ON CHOLERA.

[We took some pains in our 20th volume (for July to December, 1849) to collect and arrange the many opinions on Asiatic Cholera, both as to its pathology, causes, and treatment, which were published at that time. For an interesting epitome on this subject, therefore, we refer the reader to vol. 20, where he will gain all the information which seemed then to be known.

We now add some other opinions which have been published since the epidemic made its appearance in the present year of 1853. But we do not think it neces sary again to enter into so minute an analysis as we did before, because we do not perceive that there has been any very material addition to our previous knowledge on the subject. We will, therefore, merely subjoin some of the opinions on the treatment of this disease which seem to us to be the most sensible-although we must acknowledge that the difference of opinion has sometimes greatly amused us.]

153. Blood of Cholera Patients.

[DR. WILLIAM ROBERTSON, of Edinburgh, Editor of the Monthly Journal,' draws the following conclusions from thirty-five chemical analyses of the blood taken from cholera patients in different stages of the disease:]-1st, That anemic subjects are more prone than others to attacks of cholera. We have already seen that in all the six cases composing Table I., the per centage of globules was low. We know that during the late epidemic a large proportion of our patients were females, that of these many were pregnant, nursing, or exhausted by uterine discharges. We know that the disease was, with very rare exceptions, confined to the poor, and that the ill-fed and dissipated were its usual victims. It seems not unnatural to conclude that an impoverished condition of the blood predisposes to cholera. This consideration is calculated to increase our faith in the efficacy of sanitary means as a prophylactic against cholera. Pure air, cleanliness, abundance of wholesome food, temperance, and regular exercise, the means. in short, by which the physical powers of the body are most certainly developed, are the best securities against disease. 2nd, I think that it is shown by the first three tables, that the changes which so rapidly affect the blood during cholera, are concentration of the serum and globules, from the abstraction of water, together with a proportionate loss of salts. 3rd, The changes subsequently effected during the stage of reaction are far more complex. I shall only allude to the chief of these. Water seems to pass rapidly into the circulation, dilutes the serum, and causes a notable diminution in the proportion of its salts. By direct analysis it has already been shown, that the relative proportion of salts is smaller during the period of reaction, than at the commencement, or during the violence of the disease. This result is, I think, fatal to any theory which proposes to explain the phenomena of the stage of collapse by reference to the deficiency of salts, and holds out no encouragement for the practice of injecting saline solutions into the veins during the algide stage. But although the dilution of the blood consequent on the absorption of fluid, explains the small per centage of serous salts during the stage of reaction, it will not explain the undiminished amount of blood corpuscles, the increase of fibrine, and the rapid disappearance of albumen from the serum. Is the increase of fibrine connected with inflammatory processes in the lungs and kidneys? Are blood corpuscles formed during returning health with great rapidity, so as to maintain their normal standard while the serum becomes diluted? How is the superfluous albumen which manifestly leaves the system disposed of? The last of these questions can alone be confidently answered. The albumen which quits the serum is, in part at least, excreted by the bowels and kidneys. It has been detected in the stools, and, in a very large number of cases, has been detected in the urine passed during convalescence. Dr. James Begbie, who, at my request, made about 100 examinations of the urine passed by my cholera patients, found albumen in about 80 per cent. of the first urines of convalescence, and in about 76 per cent. of the whole number of specimens examined. In several of the cases in which no albumen was detected,

