even to a whisper. Respiration
becomes quick, irregular, laborious and imperfect. The inspiratory
act being performed with difficulty, and expiration being quick and
convulsive. The flow of bile into the intestines is suspended, the
urinary secretion and micturition entirely suppressed. Almost the
only organ which seems to preserve in any good degree its powers is
the brain--the mental faculties in some cases being retained till
the close of life;--in other cases feeble, weak, and much impaired.
On the accession of the spasms, the vomiting--and the purging--the
disease may be considered as being fully developed, and the crisis at
hand, which, in a few hours, must decide the fate of the patient. Its
progress is now rapid, and must speedily terminate either favorably
or unfavorably. If the result be unfavorable, the patient may die with
all these symptoms distinctly and strongly marked. If the termination,
however, be favorable, these violent symptoms soon yield, and seem
to be materially relieved; yet, though these indications favor the
return of normal power--the weakness, the cessation of the pulse, the
coldness and blueness of the surface, and the sepulchral expression of
the countenance, clearly show that a few hours must close the scene. To
many death thus often comes calmly and quietly, without any struggle to
mark the precise time of this life's departure.
"If the patient," says an eminent author, "should happily survive the
cold stage, the disease may terminate by a rapid recovery, or it may
pass into the second or febrile stage." The former is the more usual
course in India, the latter in Europe. The first symptom of returning
health is shown by the patient falling into a sleep of unusual
soundness, during which the respiration becomes light and easy,
the pulse freer, while a gentle, warm perspiration bedews the whole
body. This grateful pause in the disease appears to be the result of
the returning powers of life, uninfluenced by medicine, for it often
occurs where none has been given. After this balmy slumber the patient
awakes refreshed, and often recovers so rapidly, that in the natives
of India it almost resembles a restoration after syncope. In all the
Presidencies, indeed, and especially in Bengal, the recovery of the
European has, in general, been followed by a stage of reaction, usually
slight, but in some cases assuming the form of the bilious remittent
fever of the country, which has occasionally terminated fatally.
In most cases, however, the reaction is more considerable, and the
patient, in a few hours after the subsidence of the cold stage, labors
under a severe form of fever, resembling the typhoid. During the first
few hours after the febrile reaction commences the tongue is white,
but it quickly becomes brown and dry, while black sordes incrust the
teeth and lips. The eye becomes deeply injected and red, the cheek pale
or flushed, the pulse rapid, and the temperature of the body a little
above the natural standard. The patient, either delirious or comatose,
then lies in a state resembling the last stage of the severest typhoid
fever of this country. This struggle usually lasts from four to eight
days, when the symptoms either gradually yield, or death ensues. In a
few mild cases the fever assumes an intermittent type, or sometimes a
quotidian, sometimes a tertian form: all these cases usually recover.
Such is, in brief, a summary of the more important symptoms of the
Epidemic, or Asiatic Cholera, especially in its earlier or cold stage.
The phenomena, especially developed in, and belonging to, the stage
of reaction, being of minor importance, they have received only a
very brief consideration; sufficient, however, to show the general
character and tendency of the disease in this stage of its progress and
termination.
CHAPTER III.
SECTION I.--UNSUCCESSFUL MODES OF TREATMENT--VENOUS TRANSFUSION
EXPLAINED.
In this discussion we shall avail ourselves of the researches and
investigations of eminent Professors, whose observations, experience,
and position give their views the highest authority. The latest and
most deserving record on this subject is from the pen of Professor
Aiken, of Edinburgh, who observes, "There are few diseases for the cure
of which so many different remedies and modes of treatment have been
employed as in Cholera, and, unfortunately, without our discovering an
antidote to the poison. In Moscow it is said that the mortality was
not greater among the destitute of medical aid than among those who
had every care and attention shown them. It may be fairly inferred,
therefore, that in the severer forms of the disease, the action of
this poison is so potent as to render the constitution insensible to
the influence of our most powerful remedial agents. When, however,
the disease is mild, or on the decline, much may be done by obviating
symptoms to promote the recovery of the patient."
