This disease is one of the most insidious in its approaches. Aside from a mild diarrhoea, it gives no warning of the attack. So little are patients conscious of danger, that they often apologize for giving the physician the trouble of visiting them, when a glance suffices to show that they are on the verge of collapse. It behooves the physician, in all cases of simple diarrhoea during an epidemic of cholera, to watch carefully the evacuations with reference to the diagnosis. On the other hand, during an epidemic, physicians. are not infrequently called to see persons who, under intense nervous excitement, imagine they are about to be attacked, when no symptoms whatever of the disease are present. These have been aptly called cases of choleraphobia.

PROGNOSIS. Of those attacked with cholera, a large proportion die. The average mortality in hospitals varies from one-half to one-third. In private practice, especially among the better classes of society, the mortality is considerably less. In individual cases the prognosis is widely different, according to the period of the disease at which the patient is first seen. If seen immediately after the attack, before serious blood-lesions have occurred, the prospect of an arrest of the disease is good. But if the disease have advanced to the stage of collapse, the prognosis is always exceedingly unfavorable. After reaction from the collapsed state occurs, the danger is still considerable, but the cases in which recovery takes place preponderate. The statistical researches of Duchesne show the rate of mortality at different periods of life in the epidemic at Paris, in 1849.1 The proportion in 1000, in subjects under 5 years, was 148; from 5 to 15 years, 50; from 15 to 30 years, 177; from 30 to 45 years, 254; from 45 to 60 years, 206; and from 60 to 85 years, 162.

PREVENTION OF CHOLERA.

The prophylaxis of cholera claims consideration under a distinct heading, and I give it precedence over the therapeutical management, in view of its greater relative importance. In addition to the removal, as far as possible, of all the auxiliary causes of disease which contribute to render the special cause of cholera efficient, the prevention involves prompt attention to the diarrhoea, which, in the great majority of cases, precedes the attack. This premonitory diarrhoea is amenable to simple measures of treatment, and if effectually treated there is reason to believe the supervention of cholera is prevented. All physicians who have had much practical acquaintance with this disease will bear testimony, first, to the fact that an attack of cholera is generally preceded by diarrhoea, and, second, to the fact that an attack very rarely occurs when this diarrhoea receives appropriate attention. Giving the results of my own experience with respect to the facts just stated, in 1849, for the space of three months, I prescribed for as many private patients with the premonitory diarrhoea, or cholerine, as my physical endurance would permit, my practice being chiefly among the prudent classes, and I had, during this epidemic, but 10 cases of cholera in private practice. In only one of these 10 cases did I prescribe for any premonitions, and, in the single. case, the prescription was for a slight nausea only. In each of the 10 cases, either the premonitory diarrhoea did not exist, or it was neglected. During another epidemic in 1852, I had about the same number of cases of cholera in private practice; in not a single case had I been called upon to prescribe for premonitory diarrhoea, and I prescribed for hundreds of persons with simple diarrhoea, not one of whom had an attack of cholera. The experience of others would doubtless furnish, in like manner, evidence of the above

Valleix, op. cit.

stated facts, and from these facts the following conclusion may be drawn: Excepting the very small proportion of cases in which cholera is not preceded by diarrhoea, it may with almost absolute certainty be prevented. It needs but a little reflection to see the immense practical importance of this conclu

sion.

The treatment of diarrhoea during a cholera epidemic is very simple. An anodyne astringent remedy, with regulated diet, rest, and recumbency, suffice. A few drops of laudanum with camphor, or the camphorated tincture of opium in conjunction with the tincture of kino, catechu, or krameria, a salt of morphia or opium in pill or powder with tannic acid, the acetate of lead, or bismuth and capsicum, may be given in doses sufficient to arrest at once, and repeated often enough to prevent recurrence of, the diarrhoea. Cathartics are on no account to be given. If there be sufficient constipation to occasion inconvenience, the bowels should be relieved by simple enemas. The great difficulty, as regards the prevention of cholera, is in the prompt. application of simple but effectual treatment in all cases of diarrhoea during the epidemic. Very many pay no attention to the premonitory diarrhoea, through ignorance, and not a few of those better informed neglect it, either from recklessness or because they cannot appreciate the fact that a disorder so slight and ordinary can be a precursor of a malady of such gravity as cholera. Public announcements by handbills, articles in newspapers, etc., of the importance of promptly resorting to treatment for diarrhoea, fail in accomplishing the object. The only effectual plan is to organize a sanitary benevolent police, and provide for one or two domiciliary visits daily at every house within the limits of the epidemic; the purpose of the visits being to inquire if any one be affected with diarrhoea, to impress the importance of immediate attention to it, and, when circumstances render it necessary, to supply at once appropriate remedies. This plan, faithfully carried out, would, I believe, demonstrate that cholera is in a great measure preventable. prevention is effected by arresting at once diarrhoea, as often as it occurs and as soon as it occurs.

