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sons who surrounded Liddle in her illness, escaping all infection. In many

other instances in which the disease has appeared in a mining district or village (and it has spread extensively in such situations), the first cases could not be traced to communication with infected places. In certain cases, however, and we shall mention that of Hetton, the persons first seized had been in communication with infected districts. 7. On the first appearance of the epidemic in certain places, several have been simultaneously attacked; at Earsden colliery, for example, thirtytwo. On its first breaking out here, it manifested itself in three distinct points, between which no communication could be discovered; and the attacks in two of these points were simultaneous. It could not be traced from any source of infection to the individuals first attacked. In many instances, likewise, instead of residents in the same house being successively attacked, its invasion of several has been simultaneous. 8. There were feelings experienced by various persons, either otherwise in perfect health, or laboring under complaints distinct from the epidemic during its prevalence here, such as spasms, thrilling sensations of the extremities, and various affections of the nervous system, which appeared to betoken the influence of some cause more generally diffused than contagion; since many persons thus affected had not been exposed to any source of infection. The writer was at first disposed to attribute these occurrences to the influence of imagination; but they occurred in too many instances, and in persons too little sensitive and imaginative, to allow him to adhere to this explanation. After assigning these reasons for questioning the exclusive operation of contagion, we think it right to remark that epidemic choleric fever has committed fearful ravages in some families, especially in those of which the circumstances were calculated at once to give intensity to the causes of the disease, and to render the individuals composing them more obnoxious to the action of such causes. Of one family, seven were attacked with the disease, of whom five perished. The case of the first individual of the series constituted one of the sporadic cases; and it is incredible that the next in succession should have received infection from him, four months having elapsed between the dates of the respective attacks; but it is probable that contagion was transmitted from the secend and subsequent cases, the diseases

having commenced on the following suc cessive dates-the 11th, 12th, 13th, 16th, 17th and 20th of December. The case which occurred on the 20th was that of an infant, aged thirteen months, taken from the breast of the fifth patient in the order of succession. Many other examples of transmission through families have occurred, but few so striking as this. We are disposed to attribute to contagion its full share in the production of such cases, aided by the circumstances of nightwatching, neglect of order and cleanliness, &c., which are accompaniments of sickness in the dwellings of the poor; but we must remark that cases have fallen under our observation, and come to our knowledge, which show a proneness to the disease in certain families, independent of reception from a contagious source. The following is an example of this kind: A respectable female, living in the village of Jesmond Vale, where the disease did not exist, and who had had no intercourse with the sick, received a letter, announcing that a sister, whom she had not visited during her illness, and who resided at Hartley, a distance of nine miles, had died of the complaint. She sickened in an hour from the receipt of the intelligence, and died in thirteen hours from the commencement of the attack.* The following propositions appear to be reasonable corollaries from the facts presented by this extensive and intricate subject. 1. Epidemic cholera originated in a certain district under peculiar atmospheric circumstances; but, these circumstances having previously occurred in the same district without the production of a disease identically the same, we must regard its terrestrial or atmospheric cause unascertained. 2. On many subsequent occasions, there have been marks of its commencement and gradual rise in other districts, which show that, in their soil or atmosphere, there has been a tendency to the production of the disease from causes equally unascertained as those which first originated it, and, in such districts, it has ultimately displayed itself. 3. It has thus appeared to arise in various districts, not by any means always continuous with those previously contaminated, but often situated in some general direction with regard to them, declining in one district as it arises in another, and thus appearing to move in a succession of local epidemic visitations. 1. Within the district which it occupies, it possesses a contagious property, or, in

* Related to the writer by Mr. Greennow surgeon, of Newcastle, who attended the case,

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other words, those individuals who have intercourse with the sick, especially in a locally impure atmosphere, are attacked in a greater proportion than other members of the community; and it is probable that this same contagious property may be the means of diffusing it through a district disposed to the production of the disease, earlier than it might have risen spontaneously there, or of exciting it in a district in which, notwithstanding a degree of predisposition, epidemic choleric fever might not have arisen spontaneously; but facts which we have mentioned tend to render it questionable whether it can be thus transferred to districts unpredisposed to receive or engender it. 5. Within the district where it prevails, ordinary endemial causes mingle their agency with that of the general cause of the disease, and the malady is found to vary in prevalence and intensity in different portions of the same district: thus the disorder is found to assail more individuals, and to be more destructive in parts which are dirty, and in those placed low or near the banks of a river, than in portions of the district differently situated. The effect of these endemial influences is illustrated by the progress of the disease in the town of Sunderland, and by the ravages it has committed in the village of Newburn. The latter place is built along the margin of the river Tyne, and between it and the river there intervenes only a bank, formed of a mixture of mud and sand, partially covered at high water, whilst a shallow stream of water flows through the village. Here, although the disease has not yet ceased, 320 persons have been attacked, and 55 have perished, out of a population of 550. 6. The character of the disease varies considerably in the different districts which it invades. Thus we had occasion to observe that, in a mining population dispersed over an extensive tract of country (the township of Hetton), the disease was attended with less collapse than in the lanes and alleys of a populous commercial town, and the mortality was consequently much less; for we cannot too strongly repeat what we have already remarked, that the collapse is the measure of the danger. These observations are made with no view of depreciating the medical practice adopted in that district, which was extremely skilful and prompt, and even with due allowance for the difference of the character of the disease, very successful. It should be remarked,moreover, that extremely collapsed were intermingled with the milder

