MURRAY, Hospitals, N. W. Provinces. I have had frequent opportunities of observing cholera during the last 34 years; from this experience I have deduced the following conclusions. The implied theory reconciles the course of the disease and the action of the remedies, and it affords a guide to perseverance, though treatment in a certain stage may prove powerless. 1. The specific poison of cholera has not been individualized by chemical or spectral analysis; but there is a peculiar sickening smell perceptible near a cholera patient, more particularly from the congee evacuations. It is somewhat similar to that from tainted fish or flesh, or the flower of the Arum Inspector-General of

Maculatum. We judge of its nature by its action on the living system, comparing the symptoms with those induced by poisons more generally known, such as agents that can be chemically tested, or others recognised by their symptoms, as typhus fever, where there is a peculiar putrid odour in the vicinity of the patient; or ague, where there is a peculiar smell perceptible in the marshy places in which the disease originates. This latter disease is sometimes combined with cholera, producing a remitting form of disease, with very profuse perspiration, " which I have called the Malwah sweating sickness." This is the sickness or black death of former ages, sweating probably and the Fievre Algide," or Fievre pernicieuse cholerirjue," described by French authors, as found in Algiers. 3. The poison enters the system through the lungs, intestines, or skin, and is circulated in the blood. It may be eliminated from it, leaving the blood in its normal state, in the same 2.



manner as


alcohol passes offt eliminated through


pulmonary symptoms


elimination of alcohol by

peculiar smell



the lungs,



further than follow the this channel. In severe cases the in the breathing; but not in slight



When eliminoted by the kidneys, there is often a very of limpid urine, which is followed by immediate relief from the depressing sense of malaise, generally felt H.

copious discharge

September 1,




the epidemic, particularly by those in contact with the affected. C. When eliminated by the liver, there i3 bilious diarrhoea There is absence of bile in the white or healthy evacuations. diarrhoea ; the action of the liver at this time being depressed

in intense cases; and want of appetite, with desire for stimulants, in milder cases, similar to the action of Hydrocyanic Acid, or Tartar Emetic, Strychnine, &c. 5. The disturbed functions of the secreting organs supplied




suspended. eliminated

by the bowels, diarrhoea is inand watery, often containing undigested food ; sometimes acrid and irritant, with tormina, but generally painlesp, giving a feeling of relief when evacuated. Semi-transparent congee-like evacuations follow, which are in D.


duced, white, copious,

part discharged by vomiting. The source of this congee-like discharge is uncertain. It has some analogy to the Pancreatic juice, and the pancreas resembles in structure the mammary gland, which continues to secrete during collapse, when the liver and kidneys have ceased acting. The mucous follicles or glands secrete a somewhat similar fluid, and there doubtless is mechanical exudation the


exosmosis of




membrane. It is probably from a combination of these sources that the congee discharge emanates. This appears to form the last vital vehicle through which the poison is eliminated from the system, as it continues after the blood,



the liver and kidneys have ceased to act. The worst cases those where this ceases, before reaction has taken place. smell is most marked in these evacuations. The




When eliminated


the slcin, there is profuse

cold perspiration.

there is little abnormal derangement of the functions; individual peculiarities of constitution evidently determine the channel through which the poison is thrown off. G. It does not afford immunity from future attacks, like the poison of small-pox, yellow fever, &c., which acts on the F.

