OF THE CHOLERA. .':<:■';>v •> v___________ ,i.n- J. HE chief fymptoms in this difeafe are a vomiting and purging concurring together, or fre- quently alternating with one another. And the eva- cuations both upwards and downwards are manifedly mixed with bile. From this laft circumdance the difeafe appears to depend upon an increafed tecretion of bile, and its copious effufion into the alimentary canal. This effufion of bile irritates, and excites the motions abovementioned. When the difeafe begins with violence the fpafmodic eontradions of the intedines are foon communicated to the abdominal mufcles, and very frequently to thofe of the limbs. In this manner the difeafe frequently in- creafes rapidly in violence, till the ftrength of the pauent is greatly and often fuddenly exhauded, while a coldnefs of the extremities, cold fweats, and faintings coming on, an end is put to the patient's life, fome- times in the courfe of one day. In other cafes the difeafe is lefs violent, continues for a day or two, and then ceafes by degrees y though fuch recoveries feldom happen without the afliftance of re- medies. In many cafes of young children a diarrhoea returns after the vomiting has ceafed, and after continuing to harrafs the patient for many weeks, proves fatal. The attack of this difeafe is not preceded or accom- panied with febrile fymptoms, and though during its courfe, both the pulfe and refpiration are frequent and irregular, yet thefe fymptoms are generally fo en irely s B remove i ( » ) removed by the remedies that relieve the fpafmodic af- fedions peculiar to the difeafe, as to leave no ground for fuppofing that it had been accompanied by, or was conneded with that affemblage of fymptoms which de- fignate fever. Dr. Sydenham confidered the appearances of the Cholera in England to be confined to the month of Augud, and obferves, that in proportion to the heat of the air, the violence of the difeafe was greater. In Philadelphia it is mod prevalent in the month of July, but cafes frequently occur in June and Augud. From thefe circumdances, and from' the fads dated by Tropical writers, it appears evident that this difeafe is the-effect of a warmer atmofphere inducing a defici- ency of vigour in the feveral fnndions of the human body, and efpeciailv in the fnndions of the liver, in con- fequence of which, a preternatural fecretion and excre- tion of bile is readily induced by the remote caufes. The chief of the remote caufes of this difeafe appears to be a fudden change in the temperature of the atmof- phere, for it is always moil prevalent, when after extreme hot and dry weather, a fall of rain has cooled the at- mofphere. In fame cafes after the heat of the feafon has given the predifpofition, the difeafe is induced by eating too freely of crude vegetables, and fuch fubdances as are of difficult digeftiofi. Emetics of the dradic kind are very apt to induce this difeafe when employed dining the h6t feafon. Though the effufion of bile into the alimentary canal generally gives rife to the difeafe at fird, it often con- tinues after the bile is completely evacuated, owing to the debility and exqnifite irritability, firft induced by its irritation. This is fimilar to what happens after taking an over dofe of Tartar emetic ; the vomiting often continuing after every particle of the emetic which fird excited it, has been evacuated. The pores of the fkin being relaxed and enlarged by the fummers' heat, and accommodated to the in- creafed quantity of perfpirable matter, which is deter- mined thither and exhaled, any plethora occafioned by ( 3 ) by a diminution* or fuppreflion of that difcharge, mud load thofe Vifcera in the abdomen, whofe ordinary fe- cretions are mod languid at thatti'me. The confequence of this dertermination is, a diftention of the veitels of the abdominal vifcera, and of courfe irritation and pain, and this irritation and pain, occafion ail increafe of the internal fecretion, and among the red, that of the bile.— • The bile, and the pancreatic fluid, as well as the gadric fluid, appear to be more acrid in this difeafe than in a date of health, at lead experiments prove this to be the cafe with the gadric fluid; hence the appli- cation of thefe, or of any other acrid fubdance to the debilitated and irritable fibres of the domach and. in- tedines, occafion thofe enormous and irregular mo- tions in their fibres, which have been defcribed. Thefe contradions fometimes exhibit an appearance qf increafed power, as well as of adion, but this ap- pearance is falacious, otherwife fedative or debililating and not ftirnulating remedies would afford relief. 