rises by the aid of a suitable regimen. Sometimes, however, the debility is considerable and protracted, and requires medical interference. Occasionally the patient is left with a troublesome diarrhoea, or with other evidences of a continued irritation of the stomach and bowels. In intemperate persons, the checking of the cholera is apt to induce delirium tremens.

In persons of good constitution, the disease is yery rarely fatal. It is most apt to prove so in the very old, the feeble, and the intemperate.

Causes. Hot weather, long continued, strongly predisposes the system to cholera morbus, and may of itself occasion the disease without any other cause. The same may probably be said of marsh miasmata; for cholera morbus very often precedes the breaking out of miasmatic fevers, as if resulting from the operation of the same cause in a less degree. Most commonly, however, the immediate attack is brought on by some exciting cause, capable, either directly or through the nervous centres, of irritating the stomach and bowels. Among such causes may be mentioned, exposure to cold when the body is heated and perspiring; the use of certain indigestible and irritating articles of food or drink, as cabbage, cucumbers, melons, various unripe fruits, fat pork, lobsters, crabs, sour and incompletely fermented liquors, putrid water, &c.; excesses at the table, independently of the character of the food; the use of ice, or very cold drinks in excess; strong mental emotions, as fear or anger; and various movements which produce sickness of stomach through their ac tion on the brain, as riding backward, turning rapidly in a circle, and sailing upon a rough sea. The disease prevails especially in hot countries, and during the hot season in temperate latitudes. Sometimes it is so prevalent as to put on the appearance of an epidemic, though probably dependent on the heat of the weather, or the local miasmata, in the same manner as our endemic remittent fever. In this country, it is most common in the months of July and August. It chiefly attacks adults.

Nature. This must be inferred from the symptoms and causes; as dissection reveals nothing which can lead to any accurate conclusion. Sometimes redness or other evidence of inflammation is discovered in the stomach, or some portion of the bowels; but often no such phenomena are presented, and neither the alimentary mucous membrane, nor any other structure exhibits appearances which could explain the symptoms. The probability is, that the disease consists essentially in congestion of the portal system, produced by the continued action of a high temperature, by miasmata, or both, and inducing an irritation both in the liver and lining membrane of the stomach and bowels, which exhibits itself in an increased and altered secretion. Should the congestion from these causes be alone inadequate to the result, a superadded irritation, from the various exciting causes above enumerated, may be required for the production of the phenomena of the disease. The painful gastric and intestinal symptoms may result either from the general state of sanguineous congestion in the whole canal, or from the irritating quality of the morbid bile and intestinal secretions, or from both. That the liquids referred to are the source of much of the pain and spasm, is evident from the temporary relief which follows their discharge. The prostration is owing partly to the profuse evacuations, partly to the depressing influence of the nausea. The extreme thirst, instead of being an evidence of inflammation of the stomach, is the mere expression, in the throat and neighbouring parts, of the wants of the blood-vessels, deprived of a large portion of their more fluid contents. The spasms of the extremities are probably one of the consequences of the gastric and intestinal irritations, acting through the nervous centres. Diagnosis.-Vomiting and purging, with more or less bile in the evacuations, are not unfrequent attendants upon other diseases, as bilious fever,

gastro-enteritis, and inflammation of the liver. From the first of these, however, cholera morbus may be distinguished by the absence of a hot skin, a strong pulse, and headache, and by its much shorter course; from the two latter by the same absence of decided febrile symptoms, and the less degree of tenderness. There may be greater difficulty in distinguishing it from the effects of certain mineral poisons. I have seen the operation of calomel in some instances so exactly like cholera morbus, that the most experienced eye could scarcely have detected the difference. But, in poisoning by corrosive substances, the vomiting generally precedes the purging by a considerable interval, the discharges are seldom so highly bilious, and the poison may often be detected in the evacuations. The circumstances attending the origin of the complaint, and the season of the year, may also be taken into consideration in forming the diagnosis. Bilious diarrhoea is sometimes attended with moderate vomiting; but this affection may be considered as only an inferior grade of cholera. The vomiting and purging produced by indigestible food, in a system not predisposed to cholera morbus, are scarcely entitled to rank with that disease.