cases, but in proportions the very reverse of those we had observed elsewhere. In certain districts in Northumberland, we have reason to know the disease resembled, in its general character, that which prevailed at Hetton; but, among someother mining communities, the extremely collapsed has been the common form of the disease. We have remarked, too, that, whilst in some situations the cases have, almost without exception, commenced with diarrhoea, in others the proportion of instances in which this has constituted the initiatory symptom, has been smaller. This difference in the form of cholera in different local epidemic visitations, the cases occurring in any given district possessing a general correspondence in character, and being distinguished from those which occurred elsewhere, was observed in India by Mr. Scot; and it appears to us that this circumstance, coupled with the transmutation of the disease more and more into a febrile form, as it has approached more northern climes, displays a deviation from that sameness of character observed in diseases engendered exclusively by human contagion. It will hardly be expected that we should leave entirely untouched the question, whether the disease originated spontaneously in Sunderland, or was introduced from abroad; but the extent to which we have already pursued this intricate portion of our subject, forbids our discussing it at any considerable length. Those who reason from the postulate that the disease is diffused only by human contagion, will of course decide for importation; but others will very reasonably expect that, before this be admit ted, it should be proved by the same positive evidence that would be required to substantiate any other fact of importance. Any thing approaching to this, or even any considerable probability of such an occurrence, we have been unable to discover; and we cannot but agree with doctor Ogden, that, whatever were the facilities for the importation of cholera here, they were much greater in other places; and that if it has been imported, so far from following the great routes of human intercourse, it has chosen one of the least frequented paths.* The predisposing causes of the disease, and the means to be adopted for preventing its diffusion, have been published to the world in such multitudinous documents, that we consider it unnecessary to occupy our

* See Medical Gazette for January 21. 1832

pages with remarks on subjects now so familiar.

Treatment. Previously to entering on this subject, we shall endeavor to correct the misconception which appears to prevail very generally among members of the profession, who have not as yet witnessed the disease, that some one specific remedy, or, at least, plan of treatment, must be sought for, and, when discovered, invariably adopted. The importance very properly attached by all writers to collapse, as a feature of the malady, and their candid avowal of the difficulty they have encountered in combating it, is the explanation of the fact that medical men who are practically unacquainted with epidemic cholera, have taken a view of its treatment, which, in the case of almost any other disease, they would have repudiated as unscientific. We know no condition more hopeless than that of extreme collapse in the disease: so hopeless, indeed, is it, that often have we questioned, in watching a patient in this state, whether our art at present possesses, or is likely to possess, any resources against it; or, in seeing him emerge from it,-and he has sometimes done so most unexpectedly,whether the remedies employed, or some hidden power of the constitution, had been instrumental in effecting reaction. But it should be remarked that only in a proportion of cases—a proportion varying, as we have already observed, in different localities, and in the same locality at different periods of the epidemic-does this extreme collapse occur; and that even in cases of which the natural tendency is to pass into this deplorable condition, much may be done by early treatment for its prevention. These considerations should teach physicians and patients that safety is to be found only in the early administration of remedies; and the former, when brought into contact with the disease, will soon discover that success in its treatment must result, as in the treatment of other fevers, from adapting his remedies to the varying circumstances of individual cases, and of the different stages of the same case, rather than from the trial of specifics for one portion only of an extensive series of changes;

that his practice, in short, to be successful, must be rational, not empirical. In our observations on the treatment, we shall follow the natural subdivisions adopted in describing the disease.