the urinary secretion had been restored for some hours, or even days, but the earlier portions of urine passed (in which we should naturally have expected to detect albumen) had not been preserved for analysis. I think that Dr. James Begbie's analyses, which he has carefully recorded and put at my disposal, prove that the presence of albumen in the urine of reaction is the rule-its absence the exception; and render it highly probable that the kidney is one of the channels by which the blood is relieved of its superfluous albumen. The restoration of the urinary secretion I have always regarded as the most important step towards convalescence. If the secretion be long suspended after the stage of collapse has given way to reaction, the prognosis is most unfavourable. The patient soon falls into a drowsy state, moans incessantly, but gives occasional indications of consciousness, by returning a short answer to questions put in a loud voice and frequently repeated. From this state I have seen few recover; it passes into profound coma, and the fatal event is sometimes preceded by general convulsions. There can, I think, be no question that these symptoms are caused by the presence of urea, and possibly of other principles, in the blood. The researches of Dr. Christison and others have made us familiar with similar symptoms, produced by a like cause, in the later stages of Bright's disease, and in certain cases of our short or relapsing fever. But in no disease has the urea been found in the blood in such quantity as in cholera. During the reaction stage, in particular, it seems to be formed with great rapidity, amounting, in some instances, as has been proved by analysis, to nearly 2 parts in 1000 of blood. The important therapeutic indications which this fact suggests are sufficiently obvious. The danger most to be feared is the formation and retention of urea in the blood. Safety must be sought in the employment of diuretic remedies, and especially of such as are believed to possess the property of expelling urea from the system.-Monthly Journal of Med. Science, Sept. 1853, p. 250.

154.-Pathology of Cholera.

[Dr. SIBSON makes the following sensible remarks previous to his relating a case of Asiatic cholera :]-Admit that cholera, like typhus, is nothing more than the effect of a virulent principle, which at certain times, and in certain places, is carried by the atmosphere, and all the symptoms are easy of explanation, and a treatment which might almost be called rational naturally flows from the hypothesis. The vomiting and dejections are a kind of violent attempt at elimination; the blood, perhaps still charged with the virus, becomes thick from the loss of its watery parts, and the two causes (one in some degree vital, and the other mechanical) give rise to an arrest of functions, to congestion in the cerebrum, and eventual death. When the vomiting and purging are over, the patient has to contend against-first, the weakness consequent upon the loss of so much albuminated fluid, and, secondly, the remains of the virulent principle in the inspissated blood left after the loss of so much water; and if his medical attendant can keep him alive until the blood becomes more dilute, and the poison thereby less active, he will have the credit of a cure

That the poison once admitted into the circulation causes a kind of irritation in the blood is extremely probable, and the consequence of that irritation and abnormal state is an undue activity of the veins and glands of the intestinal and gastric mucous membrane. It may thus be doubted whether diarrhoea be really and truly a premoni tory symptom; one might, on the contrary, be inclined to maintain that looseness of the bowels does harm during an epidemic of cholera only so far as it tends to weaken the individual. But his diarrhoea will be as free from serious results as it is in ordinary times, if the subject do not inhale a portion of atmospheric air sufficiently charged with the virulent choleraic principle.-Lancet, Oct. 1, 1853, p. 311. 155.—Prevention of Cholera.

[DR. SNOW observes, that if cholera commenced with general symptoms, we should not know by what channel the morbid influence had entered into the system: as it is, however, it is quite clear from the disturbance of the alimentary canal, that the effects which follow in the course of the disease, are only the result of what has occurred in this organ.]-The exudation of the watery part of the blood into the stomach and bowels causes the faintness and sinking. The blood which remains in the vessels being too thick to pass readily through the capillaries, both the pulmonary and systemic circulations are impeded; hence the difficulty of breathing, the

general coldness, and state of collapse. How far the cramps depend on irritation of the nerves of the alimentary canal, and how far on the want of fluidity and proper circulation of the blood, is not very evident; but it is quite certain that they do not depend on any cholera poison circulating in the blood, for the cramps and all the symptoms of collapse disappear for a time on the injection of a weak saline solution into the veins, which merely replaces what has been lost by the bowels. It is evident from this circumstance that the blood is not poisoned in cholera, except in cases of secondary illness, when it becomes charged with urea and other excretory matters, owing to congestion of the kidneys. The primary and essential morbid actions of cholera being confined to the alimentary canal, it follows that the materies morbi of cholera must find access to it by being swallowed, that it must increase and multiply there, and be discharged to be a source of danger to others.