'RE MED IES. IN every cafe of Cholera, the bilious and other acrid matters fhould be immediately diluted, and carried oft* by large and frequent draughts of camomile tea or warm water, and where the patient will fubmit to them by injedions of the fame. • So foon as this is accorrtplifhed, or fooner, if the fpafms have begun to affed the limbs, recourfe fhould be had to the internal ufe of opium, which fhould be ad- miniftered in a liquid form by the mouth, if the domach will retain it. To an adult, thirty drops fhould be given in a table fpoonfull of fimple peppermint, or cinnamon water, and repeated every hour if retained on the do- mach, till the evacuations and fpafms ceafe, but if re- jeded, it fhould be repeated immediately, after every evacuation. The laudanum fhould be proportioned to the patients age and vigor; to a child from one month to a year, from one to fix drops will1 be proper." To render the laudanum more cer-tainlyeffedual: every means fhould be employed to redore the determination to ( 4 ) to the furface. For this purpofe, when pradicable, the patient fliould be hnmerfed in the warm bath, but where that is impradicable, flannel clothes wrung out of hot wa- ter fhould be applied to his domach, abdomenand iimbs, as hot as he can conveniently bear, and the application of thefe flannel cloths fhould be repeated as often as they become cool. i hefe failing, from eighty to an hundred drops of Laudanum fhould be thrown up the bowels, in a glider of chicken broth, rice gruel, or camomile, and fen- nel-feed tea, or any other fimple liquid, moderately warm; and fhould be repeated every two hours, or after every evacuation, till the fymptoms ceafe. If the difeafe fhould continue, notwithdanding the judicious application of the remedies which have been direded; Blidering pladers, or finapifms fhould be applied to the domach and infide of the legs, and the whole of the fpine rubbed with mudard, mixei with the fpirits of fal vol. amnion, or a mixture of the oil of cloves and volatile fpirits ; and the patient fhould lie between heated blankets, the doors and windows of his chamber being open, for the benefit of pure air. When the domach rejedsopiumin a liquid form, one grain of folid opium may be adminidered every hour, or after every evacuation, to an adult; and a proportion- able quantity, with any agreeable preferve and aromatic tea to an infant. In fome cafes double flannel cloths fprinkled with warm fpiced brandy, or a mixture of oil of cloves, volatile fpirits and brandy, applied to the domach and bowels, and a common heated flat or fmoothing iron paffed over the flannels have afforded fpeedy relief. In fome cafes alfo, aether exhibited in dofes of thirty or forty drops in any fimple herb' tea, and frequently repeated, has alfo fucceeded when opium has failed. This difeafe is very liable to return the day following, unlefs prevented by having recourfe to preventitives: I therefore make it a rule to exhibit ten or fifteen drops of laud, liquid in fome agreeable draughts every twelve hours, for three or four days after the evacuations have ceafed. . ; At ( 5 ) At the fame time the patient fhould take a decoction or infufion of Columbo root, with the addition of a few drops of lavender compound, or a little old brandy four or five times a day, to redore itrength and eafe to the domach and interlines. The lighted and moil grateful food, fhould be taken in a fmall quantity, at a time. In general, adult patients foon recover perfedly from this difeafe, if managed agreeably to the preceeding di- redions; but in infants and young children, the diarr- ahoea, with occafional vomiting, is very apt to continue obilinate for a great length of time, and in general, proves more fatal to them, than any other difeafe to which they are liable. The bilious diarrhoea of children, fhall therefore be the fubjed of the next chapter. Of the Bilious Diarrhoea of Infjnts, and young Children. THIS difeafe is much more prevalent in populous cities, than in villages or farm houfes of Ameri- ca, and like the Cholera, of which it is frequently the confquence, is confined to thefummerand autumnalfea- fons. It is mod frequent and violent, during thofe feafons immediately after a fudden change of the wind, to a colder quarter, and efpecially after rain, which gives a fudden coolnefs to the air. This difeafe,is confined principally to infants at the bread, and thofe under two years of age : it feldom occurs violently, or proves fatal, after this tender age. In Philadelphia, more children are annually dedroy- ed by this difeafe, than by all the others to which they fubjed. This-difeafe either returns after the fufpenfion of the Cholera, or comes on fuddsnly after expofure to cold, generally C 6 ) generally in the night, and is didirvguifhed from com- mon diarrhoea, by the feverity of the griping, and the bilious coloured dools, accompanied with a frequent inclination to puke, particularly a little before the pa- tient has an evacuation by dool, or at the time of fuch evacuation. It may alfo be diftinguifaed from the Diarrhoea arifing from teething by the pulfe, condition of the ikin, the flrength of the patient, and the afped of his counte- nance. In the latter, thefe differ very little from their natural date, for feveral days after the commencement of the difeafe, whereas in the bilious Diarrhoea, the de- bility in mod cafes, is evident from the commencement. The pulfe is weak, low, quick and foft, the fkin pale, cold and dry, or cold and moid, efpecially on the limbs —the eyes dull, and the countenance contraded, de- prelfed and lidlefs. The internal heat and third are great—the flefh grows daily more relaxed, foft and emaciated, the third increafes, the appetite fails; every kind of food is loath- ed and retufed ; no drink but cold water acceptable, and, that thrown up foon after it is taken. In the pro- grefs of the difeafe, all the enumerated fymptoms in- creafe, in fome ^tadually, in others more rapidly. In the word and molt obdinate cafes, unlefs early relieved, the