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proportion of brandy, may be administered. Should the emetic selected fail to produce its effect in a quarter of an hour, it ought to be repeated; or should the circumstances of the case lead the attendant to suppose that the sensibility of the stomach is very low, a larger dose of the emetic drug may be administered. We recollect having produced full vomiting by an ounce of mustard in a case of extreme collapse, in which two smaller doses had been administered successively without effect. Simultaneously with the exhibition of the emetic, dry heat should be applied by some of the methods already mentioned, or by that very convenient and simple apparatus, the hot air-bath. Various internal medicines of the stimulating class have been recommended for this state. Those of which we have been led to form the most favorable opinion are mustard, carbonate of ammonia, and oil of turpentine. The first-named substance we have not unfrequently administered in doses of a drachm (a tea-spoonful unheaped), at intervals of an hour or an hour and a half, apparently with the effect of giving additional vigor to the pulse, which had perhaps been restored by the vomiting; of producing bilious discharges from the bowels; of restoring the urinary secretion, and aiding the system in the transition into the febrile stage. If the carbonate of ammonia be the stimulant employed, a convenient mode of giving it is in doses of five grains every hour, with carbonate of magnesia, which makes it more easily retained should the stomach still retain its irritability. Should oleum terebinthinæ be selected, doses of two drachms may be given every second hour. Whatever stimulant medicine be employed, we should advise that calomel, in doses of five or six grains, repeated at intervals of three or four hours, should be given at the same time, with the view of aiding the restoration of secretion; and, with the intention of at once rousing the system and lessening the irritability of the stomach, that a large sinapism should be applied to the abdomen, and another along the course of the spine. Various stimulating nostrums, if applicable to any, certainly only to this period of the fever, have been bruited forth to the world as specifics for the disease. In many of these we are of course inexperienced, and of all we are convinced the powers have been overrated, in some instances from partial and mistaken views of the malady, and, in others, from less pardonable reasons. It will not be deemed necessary that we
should pass them all in review; but, of certain remedies which have been proposed for collapse, the professional reader will require some notice. The inhalation of oxygen gas has been suggested from many quarters; and, in some cases in which it has been tried here, an instantaneous amelioration has been manifest, the pulse having become more vigorous, the lips florid, and the patient having experienced relief from præcordial oppression and other distressful feelings, to an extent and with a promptitude not afforded by any other measure. But the experience of medical observers in general has led them to conclude that this effect is very transitory; and some are of opinion that they have witnessed an increase of the collapse after the temporary excitement, as if the yital power, instead of being permanently increased by the measure, had been expended in a momentary flash. Of some gentlemen, however, the opinion regarding it is more favorable. Our own opinion is, that, inspired for a few seconds in single bladders, no great benefit is likely to accrue from it; but we should speak less positively of the effect of an atmosphere of diluted oxygen breathed for a considerable period. The tobacco enema has been suggested by Mr. Baird, of Newcastle, and, as he assures us, employed with considerable success. We acknowledge that a priori reasoning would rather have led us from this remedy than suggested it to us; but, knowing the fallacy of such reasoning in medicine, we are not disposed to treat with neglect, still less with contempt, a measure, of the beneficial effect of which a gentleman of talent and character adduces several examples. It was proposed after the disappearance of the epidemic from Sunderland, and we have no experience of it; but we would recommend that it should be tried in a case to the successful treatment of which other measures seemed inadequate, the practitioner being governed, as to its subsequent employment or rejection, by its effect. Two remedies have also been mentioned to us by an individual of talent, and of great experience in the epidemic, Mr. John Fyfe, of Newcastle: we shall, with his permission, make the reader acquainted with them. One is the employment, in the period of extreme collapse. of an enema consisting of two pints of warm water, from four to eight ounces of brandy, and from one drachm to two drachms of laudanum, or Battley's sedative liquor. This, he assures us, has the happiest effect in abridging that stage of
the disease on the intensity and duration of which so much of the danger depends. The other is an enema containing a drachm of powdered mustard, which he has found to be very speedily instrumental in restoring the urinary secretion. This accords with our experience, as already stated, of the efficacy of this substance given by the mouth, in accomplishing the same object, and the restoration of the secretions generally. Weak brandy and water may be given occasionally during the collapse; and we have observed no injurious effect, in this or any stage of the disease, from the ordinary diluents taken in moderate quantities.