The

Another mode of escaping the disease is to remove without the range of its prevalence. Persons not compelled to remain by necessity, or by a sense of duty, should go beyond the limits of the epidemic; and the removal of persons in districts where, owing to the activity of auxiliary causes, the disease is especially rife, should be enforced, as a sanitary measure, by municipal authority.

TREATMENT. To consider the host of remedies and therapeutical measures which have been advocated as more or less efficacious in the treatment of this disease would require not a little space. There are but few articles in the materia medica which have not been tried, even including antimony and drastic purgatives. Much injury has doubtless been done by over-medication under the idea that the treatment, as regards activity, must be proportionate to the amount of danger from a disease. On the other hand, many of the remedies which have been employed exert little or no effect either for good or harm. During the epidemic of 1849, a writer in one of our medical journals gravely announced as a remedy, hogs' bristles or the hair from a cow's tail burned to a cinder! It would be unprofitable to devote space to the consideration of the great variety of practice which the literature of cholera affords. There is no known remedy which is to be considered as a specific, yet there is reason to believe that the disease is frequently controlled by efficient treatment, and, when not arrested, the recovery may depend on the judicious employment of measures for that end. I shall limit myself to a brief statement of the principles of treatment which my own experience

and reflections have led me to regard as most consistent with our present knowledge.

The treatment is to be considered as applicable to the different stages, viz., before collapse, during the collapsed stage, and after reaction. Prior to collapse, the paramount object is the arrest of the intestinal effusion. This effusion is the first appreciable link in the chain of morbid sequences, and, if promptly arrested before it has proceeded so far as to affect seriously the blood and circulation, the patient is usually safe. The remedy on which most dependence is to be placed in effecting this object is opium. Some form of opiate is to be given promptly in doses sufficient to effect the object. The form of opiate is to be chosen with reference to promptness of action and the probability of its being retained. Opium in substance is unsuitable from the comparative slowness with which it is absorbed. Laudanum, the acetated tincture, or an aqueous preparation, are to be preferred. But the article which I have been led to regard as the most eligible is a salt of morphia, administered by placing it dry upon the tongue. In the endeavor to effect the object of treatment in this stage, moments are precious, for there is always danger that, if the object be not promptly effected, the patient will fall into the collapsed state. The opiate should, therefore, be given at once in a full dose. A grain of a salt of morphia is rarely, if ever, too large a dose for an adult. A physician should, if possible, remain with the patient. If the first dose be quickly rejected, a second should be instantly given. The doses are to be repeated at intervals of from half to three-fourths of an hour, until the dejections and borborygmi cease. If, owing to the occurrence of vomiting, the administration by the mouth be ineffectual, it should be given by the rectum; and in cases in which the symptoms are urgent, both modes of administration should be resorted to. The system, even in this stage of the disease, is not readily affected by opiates. In view of the importance of the object, if it be necessary in order to effect it, some risk of inducing narcotism is justifiable; but if the administration be in the hands of the physician, and the effects of the doses watched with care, danger from this source may generally be avoided. The practical point is to employ the remedy freely and promptly so as to effect the object, bearing in mind the fact that the delay of half an hour or an hour is often fatal. Relying upon the opiate, it is best not to add other remedies, lest by increasing the bulk of the doses they will be more likely to be rejected. A full dose is preferable to small doses frequently repeated, because the effect within a short space of time is greater, and the remedy is more likely to be retained. Aside from the rejection of the remedy, vomiting is, if possible, to be prevented in view of its perturbatory effects. The patient, in this stage, should be restricted to a very small quantity of water, or spirit and water given at short intervals, or to small pieces of ice. Perfect quietude is important. He should not be permitted to get up to go to stool, and he should be urged to resist, as much as possible, the desire to evacuate the bowels. Frictions, the warm bath, sinapisms, etc., in this stage, are of doubtful expediency.

I have repeatedly succeeded in arresting the disease by this plan of treatment, and when arrested before proceeding to the stage of collapse, the recovery is usually speedy. Regulated diet, rest, with, perhaps, a tonic remedy, suffice for the cure. The bowels should be allowed to remain constipated for several days, and then, if movements do not spontaneously occur, simple enemas will probably be sufficient; if not, a little rhubarb or some other mild laxative may be given. I believe no other plan of treatment promises more than this, but it is not to be expected that it will always prove successful. It will fail, or rather it is not available, when, owing to persistent vomiting and frequent purging, the remedy is not retained suffi

ciently long to exert its effect; and it is not available when, owing to the great rapidity of the transudation, the state of collapse occurs so quickly that there is not time enough to obtain a remedial effect. These difficulties are equally in the way of success from any remedies.

In the stage of collapse, the plan of treatment indicated prior to this stage may prove not only ineffectual, but hurtful. It is still an object to arrest intestinal transudation, if it continue, but, to employ opiates very largely for this object, may not be judicious with reference to the recuperative efforts of the system. The symptoms in this stage are due, mainly, to the damage which the blood has sustained in the loss of its constituents from the transudation which has already taken place. Opiates should be given, and, owing to the remarkable degree of tolerance under these circumstances, they may be given in considerable doses, but much care should be observed not to induce narcotism. Astringent remedies, if the stomach will retain them, may be added, such as tannic acid, the acetate of lead, bismuth, etc. If, however, these or other remedies provoke vomiting, they will be likely to do more harm than good. Remedies to allay vomiting may be tried, viz., the hydrocyanic acid, creasote, and chloroform.

