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. our observations on the treatment, we shall follow the natural subdivisions adopted in describing the disease.

In

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 diluent diet, and kept within doors and warm. The treatment of the diarrhoeal 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 diarrhoeal 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, gr. viii, vel x. Opii, gr. ii.

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

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,f-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 arrest of the circulation arise from spasm of the

heart?

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 litthe 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 mus mustard, which is of a uniform bright yellow color, tard sold in the shops under the name of Durham is the most pungent and efficacious.

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 vital 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 action 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 been 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 fe

ver.

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