3. Treatment of the Excited or Febrile Stage. This division of the subject will not require such lengthened discussion as the preceding, which may be considered as more exclusively belonging to this disease; for recognised principles, applicable to the treatment of pyrexia in general, must be our guides in conducting this fever. The fever constituting this stage, be it in essence what it may, has inflammation accompanying it, of which the principal sites are the brain and the lining of the digestive canal; and to the subduing of these, by such measures as the state of the system admits, our attention should be carefully directed. A form of fever has been described as supervening on an extreme and long-continued collapse in the cold stage, and in which fever it was mentioned that the vascular action was low and feeble, the temperature of the surface under the healthy standard, and the distribution of warmth very partial. In this low form of disease, we have not ventured on general blood-letting: local bleeding from the temples has been freely performed, and occasionally, too, from the integuments of the abdomen, when there were any indications of inflammatory affection of the digestive canal; but the great degree of intellectual torpor and insensibility which attends these extreme cases, renders the discovery of such an affection extremely difficult. Blistering the nape of the neck, and shaving the head, so as to permit the application of cold, will be found very suitable measures. A degree of irritability of stomach, with occasional vomiting, is a very frequent accompaniment of such a case for the first two or three days; and, under such circumstances, leeches, and subsequently a blister to the epigastrium, have been resorted to with benefit. Of internal remedies, that on which most reliance is to be placed is calomel, from its effects on
the secretions, particularly of the intestinal canal, and from its facilitating the ac tion of the laxatives, which the state of the brain renders it advisable to administer. If two grains of calomel are given at intervals of three or four hours, an occasional gentle laxative, such as castor oil or calcined magnesia, will generally produce two or three bilious discharges from the bowels. Simultaneously with the administration of these remedies, the imperfect developement of heat, and its partial distribution, require attention. The patient should be placed near a stove, or in some warm situation, and bottles of hot water, or hot flannels, should be applied to the feet, or other parts which are chilled. Even whilst endeavoring, by local depletion, to relieve partial determinations of blood, the general state of the system has been such as to require a little stimulus; and wine and water has beer. given, especially at an advanced stage of the disease, and occasionally medicinal stimulants, such as carbonate of ammonia, camphor, and sometimes, as a tonic, sulphate of quinine; but we cannot say that much benefit has resulted from the latter class of agents. Such is the treatment we have generally adopted in that form of the febrile stage which is distinguishable from any fever we have been in, the habit of observing here or elsewhere. The more excited form admits of one general bleeding with advantage, the amount of blood drawn being regulated by the degree of vascular action, of headache, of injection of the eyes, and various circumstances which would influence our proceeding in any ordinary fever. Should the head, as it generally does, continue affected after the bloodletting, the application of leeches and cold should be resorted to, the former being repeated, if necessary, to such extent, and at such intervals, as the degree of headache, intellectual torpor and vascular excitement may seem to require. Laxative medicine should be administered; and the purpose is exceedingly well answered by calomel, in doses of four or five grains nightly, and six drachms or an ounce of castor oil every morning. The diet, under such circumstances, should consist of the mildest and simplest diluents, such as would be demanded in any case of inflammatory fever. After the case has subsisted some days, a little wine and water may be given, if exhaustion be manifest; but it should not be continued beyond the necessities of the case. Though we have seen few or no cases without a de
gree of cerebral affection, examples are met with in which the disorder of the intestinal canal is more considerable than that of the brain. Diarrhoea, the discharges being deeply bilious; a red, glazed, and very dry tongue; some degree of fulness and tension of the abdomen, and of pain on pressure there; and scanty, high-colored urine, generally attend such cases. The general treatment of cases in which such an affection exists, must depend on the state of the system; but the intestinal disorder demands the free application of leeches to the parietes of the abdomen, repeated according to circumstances, and the internal exhibition of mild mercurials, such as hydrargyrum cum cretâ, or blue pill, with a small quantity of opium. That kind of permanent fomentation which is afforded by hot poultices to the abdomen, after the application of leeches, has been found beneficial. The diet throughout a case in which this inflammation of the mucous lining of the intestines exists, should be mild and demulcent. In cases of this description— indeed, in the most excited as well as in the lowest forms of the disease in which the collapse of the cold seems prolonged through the febrile stage-it is advisable to counteract, by warmth to the extremities and other points, that tendency to irregular distribution of blood which forms so striking a feature of the disease. Cases are occasionally met with, so mild in all their stages, that the fever requires no medical treatment but a few leeches to the head, a little laxative medicine, and abstemious diet for a few days. Convalescence is in many cases tedious, the strength being slowly restored, and slight irregularities of diet sufficing to disorder the system, and even to produce relapse. For weeks after the fever, we have found the patient still languid, and exceedingly prone to irregular distribution of blood, especially to undue determination to the head, inducing headache (requiring the application of leeches) on any considerable exertion. To prevent such occurrences, we have found it advisable that the diet should consist, in the early period of convalescence, of a moderate quantity of vegetable matter only, and that the transition to more abundant and substantial food should be very gradual; in short, that convalescence from this disease should be conducted in the same manner as that from other fevers. We have stated that relapse may be produced by dietetic irregularities; and it is important to observe that even the best directed treatment of the
incipient or diarrhoeal stage may fail in its object, that of cutting short the disease, if such irregularities are indulged in. The relapses, properly so called, have occurred at an early period of convalescence; but we have witnessed one example, and that a very severe one, of the recurrence of epidemic choleric fever after an interval of two months from the preceding attack. This we were disposed to consider rather as an example of a second invasion than one of relapse, though it is proper to remark that the patient had remained feeble from the period of the previous disease. No assignable cause existed for the second attack.