Before pointing out the precautions which these views suggest, it will be well to examine what light they throw on the progress of cholera, and what confirmation they receive from general and particular facts connected with its history. It has been observed, in all parts of the world, that nothing assists the spread of cholera more than want of personal cleanliness. When we consider how free the evacuations from the stomach and bowels of cholera patients often are, both from colour and odour; how suddenly and copiously, and with what force they are generally discharged, it is evident that the hands, both of the patient and his attendants, are liable to be soiled with them. Unless great care is taken to wash the hands frequently, and more especially before taking food, or handling and preparing the food of others, small quantities of the evacuations must necessarily be accidentally swallowed. The influence of dirty habits in aiding the spread of cholera is thus clearly accounted for. It is analogous to what occurs among house-painters in regard to lead-poisoning. Those of cleanly habits escape; while others constantly swallow a little paint with their food and become affected with colic. The scarcity of water, of course, is an obstacle to cleanliness, even when the inclination prevails; and this has frequently been observed to be connected with the unusual extension of cholera in a town or neighbourhood. The reason why medical men, and other persons of cleanly habits, who do not stay to eat and drink in the sick room, are scarcely rendered more liable to cholera by their avocations, while it often fares differently with the social visitor, is perfectly explained by the above views. It is evident, also, why the medical man can make inspections of the dead bodies of cholera patients with impunity; while they who wash and lay out the body often suffer. The medical man is certain to wash his hands after his operation, while the persons who perform the other offices mentioned, especially among the poor, are almost as certain to neglect that duty. It is obvious that, where a whole family live, night and day, in one small room, in which the cooking is done and the meals are caten, that the food is very liable to become contaminated, in the event of a case of cholera occurring; and where several families live in one room, the risk amounts almost to a certainty.

[The cholera poison may not only act upon the system when it is taken in with the food, but when it is diffused also in a very large quantity of water. One great cause of the spread of cholera is that, owing to bad drainage, the evacuations of patients are allowed to remain on the surface contaminating all who come in contact with them; and besides, by percolating through the earth, they infect pump-wells and other supplies of water.]

The measures for the prevention of cholera which are suggested by the circumstances and views above detailed, may be divided into those which can be carried out in the presence of the epidemic, and those which, as they require time, should be taken beforehand.

The measures which should be adopted during the presence of cholera are:— 1st. To take care that there is a hand-basin, water, and towel, in every room where there is a cholera patient, and to take care that they are used by the nurse and other attendants, more particularly before touching any food.

2nd. To immerse the soiled linen of the patient and his bed in water as soon as it is removed, until such time as it can be washed, lest the evacuations should become dry, and be wafted about as fine dust.

3rd. To take care that the water employed for drinking, cooking and preparing food (whether it comes from a pump-well, or is conveyed by pipes), is not contami

nated with the contents of cesspools, house-drains, or sewers; or, in the event that water free from suspicion cannot be obtained, to have it well boiled and, if possible, also filtered.

4th. When the cholera prevails very much in the neighbourhood, to have all the provisions which are brought into the house well washed with clean water, and exposed to a temperature of at least 212° Fahr., or to make them undergo at least one of these processes.

5th. When a case of cholera appears among persons living in a crowded room, the healthy should be removed to another apartment where it is practicable, leaving only those who are useful to wait on the sick.

6th. As it would not be practicable to clean out coal-pits and establish privies and lavatories in them, or even to provide the means of eating a meal with anything like common decency, when the cholera makes its appearance, the time of working should be divided into periods of four hours instead of eight, so that the pitmen might go home to their meals, and be prevented from taking food into the mines.

The measures which can be taken beforehand to provide against a visitation of cholera, are,

7th. To effect good and sufficient drainage.

8th. To provide the inhabitants with an ample supply of water, which is quite free from contamination with the contents of sewers, cesspools, and house-drains, or the refuse of people who navigate the rivers.

9th. To provide model lodging-houses for the vagrant class, and sufficient houseroom for the poor generally.

10th. To inculcate habits of personal and domestic cleanliness among the people everywhere.