In mild


constituents of the blood. I have had the disease three times. I have seen the intermitting form of the disease return periodically at Mhow. Custom induces a power of toleration, or facility of elimination of this as of other poisons. H. The course or development of disease in the body appears to be limited to a few days, though there may be a succession of impregnations during the epidemic. The period it may remain attached to external objects, clothes, &c., is more extended. I have suspected its remaining quiescent in the ground or buildings for a whole year. J. It appears to require the human body for propagation. Animals are rarely affected. I have seen congee evacuations from a dog during the epidemic, and poultry have been said to die frequently. Flies are often very numerous when the I.


attack is very severe. K. High temperature, i. e., 2123 F., destroys the'poison, and warm moisture assists its development, but frost does not arrest its progress. L. It is disseminated outside the body at certain seasons of the year, varying in different countries. It sometimes apThe season in pears to lie dormant till this season returns. Bengal is the spring; in the North-West Provinces in the

earlier, and in the Punjab in the later part of the rains ; and at Mecca, in the hot season, viz., May and June. The limit of the season vibrates, but the disease does not spread in the cold season in India, though there may be sporadic cases at all seasons and in any locality. M. It is probable that something more is required than the specific poison and the season of the year for the dissemination of the disease.

primary action is on the sympathetic nerve, and is in proportion to the intensity or or paralysing, quantity of the poison. The mental functions of the brain, and the voluntary action and sensation of the spinal nerves, continue unimpaired, till a very advanced stage of the disease, whilst there is a dull} dead feeling ia the abdomen, from the first, 4.



the liver, kidneys, lungs, and the first indications of its action on the body. 6. The effete portions of the body, which should have been eliminated by their secretions, accumulate in the blood as the



ganglionic system, viz., are

disease progresses, and induce their characteristic symptoms, as diarrhoea, urcemia, and asphyxia, A. The retention of the parts separated by the kidneys acts most rapidly ; the uneasiness in the head and vomiting The white diarrhoea are connectcd with the retained urea. has some resemblance to the white frothy diarrhoea, on


disease of the



B. The suspension of the functions of the lungs is shown in the livid appearance of the countenance, congested eyes, and blue nails, with the feeble action of the heart and circulation, and the dark state of the blood.

suspended action of the liver is shown by tho of the stools, and the defective manner in which the secondary functions of the bile are performed in digestion. 7. These secondary symptoms are most prominent on reaction after collapse, when these impurities have accumulated in C. The white colour

the blood.

A. The slightest symptoms are exhaustion or debility without local pain, slight dryness of skin, and weight in the head. B.


bilious or



pain and


times blood,?on other occasions light and frothy stools. C. Irritability of stomach is not unfrequent. D. Headache and febrile symptoms, with delirium, coma, and all the symptoms of low typhoid fever, often follow long

protracted collapse. JE. Coagula occasionally form in the heart, followed by rheumatic pains. The remedies used during collapse influence some of these symptoms, especially those of the head, when alcohol or chloroform have been freely used. 8. The symptoms caused by the presence of a small quantity of the poison are depression of spirits, want of appetite, light-coloured stools, and scanty urine. Choleraic diarrhoea is the first stage of cholera. The following stage commences with the appearances of congee evacuations.

It differs from the

ordinary forms of diarrlicea in its sudden appearance and short duration, and by its appearing during the prevalence of cholera, by the absence of bile, mucus, and pain. There is no appreciable difference between it and the diarrhoea which precedes collapse. The cases of white painless diarrhoea, which occasionally occur at all seasons, and the hill diarrhoea, which is very prevalent at Simla and other hill stations in India, these as well as the white frothy stools dependent on disease of the kidneys, want the characteristic smell of cholera. 9. It is the light colour, not the consistence of the stools, that is characteristic of cholera. They often become formed especially under the use of opium or lead, whilst the disease remains uneliminated, as shown by the tendency to the recurrence of diarrhoea with collapse. 10. When the quantity of the poison is great, either originally or in proportion to the powers of resistance which have become exhausted, the secretions of the liver and kidneys are suspended or suppressed, showing paralysis of the sympathetic nerve, and forming the stage of collapse. There is watery exudation from the skin, as cold perspiration; the nails are blue, and the fingers shrivelled, like a washerwoman's ; and serous discharge from the bowels, like congee water. There is sudden sinking of the spirits, burning pain in the stomach, livid countenance, and feeble action of the heart; and the voice a broken whisper, often accompanied by spasms of the voluntary and involuntary muscles,


240 11.