"The heroic remedies that have been employed in Cholera are bleeding,
and calomel and opium, either separately or conjointly. With respect
to bleeding, it may be stated, that in every country the patients
bore bleeding badly in any stage, and that the practice in Europe was
at length limited to a few leeches occasionally to the head. As to
calomel, that medicine was used to the greater part of an ounce in the
twenty-four hours, but with so little success that many patients have
been seized and have died under the full influence of mercury. On the
appearance of cholera in Europe, opium was administered in the doses
recommended by the Indian practitioners to the greater part even of an
ounce of laudanum; but it was soon seen that in the cold stage it was
inefficient in controlling the vomiting or purging; that it did not
allay the spasms, and, moreover, hardly produced any narcotic effect.
The action of the accumulated doses of opium, however, though suspended
during the cold stage, was often fully developed in the last stage,
and occasioned so much affection of the head that most practitioners
either abandoned its use or limited it to a mere fractional dose of
that usually given in India, namely, from three to twelve minims of the
tincture of opium, or half a grain to a grain of solid opium every four
or six hours."
Let us now turn to a paper by the justly celebrated Professor Maclean,
whose observations and experiences have been more extensive than
perhaps those of any other professional gentleman either in Europe or
America. Unlike many of his brethren, he holds on this subject the
safer doctrines of practice, and very frankly and earnestly expresses
the same in the following language: "Opium in cholera should be given
only in the premonitory diarrhoea. At this stage, in combination with
a stimulant, it is of the highest value. If persevered in, particularly
in the strong doses (justly reprobated), it is a dangerous remedy,
inducing fatal narcotism, or, at the least, interfering with the
functions of the kidneys, and so leading directly to uræmic poisoning."
"Urgent thirst is one of the most distressing symptoms in cholera;
there is incessant craving for cold water, doubtless instinctive, to
correct the inspissated condition of the blood, due to the rapid escape
of the liquor sanguinis. It was formerly the practice to withhold
water--a practice as cruel as it is mischievous. Water in abundance,
pure and cold, should be given to the patient, and he should be
encouraged to drink it, even should a large portion of it be rejected
by the stomach; and when the purging has ceased, some may, with much
advantage, be thrown into the bowel from time to time.
In the stage of reaction, the fever may be moderated by cold sponging,
or by the wet sheet; the secretion of urine may be promoted by dry
cupping over the loins by the use of chlorate of potash, and the like.
But suppression of this secretion is most to be dreaded where opium has
been too freely used in the treatment. In men of intemperate habits, we
often see, during the stage of reaction, obstinate vomiting of thick,
tenacious, green, paint-looking matter, probably bile pigment, acted
on by some acid in the stomach or alimentary canal. It is a symptom
of evil omen, and often goes on uncontrolled until the patient dies
exhausted, and this although all other symptoms may promise a favorable
issue. I have known it last for a week, resisting all remedies, and
proving fatal when the urinary secretion had been restored and all
cerebral symptoms had subsided. Alkalies in the effervescing form, free
stimulation of the surface, and chloroform in small doses offer the
best hope of relief. The patient should be nourished more by the bowel
than the stomach when vomiting is present. Ice should be not only to
dissolve in the mouth, but to swallow in pieces of convenient size."
"Another heroic plan," says Dr. Aiken, "peculiar, perhaps, to this
country, which was practiced when the inefficiency of medicines was
generally admitted, was an injection of a solution of half an ounce of
muriate of soda, and four scruples of sesquicarbonate of soda in ten
pints of water, of a temperature varying from 105 to 120 Fah., into the
veins of the suffering patient. The solution was injected slowly; half
an hour being spent in the gradual introduction of the ten pints, and
the immediate effects of this treatment were very striking. The good
effects were rapid in proportion to the heat of the solution, but a
higher temperature than what is stated could not be borne. After the
introduction of a few ounces, the pulse, which had ceased to be felt
at the wrist, became perceptible, and the heat of the body returned.