Treatment. The following mode of treatment will very generally be found promptly effectual, in ordinary cases of cholera morbus. It is founded on the indications, 1. of removing the irritating causes by clearing out the stomach, 2. of checking the irritation directly by the moderate action of opium, and indirectly by powerful revulsion to the surface, and 3. of changing the morbid action of the liver by the alterative influence of calomel. Mild diluent drinks are to be administered freely; a sinapism of pure mustard mixed with water, to be applied over the epigastrium; and a pill containing the sixth of a grain of calomel and from the sixth to the twelfth of a grain of opium, to be given every half hour, or every hour, according to the urgency of the symptoms. The drinks should consist of chicken tea made by boiling, for a very short time, a portion of chicken, deprived of skin, in a large quantity of water so as merely to impart a slight taste to the liquid; of mucilaginous or farinaceous fluids, such as solution of gum arabic, mucilage of sassafras pith or flaxseed, toastwater, barley-water, &c.; of mild herbaceous infusions, as balm or mint tea; or, finally, of lukewarm water. They should be given freely at first, so as to facilitate the evacuation of the acrid bile, and then suspended, or administered moderately merely to relieve the thirst of the patient. For this purpose, also, as well as to quiet irritation of stomach, carbonic acid water, in small draughts of about two fluidounces, frequently repeated, answers admirably well. The mustard cataplasm should be left on for half or three-quarters of an hour, or until it reddens the skin intensely, and becomes no longer tolerable. In severe cases, or in the advanced stages, when the prostration is great, it is often necessary to administer opium more freely than above directed. From half a grain to a grain of opium in pill, or, what is generally preferable, from twelve to twenty-five drops of laudanum, or an equivalent quantity of the solution of sulphate of morphia, may be given, and repeated at longer or shorter intervals until the violence of the symptoms abates. But the least quantity of opium that will answer the purpose is the best; as, though it is necessary to allay the pain, and check the discharge, yet a complete and sudden suspension of the secretion is not desirable. There is danger, if the congestion be not allowed to relieve itself, that fever or inflammation may ensue. Hence one of the advantages of uniting calomel with the opium. Large doses of the mercurial are not required; as experience has shown that, in the minute doses before mentioned, frequently repeated, it acts effectually on the liver, while it is less liable to irritate the stomach and bowels.

If the disease should resist the above measures, recourse may be had to a

blister over the epigastrium, and powdered acetate of morphia may be sprinkled on the blistered surface deprived of its cuticle. Injections of laudanum, with thin starch or mucilage, may also be given. In cases of great prostration, rubefacients may be applied externally, and blisters to the insides of the arms or legs; and tincture of camphor, aromatic spirit of ammonia, wine-whey, and even ether, may be given internally, in conjunction with the opiate.

Should diarrhoea continue after the vomiting has ceased, it should be treated as directed under the head of that disease. Should fever follow a suspension of the discharges, the bowels should be kept open by small doses of some mild cathartic, as the Seidlitz powder, or a solution of carbonate of magnesia in earbonic acid water, commonly called liquid magnesia; and the effervescing draught and cooling drinks should be administered at short intervals. Symptoms of gastric inflammation may be counteracted by leeches to the epigastrium, followed by warm fomentations or emollient cataplasms. Intestinal irritation may be treated by emollient enemata, and mild laxatives, as castor oil with a little laudanum.

Various other modes of treating cholera morbus have been recommended. Some practitioners, considering it essentially gastritis or gastro-enteritis, have relied chiefly upon bleeding, leeching, and demulcents. But this is hazardous practice. Ipecacuanha, in emetic doses, has had its advocates. Nitric acid has been lauded as a specific. Hope's mixture, consisting of a drachm of nitrous acid, forty drops of laudanum, and eight fluidounces of camphor water, and taken in doses of two fluidounces every three or four hours, has in its favour the recommendation of Dr. C. D. Meigs, of Philadelphia, as well as that of its original proposer. (N. Am. Med. and Surg. Journ., ii. 419.) Dr. D. J. Cain has found great advantage from the use of creasote. (Charleston Med. Journ. and Rev., vii. 145.)