1. Treatment of the Incipient Stage. We have adverted to two forms which this stage assumes. In the one there is

some general uneasiness, nausea and vertigo: in the other these affections may coexist with diarrhoea, but the latter is frequently present without the former being discernible. The first of these forms, in which it may be remarked that medical aid is rarely requested, requires that the stomach should be unloaded by an emetic, and a table-spoonful of good mustard constitutes a very efficient one; a few ounces of blood should be drawn from a vein; a laxative of calomel and rhubarb administered; and the patient restricted to a dilu ent diet, and kept within doors and warm The treatment of the diarrhœal form, to which circumstances witnessed by us lead us to attach considerable importance, must be noticed more at length. It was mentioned that, in this diarrhœal form of the incipient stage, the evacuations are at first found to be focal and bilious; but, at the time medical aid is summoned, they have generally assumed the serous character which they bear in the choleric stage. A state of the system resembling, in some degree, collapse, it was observed, coincided with this condition of the alvine discharges. In this state, it was found very advantageous to give a dose of calomel, conjoined with a proportion of opium and some aromatic, and, in twelve or fourteen hours afterwards, a dose of castor oil. On first visiting such a patient, a large blister was generally applied to the abdomen, in the cases under our care; warmth was enjoined, indeed, where compliance with our wishes could be enforced, the patient was confined to bed,—and it was directed that the diet should be diluent. The subsequent treatment consisted in the employment of smaller doses of calomel and opium for one or two successive nights, and a second dose of oleum ricini was sometimes administered. In certain localities, the writer has found the constitutional state accompanying this stage of the disease to be one of marked excitement rather than of feebleness and collapse; and some points of the abdomen have been painful on pressure. In such cases, one general bleeding, or the very liberal application of leeches to the abdomen, has preceded the employment of other remedies. In other respects, the same treatment has been found successful as that

* The following is the formula we have usually employed:

R Hydrargyri submuriatis, g1. viii, vel x.
Opii, gr. ii.

Pulveris baccarum capsici, gr. i fs.
Confectionis rosæ, q. ss. ut fiat bolus, sta.
tim sumendus.

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adopted in the preceding form, excepting that no stimulating ingredient was mixed with the calomel and opium. Under these plans of treatment, we have the satisfaction to state that, in every case which has fallen under our immediate observation, the discharges have resumed their natural bilious appearance, and the diarrhoea has been finally arrested without the supervention of a cold stage, and, consequently, of fever, though the disease had occurred, in various instances, in persons who had been in incessant attendance on those ill of the feverish stage, and though, in all the cases, it bore the characteristic marks of what we may term choleric diarrhea. It should be remarked, however, that the choleric stage has supervened, as we have been informed, on diarrhoea, which had been skilfully treated; but our inquiries have uniformly convinced us that, in such cases, medical aid had not been summoned till the diarrhoea had existed some time, and the subsequent stage was closely impending.

2. Treatment of the Cold or Choleric Stage. In order that we may be distinctly understood in our observations on the mode of conducting this very important stage, we must adhere to its subdivision into two periods. The first period is certainly that in which alone our most powerful means of arresting morbid actions can be employed with a considerable prospect of success. It may be considered an axiom in medicine, that fevers, to be successfully, must be early treated; and the rule has a powerful application to a disease so rapid in its course as that under consideration. But there are many obstacles to its being generally acted upon amid a town population; and one considerable obstacle, we apprehend, will every where be found in that self-deception which seems to be quite a feature of the disease. We have met with persons to whom, from their peculiar situation, all the symptoms of this disease were as familiarly known as to medical men; yet, when they were attacked with it, they did not or would not recognise it; and one such individual actually walked out with the disease upon him, and failed to send for assistance till eight hours after its invasion, though it was so severe as to destroy him in twelve. So strong is this tendency to self-deception regarding the nature of the disease when the choleric stage actually

*The credit of this subdivision belongs originally to Mr. Kennedy. Experience in the disease having convinced us of its practical importance, we have adopted it in this article,

occurs, that, wherever cholera prevails, strong appeals should be made to the public, on the necessity of early treatment of this stage, as well as of due care of that which generally precedes it. The first remedy to be considered is blood-letting; and we shall endeavor to point out the circumstances which, so far as our observation extends, indicate, and those which forbid, its employment.. Its safe administration should be early, not according to mere time only, but with respect likewise to the rapidity of the disease; for one case will have made as considerable a progress towards actual collapse in two hours as another will have done in ten; and we should regard a considerable degree of collapse, indicated by feebleness or arrest of the circulation, and perceptible in the intervals of pain and spasm, for when these occur, the pulse often sinks instantly, though only a second before it had been beating with considerable vigor,t-as an imperative reason for abstaining from drawing blood. But if we find the temperature not below, or but little below, the healthy standard, a pulse of tolerable force, and strong spasms recurring at short intervals, provided collapse have not preceded this favorable condition, we should at once open a vein, and not lose an opportunity, which will never be restored, of probably preventing extreme collapse, and either its immediate fatality, or its more remote, but scarcely less fearful evils. But should this condition, with respect to circulation and temperature, have succeeded to collapse, either spontaneously or by the administration of remedies, our experience would dictate that blood-letting should be carefully abstained from, as we have seen great injury produced, under such circumstances, by its employment; cases having fallen under our notice in which the loss of three or four ounces of blood has destroyed the fruits of two or three hours' assiduous labor. The difference in the effect of blood-letting on conditions apparently very analogous, but differing in the periods from the commencement of the attack at which they manifest themselves, cannot be too strongly impressed on the reader's attention. Perhaps the only difference in external character which can be discovered between the two states, will be the existence of spasms of considerable strength in the early period, whilst, in that more advanced, they have nearly,