By the time three or four pints had been injected the pulse was good,
the cramps had ceased, the body, that could not be heated, had become
warm, and instead of cold exudation on the surface, there was a
general moisture; the voice, before hoarse and almost extinct, was now
natural, the hollowness of the eye, the shrunken state of the features,
the leaden hue of the face and body had disappeared, the expression
had become animated, the mind cheerful, the restlessness and uneasy
feelings had vanished, the vertigo and noises of the ear, the sense
of oppression at the precordia had given way to comfortable feelings;
the thirst, however urgent before the operation, was assuaged, and the
secretion of urine restored, though by no means constantly so. But
these promising appearances were not lasting; the vomiting continued,
the evacuations became more profuse, and the patient soon relapsed into
his former state, from which he might again be aroused by a repetition
of the injections; but the amendment was transient, and the fatal
period not long deferred. Of 156 patients thus treated at Drummond
Street Hospital, Edinburgh, under the direction of Dr. Macintosh, only
25 recovered; a lamentably small proportion; and, small as it is, it
seems doubtful if the recoveries were final or complete."
* * * * *
But let us turn to another page, whose beauty is especially marred by
unreasonable expedients: "The warm bath," says the writer, "was at
first tried, but discontinued from the uncontrollable nature of the
vomiting and purging, and the oppressive sensation of heat it produced
on the patient's feelings. Mr. Dalton's vapor bath and Turkish baths in
the Hospital at Scutari have been used, but without benefit, and to the
disappointment of the hopes which had been entertained of them."
"Other methods of restoring warmth were had recourse to, such as
frictions with the hand or by the flesh-brush, or rubbing the body with
some strong stimulant embrocation, compounded of garlic, capsicum,
camphor, cantharides, or other powerful irritants. Mustard poultices
also were often applied to the feet and abdomen, blisters with or
without an addition of oil of turpentine, the part having been
previously rubbed with hot sand; and in cases supposed to be urgent,
the mineral acids, and even boiling water, were employed for the
purpose of producing instant vesication."
"And, again, we read of those who tried to stimulate the waning powers
of life by galvanism, acupuncture of the heart, issues, setons, moxas,
actual cautery along the spine, and, lastly, by small pieces of linen
dipped in alcohol distributed over the body and then set fire to!!!"
Such are some of the means which have been used in the treatment and
cure of cholera.
"The failure of such powerful means at length caused most practitioners
to confine themselves to checking the diarrhoea, which so frequently
precedes cholera, and subsequently, to obviating symptoms as they
arose," and for this purpose, returned to and adopted a very simple
stimulating mixture, recommended by the Board of Health:
Rx. Pulveris Aromat., dram iij.
Tinc. Catechu, " x.
Tinc. Cardamom, C., " vj.
Tinc. Opii, " j.
Mixt. Cretæ Preparat., ounce xx.
M.----S., j ounce, as necessary.
Tinc. Kino, or the decoctum Hæmatoxyli, were sometimes added.
These remedies, it is said, frequently arrested the attack altogether.
If, however, the disease proceeded and the cold stage of cholera
formed, the same remedies were prescribed in an effervescing draught.
"To promote reaction in cholera and diarrhoea, the following formula
has met with most universal approval in this country and in India. So
highly is it valued, indeed, that it is ordered to be always in store,
and in readiness in the _Medical Field Companion_ of the army when on
the march:
Rx. Ol. Anisi, }
Ol. Cajeput, } [=a][=a]. dram ss.
Ol. Juniper, }
Æther, ounce ss.
Liquor Acid. Haleri,[I.] dram ss.
Tinc. Cinnam., ounce ij.
M.----S.: ten drops every fifteen minutes, in a table-spoonful of water.
An opiate may be given with the first and second dose, but should not
be continued."
The learned author to whom we have referred, after detailing some of
the various expedients employed in the treatment and cure of cholera,
sums up the whole under the common term--failure--and, in effect,
declares the most powerful remedial agents ineffective and useless in
controlling and subduing this disease.
This declaration is made in reference to the general result of the
remedies and the various expedients adopted mainly by one class of
physicians, to which special reference has been made. It is therefore
partial, and confined solely to what is erroneously termed the regular
practice. In declaring all remedial agents a failure, does not the
author himself commit a greater failure in omitting to survey the whole
subject of treatment, and to trace out and to show from the application
of the pathology of the disease the probable cause of such failure?