During convalescence, the greatest caution should be observed in relation to the diet, which should consist of mild and easily digested aliment, such as farinaceous substances, milk, cream, broths without fat, and the lighter forms of solid animal food.

Article II.

EPIDEMIC CHOLERA.

Syn.-Spasmodic Cholera.—India Cholera.—Asiatic Cholera.-Malignant Cholera — Cholera Asphyxia.

This disease appears to have been long known in India; but it first began to attract the attention of the medical profession generally in the year 1817, when it broke out as an epidemic with great violence in Bengal, and from that province, as a centre, commenced the fearful march, which did not cease until it had encircled the globe. In its progress westward, it ascended the Ganges, pervaded Central India, and, crossing the mountainous range of the Ghauts, established itself, in the year 1818, upon the western coast of the peninsula. During the same year, it made its way southward to Madras; in 1819, crossed the sea to Ceylon; and, before the close of the latter year, appeared in the Mauritius and the Isle of Bourbon. At the same time, it was slowly advancing towards the east and southeast; invaded the Burman dominions; attacked Siam, the peninsula of Malacca, and the island of Sumatra; and, in 1820, had reached Canton and the Philippine Islands. It was subsequently heard of as extending its ravages into the northern parts of China, and into Tartary. After arriving at the western coast of the peninsula of Hindostan, it paused for a while before leaving its native soil; and it was not till the year 1821,

that it appeared on the shores of the Persian Gulf. From this position it ascended the Tigris and Euphrates; in 1822, passed over the desert into Syria; and, in 1823, having made its way northward through Persia, reached the shores of the Caspian Sea, and seized upon the Russian city of Astracan. It had now traversed the whole length of Asia, and was pressing upon the confines of Africa and Europe. Here it again paused; and several years elapsed before it crossed the boundaries, and commenced a new career of invasion in these hitherto undisturbed regions. In 1828, it appeared at Ohrenburgh, on the borders of European Russia; but it did not fairly enter Europe until 1830, when it advanced as far as Moscow. In 1831, it took a westward course, attacked St. Petersburg, Warsaw, Dantzic, Berlin, and Hamburg, and showed itself in Sunderland, on the northeastern coast of England. In 1832, it reached Paris and London; and in the same year, overleaping the barrier of the Atlantic, appeared in Quebec on the 8th of June, and at Montreal on the 10th; and thence pursued a rapid course, along the St. Lawrence and the Lakes, to the valley of the Mississippi River. A detachment from the main line of invasion, as it crossed the Atlantic, appears to have struck the shores of the United States at New York, where the disease broke out on the 24th of June. Thence it spread northwardly up the Hudson, and southwardly to the Delaware and Chesapeake Bay, reaching Albany on the 3d or 4th, and Philadelphia on the 5th of July, and Baltimore in the course of the same month. About the beginning of November, it appeared in an island off Charleston; in February, 1833, at Havana, in Cuba, where it committed great ravages; and, before the end of that year, in Mexico. At the same time that the epidemic, leaving the northwestern borders of Asia, was spreading consternation throughout the north of Europe, it took also a southward course from Syria, penetrated the deserts of Arabia, and invaded Egypt, appearing in Mecca, in May, and in Alexandria, in August, 1831. It was very late in attaining the extreme north, and the extreme south of Europe. Thus, Sweden was not visited until one or two years, nor Sicily until four years after the epidemic had reached New Orleans. In this country, there were partial returns of the disease subsequently to its original appearance, and it prevailed to a considerable extent in the year 1834; but both in North America, and the greater part of Europe, it disappeared entirely in somewhat more than two years from its first visitation.