In the most intense form of the disease there is a sink-

ing feeling in the prsecordium ; extreme depression of spirits, or apathy ; cold, clammy perspiration ; lividity, with laborious, intermitting respiration ; feeble action of the heart; and lethargic drowsiness. The patient becomes restless, the breathing slower, with longer intervals, till at last it ceases. This form runs its course in a few hours. It is not preceded by any marked looseness or vomiting. There is often an abortive attempt at reaction, however, shown by congee vomiting and





this is


hopeful sign,

it is


delusive. reaction from collapse takes place, the restand the glazed half-shut eyes close ; sleep ensues, and the pulse returns ; the stools become coloured and less frequent. If the urine now flows, the prognosis is favourWhen



able. 13.


Till urine appears the prognosis is unfavourable. After protracted collapse, the stools at first are


and green; but in slight cases, there is frequently no intermediate shades between the congee or white stools and the

[September 1,


C. From some new properties developed in the blood, owing to the retention of some of the effete portions acting as stimulants to the nervous or sanguineous systems. D.

The vital change in the body is very analogous to the


to the natural state which follows the sweating in ague. In both there is an apparent return to health when the attack is moderate, as in ague ; whilst the restoration is imperfect when the quantity of the poison is great, as in re-




jungle fever.


There is this difference between the

only found in swampy places, generally low, and on the subsidence of water; or in autumn, it is periodical and not communicable in other localities to others, though the disease may return to the individual. or

miasmatic fever is

Cholera often appears in the dry season, witli great lieat iu or the lied Sea, or with frost in Russia. Itrcay be transported to distant localities, by land or sea, and to high mounIndia


and also

communicated toothers.

It is not periodical,


unless when combined with miasmatic

yellow, feculent, or healthy. 14. The paralysis of the sympathetic, indicated by collapse, may follow the prostration or partial paralysis of the prelimi-

13. There is an effort at reaction in all but the most extreme cases, whero the patient is a breathing corpse, insensible to medicine through any vital action, though with the mind still clear when roused.

nary stages in three ways, i. e.? A.- From the original poison



From a

cality, hospital,


acting more powerfully on a resistance, caused by exhaustion, induced

diminished power of

hy purging, fatigue,



fresh accession of

poison received from

the lo-


C. From the reproduction or development of the poison in tli3 body, bringing, as it were, a fresh crop of the disease into action. 15. The specific poison of cholera multiplies inside the body, and if it be not carried off or eliminated, it must accumulate and


increased force.

retained in the soil or attached to The extension


buildings or goods. spreading of the disease is along the

lines of human intercourse or commerce. In many cases the connecting linJc is evident, such as the arrival of individuals, ships, or goods from an affected locality, followed immediately hy the appearance and spread of cholera.

Localities where human intercourse has been strictly have escaped whilst surrounding localities have suffered. D. Animals have shown characteristic symptoms of cholera C.


that the disease has


in the

place ; but I am not aware that animals have been tliu3 when men have not been suffering from cholera.

where the disease was

raging spread,


16. The feeble action of the heart in collapse is materially influenced by the non-stimulant power of the black blood. Transfusion of a saline fluid into the veins restores the heart's action, the red colour to the blood, and warmth to the body ;

but this alone does not remove or cure the disease. The cessation of the heart's action would cause death, but something more than its restoration is required for health, viz., the elimination of poison from the system.

stage of the disease, as the hot fit is a stage of ague; only, to continue the analogy, it follows the sweating state in that disease. A. Reaction may arise from the poison having been elimina17.

Reaction is

ted from the


of the



system, thereby removing and allowing


the cause of the pathe restoration of its

development in the vital progress of the poison the flowering and fading of an annual plant, the fermentation of saccharine fluids, or tlie effervescence of chemical compounds. Ii.