However formidable this disease may appear, on account of its rapidity
and its firm, unyielding grasp upon the vital powers, the forbidding
and almost hopeless prospect of relief, and the lamentable results
which have attended some modes of treatment, it seems particularly
unfortunate for the profession that there should have been a
disposition on the part of this learned author to abandon all remedial
agents as comparatively useless, without a more thorough investigation
into the cause of failure. On this point no effort or inquiry even is
made. This is the more remarkable and surprising after dwelling at
length on the pathology of the disease. It would seem as if all the
light and science derived from this source for nearly half a century
had been overlooked, or the pathology of the disease, from some cause
not satisfactorily explained, had been deemed unworthy at least in
this instance to dictate the course of treatment. This should govern
in cases of cholera as in all other forms of disease, or else all
our efforts and remedies will prove abortive. Now, had the doctor
carefully investigated the various modes of treatment and compared
the results of each, he might have come to a different conclusion.
But, being confined and limited in his investigations, he is unable
to discover anything reliable or worthy his commendation, except the
formulas above and the recommendation of Dr. Maclean. Among all the
remedies and expedients named, there is only one tending to fulfil,
the indications required, and that one, though prompt and magical in
its effects, has been unequivocally condemned, without looking beyond
the transient result for any light it might shed upon the subject. How
it should have escaped his notice and passed so long unobserved by the
numerous professional gentlemen who had often witnessed the effect, and
were anxiously searching for light and the means of affording relief
to the suffering patient, is a most singular circumstance which can
only be accounted for on the principle that they all were anticipating
some strange phenomenon, or development of cure as mysterious as the
disease itself, which led them to overlook the simple and effective
means of relief so clearly represented and shown in their numerous
experiments for something more heroic and powerful than as yet the
imagination ever conceived.
If we trace the action of calomel, the use of opium, the effect of
cupping, bleeding, blistering, etc., etc., we shall obtain no very
desirable information; nothing valuable tending to indicate a correct
principle of practice. If we go still further, and examine the tendency
and effects of the various baths exhibited at Scutari, the use of the
flesh-brush, the bare hand, the heated sand, the embrocations, the
turpentine and other irritants, the boiling water, or the burning
alcohol, skinning and cooking the patient alive, we shall be shocked
at the enormous cruelty and barbarity that have been pursued, and turn
from the repulsive exhibition, without discovering one ray of light
to guide us in the right direction. Disappointed and baffled in our
inquiries, shall we here abandon our investigations and dismiss the
whole subject, because our course is involved in difficulties? Would
intelligence and reason justify the neglect to improve the means at
command? We think not; but rather induce us to advance in search of
truth if the elements of success are not quite exhausted. Let us be
encouraged and stimulated to untiring perseverance so long as there
remains any experiment untraced and uninvestigated in its bearing upon
the direct action of the disease. Had Dr. Aiken, or those other eminent
surgeons who took part in those numberless experiments, instituted
on the Continent and in England, especially those who initiated the
process of injecting into the veins a solution of soda raised to a
temperature from 105° to 120° Fahr., continued their investigations
patiently and assiduously, they might probably have discovered long ago
the correct theory of practice for the treatment and cure of cholera.
But they failed to see, or, if they saw at all, rejected the feeble
ray of light struck out by the experiments in which they had themselves
participated, and like the celebrated Dr. Hunter, who refused to listen
to the discoveries made by his pupil, the indefatigable Jenner, who
traced the identity of the variola with the common disease affecting
the kine; and thence extracted the vaccine lymph and established a
principle by which that loathsome disease and often recurring epidemic
has been nearly banished from the earth. Though they have thus failed,
they have nevertheless left on record, in unmistakable language,
the result of their bold experiments, which we may investigate, and
appropriate the instruction drawn thence for our own and the advantage
of our fellow-men.
What, then, are these results, regarded as shedding light on this
intricate subject? We refer only to one the most obvious which we have
already cited above. Let us repeat and analyze, and, if practicable,
show the principle evolved. There was, on various occasions, the
solution of soda injected into the veins at the temperature from 105°
to 120° Fahr.: a higher temperature could not be borne. This process
was performed slowly, thirty minutes being occupied in injecting the
ten pints. Now mark the result as the operation proceeds. Says Dr.