In India, however, the disease continued as an endemic, and, at the date of the first publication of this work, in the early part of 1847, we had received accounts of its having commenced a new march of desolation in the East. Before the close of that year it again entered Europe, and afterwards advanced regularly westward, pursuing a course singularly corresponding with that of its first invasion, both as to the succession of regions visited, and the period of its approach and departure. Setting out from India as before, it passed destructively through the cities of Persia, skirted the shores. of the Caspian, and reached Astracan in July 1847, and Moscow before the close of the year. Here its progress was suspended during the winter; but in the spring of 1848 it again advanced westward, in June arrived at St. Petersburg, in August at Berlin, in September at Hamburg, and crossing thence to Great Britain, attacked Edinburgh in October, and London soon afterwards. On the ninth of November, a ship with emigrants sailed from Havre for New York. At the time of her departure there was no cholera either in that port or at Paris, and the crew and passengers were all healthy. The vessel had been sixteen days at sea when the disease appeared on board, and she arrived with it at the quarantine ground at Staten Island, on the first of December. The passengers were landed, and very soon afterwards the disease broke out in the neighbourhood. It did not, however, extend beyond

the quarantine enclosure, and ceased entirely about the beginning of the new year. Three deaths occurred from it in the city of New York. Another ship, which had left Havre on the second or third of November, without cholera on board, was attacked with the disease twenty-six days after leaving port, and brought it with her to New Orleans, where she arrived on the eleventh of December. Cases of cholera soon afterwards occurred in the city, and rapidly multiplied, the weather being at the time very hot, and of course favourable to the spread of the disease. From New Orleans it extended to Texas, and up the Mississippi, reaching the city of Memphis so early as the twenty-second of December, and sweeping over the valley of that great stream with unheard of rapidity. It did not, however, surmount the Alleghanies; and, with the exception of the slight demonstration made in the harbour of New York, the Atlantic States remained free from the disease during the winter. The epidemic cause, however, was in the mean time pursuing its regular course across the Atlantic; and, as on the previous occasion, reached our shores in the season following that of its appearance in western Europe, though somewhat earlier than in the year 1832. It broke out in New York about the beginning, and in Philadelphia about the close of May, 1849; and while, commencing at the Atlantic coast, it visited many parts of our country on this side of the mountains, it seemed to take a fresh start from New Orleans, and again spread along the tributaries of the Mississippi with fearful violence. In its further progress, it invaded the West Indies and Mexico, and, crossing the whole breadth of the continent, reached the shores of the Pacific, producing as it went great havoc among the emigrants on their way, like itself, to California. It attacked the cities of St. Fransisco and Sacramento in October, 1850. In the summer of 1850, and in every year since that time, it has occurred to a greater or less extent in various parts of the valley of the Mississippi, in which there is reason to fear that it has become naturalized; but the section of our country, east of the Allegha nies, with some slight exceptions, remained exempt, from the period of its visitation in 1849, until the summer of the present year (1854), when it again made its appearance in the epidemic form, having pursued the same course as on former occasions, from the Eastern parts of Europe, through the north of that continent, to Great Britain, and thence across the Atlantic to the United States.

From the above brief account of the progress of cholera, it will be seen that its march is extremely irregular, in relation both to time and direction. Sometimes it advances with great rapidity, sometimes slowly, and sometimes pauses for a longer or shorter period, giving hopes to the yet unvisited countries, that they may escape its ravages. In general, its progress is arrested during the winter, to be resumed in the spring; though this is not invariably the case; for at Moscow it prevailed through most of the winter of 1830-31; and the cold weather did not prevent its spreading along the Mississippi in the winter of 1848-49. Though preferably following the course of streams, affecting low and damp places, and attacking the filthy and crowded portions of populous cities, it is yet absolutely confined to no particular character of locality, but shows itself occasionally upon lofty mountains, in the midst of sandy deserts, and among the scattered inhabitants of thinly peopled agricul tural districts. No barriers are sufficient to obstruct its progress. It crosses mountains, deserts, and oceans. Opposing winds do not check it. All classes of persons, male and female, young and old, the robust and the feeble, are exposed to its assault; and even those whom it has once visited are not always subsequently exempt; yet, as a general rule, it selects its victims preferably from among those already pressed down by the various miseries