+ Query. Does this sudden and momentary ar rest of the circulation arise from spasm of the


if not altogether, ceased; but, in the one case, blood-letting breaks the morbid catenations, and prevents collapse and congestion; in the other, it lowers the vital energies which are freeing themselves from a state of oppression. But again, in a more advanced stage, when the constitution is no longer balancing between collapse and fever, and the latter may be considered as established, bleeding is a suitable remedy, if the state of the circulation and the general condition of the patient render it admissible. Thus, then,there are three periods of the disease, at which, according to our experience, blood-letting may be employed: occasionally in the incipient stage, as has already been stated; in the early part of the first period of the cold stage; and at the commencement of the feverish stage, under circumstances to be subsequently mentioned. We have' been explicit on this head, perhaps to prolixity, because we found great discrepancy in the testimony of various Indian and continental authorities regarding it; and, in the early part of our experience of the disease, the selection of the appropriate time for bleeding, and the circumstances which indicated or forbade it, constituted the greatest difficulty we had to encounter. The measure to be adopted next in succession to blood-letting, will depend on the condition of the patient. If, in a short time after bleeding, we find a circulation of tolerable force, without much tendency to general or partial deficiency of heat, and if, at the same time, there be pain in the epigastrium increased on pressure, a very common accompaniment of cases in which the tendency to collapse is least conspicuous, a large blister or sinapism to the abdomen, and a dose of calomel and opium, in the proportion of from eight to twelve grains of the former to one and a half or two of the latter, will be suitable remedies. Should the circulation, on the other hand, be feeble, with general or partial deficiency of warmth, we should endeavor to rouse the system by full vomiting; and powdered mustard is a very proper means of accomplishing the object. Half an ounce of this substance, suspended in half an ordinary tumbler of warm water, may be considered a medium dose, and one which, in a great majority of instances, will act promptly and powerfully; but, in a more advanced stage of the disease, when the collapse has been extreme, a whole ounce has been required to produce the full effect. After full vomiting, sinapisms may

It may save the reader some trouble to inform

be applied to the abdomen and along the spine; whilst the warmth of the patient is supported by bottles of hot water wrapped in flannel, bags of hot oats, and other familiar methods of applying dry heat, directed to the extremities, or other points of which the temperature seems deficient. Frictions of the parts affected with spasm will at the same time be probably required, and should be performed under the bed-clothes. We have not found any beneficial effect, in relieving the spasms, from oil of turpentine or other stimulating embrocations; the coldness produced by their evaporation probably more than compensating for any benefit they are in other respects calculated to effect. A bolus of calomel, capsicum and opium, the latter not in a proportion exceeding a grain and a half or two grains, may be administered as soon as the vomiting from the mustard has totally ceased. The quality of the liquid given at this period ought to depend on the condition of the patient: if, for instance, the tendency to collapse be considerable, a little weak brandy and water should be given at short intervals; but, should the circulation be tolerably vigorous, and the temperature good, simple diluents, such as toast and water, constitute the most suitable beverage. Should the patient be in a state of considerable collapse, whether consequent on neglect of the earlier stage, or occurring, which will occasionally prove to be the case, in spite of the most diligent attention to it, blood-letting should not form part of the remedial agents selected. If the temperature be in any considerable degree below the healthy standard, with the hands cooling rapidly on exposure to the air; the pulse at the wrist either very feeble or totally suspended: the breath and tongue cool; the surface shrunk and pallid, or in certain parts livid; the vomiting and spasms diminishing in their intensity, or totally ceased;-at whatever period from the commencement of the disease this state of things may exist, bleeding should be abstained from. It will be advisable to endeavor to rouse the system by full vomiting; and half an ounce of mustard, or, if the attendant prefer another mode of accomplishing the object, two table-spoonfuls of common salt, a scruple of sulphate of zinc, or half a drachm of ipecacuanha, with a small

him that an ordinary table spoon, unheaped, contains half an ounce of mustard; and that the musmustard, which is of a uniform bright yellow color tard sold in the shops under the name of Durham is the most pungent and efficacious.

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