Aiken, "After the introduction of a few ounces, the pulse, which had
ceased to be felt at the wrist, became perceptible, and the heat
of the body returned." Mark the language: "only a few ounces" were
required to arrest for the time being, the progress of the disease
and restore warmth to the body; a very remarkable fact, replete with
instruction, as will appear as we proceed. Again says the Dr., "by
the time three or four pints had been injected the pulse was _good_,
the cramps had ceased, the body, that could not be heated, had become
warm, and instead of cold exudation on the surface, there was a general
moisture. The voice, before hoarse and almost extinct, was now natural;
the hollowness of the eye, the shrunken state of the features, the
leaden hue of the face and body had disappeared; the expression
had become animated, the mind cheerful, the restlessness and uneasy
feelings had vanished; the vertigo and noises of the ear, the sense of
oppression at the precordia, had given way to comfortable feelings;
the thirst, however urgent before the operation, was assuaged, and
the secretion of urine restored, though by no means constantly so."
Such is the astonishing result obtained by this experiment, and this,
too, when only three or four ounces had been injected--all the urgent
symptoms mitigated and relieved. What, we ask, could have been more
satisfactory, or better calculated to aid the discovery of an important
truth? Every distinctive and fatal symptom for the time is relieved,
and the normal condition and functions of the system restored; a result
which could only have been obtained by the evolution of a principle of
sufficient promptness and power and diffusibility to arrest and utterly
suspend for a time the force of this disease.
What, then, was the principle evolved in this experiment, which gave
immediate relief? Did it consist in the half ounce of muriate of soda
alone, or in the four scruples of sesquicarbonate of soda alone, or
in the ten pints of water alone, or in the whole combined, or more
especially in the high temperature to which the solution was raised? It
is a well-established fact that, in order to raise the temperature of
cold water to blood heat and above, a large amount of free caloric must
necessarily be absorbed, and exist mechanically in the fluid; and, in
this condition, the solution was introduced into the veins, and there
evolved its vast amount of free caloric, which immediately permeated
every organ of the system, arresting disease, raising the temperature
of the body, and restoring its normal functions. Of this there can be
little doubt. For free caloric is one of the most prompt, effective and
diffusive stimulants known, and was evidently in this case the remedial
agent which produced the result. True, it may be said the effect was
transitory, and passed off as soon as the caloric became eliminated.
This, however, cannot alter the nature, character, or influence of
the principle on which it was produced. It is usually admitted that a
remedy that has power to control disease, will, by its continued action
and influence, restore the normal condition of the system permanently,
or at least aid Nature to repair her own work. By this we would
not be understood as advising a repetition of the experiment under
consideration, even under the most urgent circumstances; far otherwise
would be our advice. We are arguing for the purpose of evolving and
establishing a general principle of practice.
The great question, then, is, Did the principle evolved fulfill the
indications required? and if so, is it available and consistent with
the pathology and the peculiar phenomena, or symptoms of the disease?
To settle this point, we need only turn to the law and the testimony,
the very highest authority on the subject. The doctrine now universally
accepted and prevailing regarding its pathology is, that a poison,
virulent, and subtle, and unknown, has been absorbed and infects the
blood, so that, after a longer or shorter time, a primary disease of
this vital fluid is produced, by which the vital energy is impaired,
and all other morbific changes induced. The term "Algide," first used
by the French Pathologists, very accurately describes one of the most
remarkable and constant symptoms, viz., the diminution of animal heat.
On this depend the altered condition of the blood, the depression of
the nervous power, the impaired functions of the respiratory and all
the vital organs which are essentially involved by the disease. The icy
coldness of the surface, the breath, the extremities and general loss
of temperature, all show the character of the disease and the wants of
the system.
Did, then, the principle evolved accord with the pathology and
phenomena of disease? And did it fulfill the indications required?
If not, we ask by what means was the disease arrested, and all the
urgent symptoms mitigated and relieved, or by what were the good
effects produced, and the normal action for a time restored? Can the
result be reasonably accounted for on any other principle than the one
assigned--the stimulating power of the free caloric? We think not; for
it accords most perfectly with the pathology and the peculiar phenomena
of the disease. It assuaged the more urgent symptoms, answered the
imperious demand of the waning powers, revivified and reinvigorated
the vital energies, and restored for the time the normal tone of
the system. What more could be desired in any single agent than the
result here obtained? That it accomplished all this, there can be no
question, according to the statement of the learned professors who have
repeatedly witnessed and described the results.