Character of the Epidemic as it appeared in North America in 1832. This portion of our article must be unavoidably imperfect; for the cholera has not yet finished its course in this quarter of the globe, although it has proceeded here with unexampled rapidity. We know, in general, from the newspapers, that, in the months of October and November, it was sweeping down the valley of the Mississippi, and that, at Cincinnati and New Orleans, it was remarkably indiscriminate in its attacks and malignant in character; but from neither of those places have any such returns reached us as to furnish an accurate account of the mode of its appearance, the amount of its ravages, or the peculiarities it presented. The following brief notice, therefore, is founded on observations in relation to the disease as it appeared in Canada and in the northeastern and middle parts of the U. States; and our remarks on the season, and previous diseases, and on the phenomena of the pestilence itself, unless specially referred to some particular place, are intended to apply to the whole extent of territory thus indicated.-The appearance of cholera on the American side of the Atlantic was an event in its history which promised to furnish a better opportunity for determining the manner of its propagation and progress than had been presented at any previous step in its destructive career. Our distance from the places it had hitherto visited, the maritime nature of all our intercourse with them, and the awakened vigilance of physicians and health officers at every point of the coast, seemed to justify the expectation that, whenever or wherever it should first appear, the manner of its coming might be established beyond any reasonable doubt. Accordingly it was looked for, on all hands, with scientific curiosity as well as universal dread. Some supposed that the cause of
the disease would be wafted to our shores by the long course of easterly winds, which prevailed to an unusual degree during the spring and early part of the summer of the year 1832; others, that some infected ship would be the bearer of the unwelcome influence, either pent up with the atmosphere in her hold, or enveloped in bales of merchandise, or lurking in the system of some of her passengers. But many more, remembering that the course of great epidemics has always been from east to west, having watched the progress of cholera in Europe, and noticed the analogy it presented, in this respect, to some familiar epidemics, thought it more rational to expect, that the same meteorological intemperament which had produced it in other parts of the globe, would also be present here, and, under favorable circumstances, manifest itself in the same way. The first recognised case of the disease in America, occurred on the eighth of June, 1832, at Quebec, the capital of Lower Canada; and, whatever may be thought of the last-named explanation of the event, it is quite certain that the facts and circumstances attending it, which were carefully investigated at the time, give no countenance to either of the others; for, although the first subjects were emigrants, they had come over in healthy vessels, and had been exposed to no source of infection other than the filthy and crowded condition of their residence, which is stated, by the board of health, to have been "a low, uncleanly and ill-ventilated part of the city, crowded with a population of emigrants of the lowest description." A considerable number of the first cases were among the passengers of a steam-boat which started for Montreal on the day before the eruption of the disease, but who were relanded, after suffering greatly from fatigue, wet, agitation and alarm, in consequence of encountering boisterous weather, which compelled the boat to return. After landing about 200 of these exhausted passengers, she resumed her voyage; and, on her arrival at Montreal the next day, one of those who remained on board sickened, and became the first victim of the destroyer in that city. From the two capitals, the disease spread itself irregularly, but rapidly, over the respective provinces; and, in the course of twenty days, it had made its appearance, with more or less malignity, in most of the principal towns, and, sometimes, in the intervening open country, throughout a territory from 500
to 600 miles square. The visitation of the epidemic was unusually protracted and destructive in the Canadian capitals, and was more severely felt by the native French inhabitants than by any other class of their mixed population. In both places it reached its height in about ten days after its commencement, when it began to decline, but not regularly. At Quebec, about the eighteenth, the number of cases was estimated at from 250 to 300 in twenty-four hours. At Montreal, the largest number of cases in a day was 474, and of burials 149. The whole number of deaths in Quebec, from June 8 to September 1, is estimated at 2218; at Montreal, for the same time, 1843. Without having established itself at any intermediate spot between Canada and New York, it appeared in that city about the last of June. On the twenty-seventh of that month, two cases occurred in children of the same family, which terminated fatally, and which were identified as cholera. On the same day, an adult, who lived two miles from the habitation of the children, was seized with the same disease, and died in twenty-four hours The mother of the children was attacked the day after they died, and became the fourth victim, on the twenty-ninth. the thirtieth, a temperate man, living on the other side of the city, was seized, and died the next day, having had no communication with either of the other subjects. By the fourth of July, cases had occurred in various places on both sides of the city. They continued to multiply daily; and all efforts to trace any of them