The advice and directions which are issued respecting cholera by authority, are directed almost entirely against dirt and nuisances; but, unfortunately, they are perfectly silent respecting that particular kind of dirt which does the mischief. The Board of Health directs its attention more particularly to offensive effluvia, as a supposed cause of cholera. When the ready means for the communication of this disease exist, it often happens, for very evident reasons, that offensive gases are not altogether absent; but it has been satisfactorily proved, that the effluvia arising from the decomposition of vegetable and animal matters have nothing whatever to do with cholera. Med. Times and Gazette, October 8, 1853, p. 367.

156.-Treatmen! by Calomel.

[DR. AYRE, of Hull, observes that in the epidemics of 1832, and 1849, calomel was the sole and exclusive remedy he employed. In excusing the imperfect nature of the report, he observes:]-As I have found myself obliged, from the circumstance of the disease being already amongst us, to anticipate the time when I should give the result of the communications to be made to me on the treatment, I must now content myself with giving such a report as the occasion will permit. From one of my correspondents I have received a report, in a tabular form, of upwards of eighty patients in the collapsed stage who were recovered by this treatment, and the true nature of whose disease is shown by an amount of calomel taken, which none but cholera patients in collapse could take with impunity, but which they received without any inconvenience ensuing, not more than four or five of the whole number having been affected with ptyalism, and none to a troublesome degree. It would be occupying too large a space in your columns to insert the whole of the cases, and I shall content myself with presenting twelve of them, taking them in the order in which they have been sent to me.

From the following table of cases, it will be found that the average quantity of calomel taken was ninety-five grains, and that the duration of the disease was brief, which corresponds with my experience; for under this treatment, the patients come from a state of disease to one of comparative health, I having on many occasions found my patients sitting at their meals with their family on the second or third day after having been in a state of pulscless collapse, so speedily are they restored when the secretion of the liver is renewed. I here subjoin the letter of my correspondent, which accompanied the cases I have copied above, and which confirms in every way my own experience in the nature and results of the treatment:

"In answer to your inquiries, I may say that only a few were affected with ptyalism in the cases of cholera, and these few would not have been so but for the anxiety of patients to continue the pills when a change for the better took place. As to consecutive fever, I hardly ever knew of a case under the calomel treatment. The cases of collapse occurred before I saw these as a general rule, because, if seen early, they rarely went into collapse. Stimulants were not given by me, with the exception of a few drops of ether or camphor-water. One or two drops of laudanum were given with each dose of calomel, up to twenty-four or thirty drops taken on the whole, when it was discontinued. I had an opportunity of seeing that treatment carried out to the letter in thirty-three, being at that time apprenticed to a gentleman who fully carried out your treatment."

Twelve Cases of Cholera in the Collapsed Stage recovered by the Use of Calomel in small and frequently-repeated Doses.

In preparing to address you, I intended to give in detail a further report of the testimony supplied to me by various correspondents, but of the communications now before me, there is such a uniformity of sentiment in favour of the practice with calomel, and so nearly in the same terms declaring what has been given above, that I shall content myself with simply quoting a single passage from each of twelve correspondents, and alphabeted below:

A. Calomel in the doses you mention has been given to a considerable extent: and, in my opinion, is a medicine deserving the highest praise.

B. Calomel administered according to your plan has been our sheet anchor. C. In the stage of collapse calomel in smal! and frequently repeated doses is alone to be relied on.

D. A patient of mine took upwards of 400 grains, was saved, and had no soreness

of the mouth.

E. We have tried every mode of treatment, and been obliged to abandon them for the calomel treatment.

F. The disease here has almost universally yielded to the calomel treatment by small and frequently repeated doses.

G. and H. We have found the calomel treatment most efficient in early stage of collapse, and when the patient had become pulseless.

I. Having seen a great deal of the cholera in 1832, and attended patients both alone and with you, I can speak in the strongest terms of the efficiency of the treatment in the stage of collapse.

K. I consider the want of success with many, by the calomel treatment, has arisen from the large doses of opium combined with it.

L. My success in the use of calomel in small doses convinces me that all who shall give it a trial will be equally convinced of its value.

M. I beg to forward you the case enclosed, as proving the power of the calomel treatment to cure the disease in its worst form.