The question, however, will arise, Can this principle be rendered
available? Most certainly it can; and though it may not be convenient
to introduce free caloric into the stomach, we can, by combination,
introduce a stimulant of equal potency which shall be equally
as prompt, effective and diffusive in its action, similar in its
influence, and similar in its results. It is the principle--not the
precise element for which we contend.
It is universally admitted that in many instances we may learn much
from observing the manner of death which, in a majority of these cases
of cholera, may be described by the term asthenia--a death similar to
that which occurs in congestive fevers, and in some cases of accidental
poisoning. Perhaps the most striking fact observed in these cases is
the perfect exhaustion attending the last moments of existence, and
the quiet, undisturbed manner in which life terminates. This very
clearly shows the exhausting nature and congestive character of the
disease, and gives us an idea of the course of treatment necessary to
be pursued. If, then, there is anything to be learned from this source
relative to its treatment, it does most certainly corroborate and
strengthen the position we have here taken.
Another feature of the case in aid of our position consists in its
entire accordance with the modes of treatment which have been most
successful in the cure of cholera. The two formulas cited above, and
now most universally adopted in Europe and India, are based on a
similar principle. So in this country 1832,-33 and 34, the successful
modes of treatment consisted in the adoption of a principle essentially
similar. Hence we infer from the teachings of this experiment, and from
all the collateral facts on the subject, that the general principle to
be observed in the treatment of this disease is a prompt and diffusive
stimulant; and hence we deduce the doctrine already apparent, that
every form of treatment, to be successful, must be based on a prompt
and effective stimulant of sufficient power to meet as speedily the
indications required, as did the free caloric in the experiment to
which we have referred.
Here we might pause for a moment and examine the suggestion and
doctrines advanced by the learned Drs. Bell, Johnson, and many
other eminent practitioners in India and Europe. We might further
investigate the principles and trace the practical philosophy of such
eminent surgeons, as Drs. Mackintosh, Thompson, Wallis Maxwell, Massy,
Hill and Brady, all of whom have had opportunity of investigating the
nature and character of the disease and extensive experience in its
treatment.
We might also, in a further examination of the subject, embrace a host
of American authors whose works teem with every shade of doctrine,
and almost every variety and description of practice, some evincing a
degree of skepticism on the subject more wonderful and marvelous than
is becoming the great apostles of medicine. It would seem as if the
guiding light of science and experience had forsaken them in this, the
hour of their need; that facts and arguments had failed to illumine
their minds, or direct their inquiries in the proper course for the
discovery of "the truth." Their conclusions on this subject are,
therefore, marvelously inconsistent and conflicting. Over this mass
of specious and conflicting testimony we might long ponder, without
deriving any very valuable information worthy an elaborate effort, or
making any discovery to aid in the establishment of a general principle
of practice for the cure of cholera. But this investigation must be
deferred to another occasion, when time may permit a more thorough
and critical examination of their doctrines and practice than can be
presented in this brief essay. We would, however, remark in passing,
that in some instances their philosophy, doctrines, and results may
lead us to the same conclusion to which we have arrived from other
sources as above, and from our regard and belief in the progress of
science, feel compelled to advocate the same, as offering the best hope
of success in the treatment of this disease.
In the employment of an anti-miasmatic principle and remedial agent,
we feel ourselves abundantly sustained, by the concurrent testimony,
of those English surgeons connected with the Medical Bureau in the
department of India, whose numerous experiments and carefully detailed
clinic cases occurring in the recent irruption and prevalence of
the disease in that section, exhibit its utility in such a striking
contrast with all former practice, as to leave no doubt as to its
direct and specific action in the cure of cholera. It is in allusion to
these experiments, and in answer to the question, what is deemed the
most successful mode of treatment, that the learned Professor Maclean
unhesitatingly observes, "Alkalies in the effervescing form, free
stimulation of the surface, and chloroform in small doses, offer the
best hope of relief." As this opinion comes from such high authority,
and is compatible with the pathology of the disease, we may, without
fear of controversy, add in conclusion, in any and every form of
medication for the cure of cholera, we must not forget that chloroform
is our sheet-anchor; and must be so combined and administered as to
meet promptly the indications required.