to any foreign source have been wholly unsuccessful. In about three weeks from its commencement, the disease was at its height, when the attacks, as nearly as could be ascertained, amounted to about 311 daily, and the deaths to 115. On the twenty-ninth of August, the board of health discontinued daily reports, when it appeared that the total number of cases was 5835, and the total of deaths, 2521. In the mean time, the citizens had become greatly alarmed, business was suspended, and a large portion of the inhabitants left the city. During the month of July, scattering cases occurred at various places in the state of New York, at Burlington in Vermont, at Detroit in Michigan territory, at Pittsburgh in Pennsylvania, at Newark in New Jersey, at Providence in Rhode Island, at New Haven in Connecticut, at Brookfield in Massachusetts; but in none of these places did the disease establish itself as an epidemic, and,
in most cases, appeared only in some transient persons who were refugees from New York or Canada. In Philadelphia, the first cases recognised by the board of health, occurred on the sixteenth of July. There were then five cases reported, all in different, and, in some instances, in far distant streets. The disease was at its height here on the ninth day, when the number of cases, for twenty-four hours, was 176, and the deaths 71; total number of cases previous to September 1, was 2192, and 747 deaths. In Boston, the first cases occurred on the fifteenth of August, and were very unequivocal examples of cholera. For a week or two previous, the city was deemed uncommonly healthy, and there were very few deaths. There were, however, many mild cases of bowel complaints. On the night of the fifth, a very remarkable eruption of disease took place at the state prison in Charlestown, about a mile and a half from the centre of the city of Boston. This disease, if named at all, must be called cholerine. It could not be satisfactorily attributed to any error of diet, or peculiarity in the regimen of the con victs. In the course of twenty-four hours, 118 were attacked; but they received prompt attention, and none of them died. There were two cases on the first day that cholera was reported in the city, and both of them clearly spontaneous. Nine days intervening, the third case appeared, in a boy living remote from the localities of the two first. After another interval of six days, a fourth case was discovered, in another quarter of the city. Instances of the disease continued to present them selves, after longer or shorter intervals, until the first of December. The largest number of cases in any one day was six; and this was on the first of September. It was generally intense and malignant in its manifestations here; and a large proportion of the cases were fatal. The total of deaths in Boston, including those at the house of industry, was 85.-For several months before the appearance of cholera on our continent, the phenomena characterizing the seasons had manifested remarkable deviations from their accustomed course and character. The winter had been uncommonly severe and protracted; and the poorer classes of the population, in Canada as well as in some parts of the U. States, had suffered extremely from the exposure and privations which always await them during that inclement portion of the year. The cold weather continued through the spring
months; and it is stated that stoves were found to be very comfortable, at Quebec, so late as the fourth of June, when the thermometer was as low as 40°. It appears, from tables accompanying the health officers' return, that the mean temperature in that city, during the month of April, was 38°, in May, 4530, and in June, 5830. It further appears from these tables, and from meteorological observations made by the medical society in New York, that, at both these places, and probably throughout a considerable extent of country around and between them, the season ex hibited other deviations. from its usual character, not less remarkable than those noticed in the temperature. The barometrical pressure, taking the average of several months immediately preceding June, was very great, but, in the course of that time, manifested variations which were extraordinary both for their suddenness and extent. In the month of November, for instance, it was very low, generally a little below 30, and, in one instance, sinking to 29.10. Between the tenth and seventeenth of December, it fell from 30.43 to 29.38, making a difference of 1.05 inch. In February, on the other hand, the barometer rose higher than the observers had ever noticed it. On the twenty-fourth of that month, it indicated 30.74 inches, and the mean pressure was 30.205 inches. Easterly winds were unusually prevalent, especially in April and May; and, throughout these months and the first of the summer, there were rather more clear days than common. The spring of 1832 was not less remarkable for its dryness, which coöperated with the cold in occasioning one of the most backward seasons within the recollection of the oldest observers. In January, 4.36 inches of rain fell, according to the New York observers, in February 2.30, in March but 1.78 inch, in April 4.46 inches, in May 4.53, and in June but .90. These unfavorable conditions of the season, besides the direct agency they may be supposed to have exerted on the health of the population, retarded the progress of vegetation, so that the early vegetables and fruits were either wholly denied to their customary consumers, or offered to them only in an immature and unwholesome state; and thus, perhaps, the cold and dryness of the spring furnished the most common exciting causes of that disease, which, by some other process, in combination with other meteorological influences, they had contributed to originate and render epidemic. There were