From such



There is a rosy tint over the intestines ; they feel doughy, filled with a whitish milky fluid. There is congestion of all the viscera, and a Hack liquid state of the blood, like that found after death from lightning. In cases that prove fatal before are

reaction, the gall bladder is generally distended with viscid bile, and whitish coagida are often found in the heart, after protracted collapse. The lungs are much gorged with blood. The mucous follicles of the intestines are often enlarged, looking like small-pox vesicles. These are all the morbid appearances that 1 have noticed in the purest form of cholera, uncomplicated by local affections or the changes induced by the suppressed secretion.

Tlie human body is the chief, if not the only medium in whicli the disease multiplies or increases, though it may be A.



19. Many remedies used previous to reaction have been supposed to promote or induce that change, which certainly prove injurious after it has taken place, and whose action during collapse is very doubtful. The remedies apparently indicated in the cold stage of ague would do little good in that stage, and they would be contra-indicated in the following hot stage. 20. The cure of cholera depends on the removal of the poison from the system by the ordinary channels through which alcohol or similar poisons are eliminated, viz., the action of the secreting organs, the liver, kidneys, and lungs. 21. The indications of treatment are to promote these secretions, to guard against and remove exciting causes of exhaustion, particularly purging, and to avoid fresh accessions of the poison. 22. The different stages of the disease require distinct modes of treatment. A. In the

preliminary stage, when medicines have their body. 13. In collapse, when medicines have lost their usual action, and are nearly, ifnot entirely, inert. C. During reaction, when medicines have resumed their


action on the

power. 23.




in the

of success depends preliminary stage.


the treatment being

24. The indications of treatment in this stage are to stimulate and strengthen the sympathetic nerve, and thereby to remove restore the functions of the organs supplied by it ; nourishdiarrlicea, the using check and to and pain irritation,

ing diet, and avoiding indigestible food, or bodily.




25. The remedies that I have found most useful and convenient in this stage are the cholera pills of asafcetida, black distributed so as to bo pepper, and opium. They are generally available, thereby saving time xvnd preventing the


September 1, disease



to the next



when medicines are almost

When there is vomiting, a mustard poultice to the stomach is useful, with small quantities of cold r iced water Should the stools continue white, with carbonate of soda.


Small doses of

calomel is valuable.


in the







It is necessary to check the vicarious white diarrhoea ;


purging, even though bilious, and carrying off the poison, induces prostration of the nervous system, which is very liable to be followed by congee stools and collapse. Ordinary purgatives are often followed by similar symptoms durinrr the prevalence of the epidemic, the poison already in the system being brought into force by the debilitating action of the as

medicine. 27. I tried bleeding thirty years ago, but not since then ; I have seen it tried on several occasions, but not with satisfactory results, in this or any other stage. the indications of treatment are to palliate the urgent symptoms, and support the system till reaction comes on ; and to avoid the use of powerful remedies which In




prove injurious after reaction.

The exhibition of medicines is limited by their having ordinary influence through the paralysis of the sym-


lost their

burning thirst is best alleviated by cold or iced water containing a little soda or carbonate of ammonia ; and the cramps by hot saline enemata and warm frictions. So long as the evacuations are colourless, congee-like, the vomiting and purging arc not injurious. The worst cases are those in which these cense. Food is not digested, and alcoholic stimuli and opium are injurious.



30. Until symptoms of reaction appear, this simple expectant treatment alone can be beneficially employed, and it can lie carried out by the hospital attendants, whilst the attention of the physician is directed to the detection of the earlier

stages, and the prevention of the spreading of the disease

amongst others. 31. Active treatment, or the use of strong remedies, has never, in my experience, produced good effects; but I have seen many injurious, if not fatal, results follow when reaction

ensued. 32. On reaction, the indications of treatment are to restore induce the secretions, restrain the vomiting and purging,






fully avoiding the patient's bein

The Pathology and Treatment of Cholera.

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