In a large proportion of cases, after collapse has taken place, little can be done with much hope of success. Even if the vomiting and purging cease, recovery may not follow. The blood may have been damaged irremediably. Under these circumstances it is plain that active treatment can effect nothing. Recovery, however, in a certain proportion of cases, takes place, and under a great variety of treatment. It may take place when no treatment is pursued. My first case of cholera illustrated the fact just stated. The patient was brought into hospital completely collapsed. I remained with him several hours, and resorted to various therapeutical measures. At length all measures were discontinued. He was allowed to drink abundantly of cold water, under the impression that the case was utterly hopeless, and, therefore, the indulgence could do no harm. Much to my

surprise, after an absence of several hours, I found the vomiting and purging had ceased and reaction was coming on. He recovered rapidly. I have been led to doubt whether, in general, active treatment effects much for the advantage of the patient in the collapsed stage of cholera, and I cannot doubt that it is often prejudicial. The object of treatment in this stage, aside from the arrest of vomiting and purging, is to excite and aid the efforts of nature in restoring the circulation together with the functions dependent thereon. The measures to be employed for this object are external heat, stimulating applications to the surface, diffusible and other stimulants, and alimentation.

The application of heat may be made by means of warm blankets or bottles of hot water placed near the body. The more active modes of applying heat are of doubtful propriety. I have never seen benefit from the warm bath, or the application of steam or hot air. It is not desirable to excite perspiration, and if perspiration occur, it should be wiped away with warm dry cloths. Violent friction does more harm than good. The surface may be gently stimulated with sinapisms or the tincture of capsicum. Diffusible stimulants, in the form of spirits and water, should be given as freely as the stomach will bear, always recollecting the risk and the evils of inducing vomiting. It will be most apt to be retained, if given in small quantities at a time, and often repeated. If vomiting be provoked by either drinks, remedies, or aliment, more or less injury is done. The ethers, stimulants such as capsicum, the essential oils, cardamom, ginger, etc., are appropriate if they are grateful to the stomach and retained. Concentrated nourishment -essence of meat, chicken broth, and milk-is to be given in small quanti

ties at a time, provided the stomach will retain it. It is doubtless desirable to introduce liquid into the system as far as possible. The only objection to the free ingestion of water is the risk of provoking vomiting. Small lumps of ice should be freely allowed.

If the patient emerge from the collapsed state, the indications are to support the system by the moderate use of stimulants and by alimentation; to restore the function of the kidneys by diuretic remedies and mucilaginous drinks, bearing in mind that uræmia belongs among the dangers of this stage; to restrain diarrhoea, if it occur, by anodynes and astringents; to strengthen by tonics, and to palliate, by appropriate remedies, the various symptoms which may arise.

CHAPTER IX.

INTESTINAL WORMS.

Ascaris Lumbricoides-Ascaris or Oxyuris Vermicularis-Tricocephalus Dispar-Anchylostoma Duodenale-Ascaris Alata-Taniæ-Trichina Spiralis.

Or the various entozoa, helminthi, or parasitic animals which dwell within the human body, several are developed in the intestines. They give rise to more or less disturbance, and are properly enough considered in connection with the functional disorders of the alimentary canal. I shall treat of intestinal worms only in so far as concerns the practical duties of the physician. The study of these and other parasites, as belonging to comparative anatomy and physiology, and as a branch of zoology, is highly interesting, and has led to valuable practical results, but other points than those which relate directly to them as morbid conditions would be here out of place.

The intestinal worms of frequent occurrence, are the ascaris lumbricoides, lumbricoid or round worm, and the ascaris vermicularis, thread or seat

The worm known as tricocephalus dispar is probably sufficiently common, but of little or no practical importance. The different species of tania, or tapeworm, are of rare occurrence in this country, but constitute an important affection. These different worms will be noticed under distinct heads. And, as appropriately classed among the intestinal worms, because they are received and developed within the alimentary canal, the trichina spiralis, concerning which highly important facts have very recently been developed, will be considered in this connection.

ASCARIS LUMBRICOIDES.

With this worm every physician soon becomes familiar. It resembles the common earth worm. It is the most common of all the intestinal worms. It varies in length from six to sixteen inches. It is of a whitish or yellowish color; the body is round, tapering toward each extremity, and the mouth is surrounded by three tubercles. The sexes are distinct.

This

The common lumbricoid worm inhabits the small intestine. It rarely exists in early infancy, and is most common between the ages of 3 and 10. It is not very uncommon in adults, but is extremely rare in old age. species of worm is not usually solitary. In different cases the number of lambrici varies greatly. Sometimes the number is very great, and in autop