dools become daily more copious, though not al- ways more frequent, and have a cadaverous fcent, the debility increafes, every thing taken into the domach paffes through the bowels undigeiled or but little altered from its natural date; the third becomes fnfatiable, the feet fwell and become cedematous, the belly fwells and grows hard, the mouth becomesaffeded with fuperficial white eruptions and ulcerations, which impedes the fwallowing; a lethargy enfues, the fkin appears livid, and often fpotted, and the patient dies. The duration, as well as violence of this difeafe, is very various, fome recovering in three or four days, others fingering for as many months, and recovering ?fter being reduced to perfect fkeletons ;. fome die be- fore the end of the fird %eek, bthfers after" lingering fix or fevihljCanci fome dill longeT. *' ": As ( 7 ) As this difeafe depends upon fimilar caiifes, only ope- rating in a lefs degree, as the Cholera, that is upon too great a determination to the liver and intedines, and a want of tone in the extreme veffels, on the external furface of the body, and a general date of debility in the circulating organs, and is occafioned by the appli- cation of debilitating powers ; it is obvious that the in- dications of cure, and the remedies employed, fhould be the fame as thofe employed in the cure of Cholera, on- iy differing in degree, or the proportion in which they are applied, at a time when the patient is in an imper- fed date of vigour. An increafed peridaltic motion of the intedines, may be confidered as always the chief part in the proxi- mate caufe of dirrahoea, and the difeafe, is diverfified by the different caufes which produce this encreafed motion. But in the fpecies under confideration, viz. that in which bile predominates in the evacuations, the increafed pe- ridaltic motion is occafioned and continued by the bile, effufed into, and irritating the intedines. THE INDICATIONS OF CURE are, therefore to evacuate the bile already effufed, and to prevent its excefiive effufion in future. To effed thefe purpofes, I have found the following treatment preferable to any other. & Pulv. Rhubarb 9'i. Magnefia Alb. 31. Ol: Minth Piper : vel Cinnam. gut i. Aq : Com : ^ii. m. Two or three tea fpoonfuls of this compofition, is to be given every hour till it alters the colour of the dools, and from ten to forty drops of the common parigoric elixir called Tinct. Opii Camphorat. in fweetened water, at bed time. The day following I dired from one to four tea fpoonfuls of the following mixture according to the age and ( 5 ) and ftrcngth of the patient, to be given every third or fourth hour * £: Cret: pp. 3ifs. Pulv. Gum Arab. jfs. Of: Minth pip. vel Cinnamon gut i. Saclu Alb. 3:s. Aq. Com. Jij. m. et Add. Tinct. Opii. gut. n° 8. Spr. Sal. Vol. Alk. gut. xvi. m. If the diarrrhcea becomes fufpended by thefe means, mild tonics fhould be admineftered to prevent its re- turn. For this purpofe the Columbo root, either in fubdance or infufion, is in high eflimation, and is gene- rally found to red better on the patients domach, than * In cafes where acidity abounds 51 of calcined magnefia fhould be fubitituted in the place of prepared chalk, And when the gri- ping is fevere, and not attended with* hot lib, tenfc pulfe, or other fymptoms of inflammatory fever, 1 have found the following formula more generally fuccefsfol than any other. §> : JVIagneft.3 Cakmat. 31 .. Pulv : Rhubarb gr. x. vel xv. Sach. Alb 3i]----Cl. Minth piper vel Cinnam. gut i, vel ij. Thefe are to be rubbed together in a mortar, and two ouncr* of water, with from fifteen to twenty-five drops of liquid laudanum are to be added and mixed together. To an infant under twelve months old, two tea fpoonfuls of the mixture may be given three times a-day, and twice as much to one from one to two years old. If the child cannot retain this mixture on its domach, the fame, articles may be well triturated in a mortar, and the liquor drained and prefled through a linen cloth, and the drained liquor given. Any pleafant tea or mild aromatic infufion, may be criven after the medicine. Children are always thirfty v/hen debilitated with this difeafe, and as they are apt to drink more than their ftomachs can bear' they generally puke up part of what they drink.— To prevent this effect, they ihould be retrained to a fmall quantity at a time, and not f tffered to take their drink very cold. Water with a piece of bread or bifcuk toafted brown, infufed in it, given in fmall draughts is not only grateful, but generally refts eafy on the ftomach. After the diarrhoea, ficknefs, and griping are relieved, a compo- fition of Thereac \ ienet. 5ij Pulv. cpii 5I Camphor 3i well mixed and fpread on leather, applied to the domach, has frequently ap- peared to prevent a relapfe. 01. JVh.nth. and Caryophil, have alfo been employcdwith fuc- eefs without the or nun. the ( 9 ) the Peruvian bark. From five to ten grains of th? powder mixedwith a draught of fimple peppermint wa- ter, or cinnamon water may be given to an infant at the bread, and repeated four or five times a-day. If the child refufes to take it in powder, it may either be triturated with water in a mortar and drained through linen, or 31j of the bruifed root may beinfufed in eight ounces of boiling water, and from 3ij to 3is of the drain- ed liquor may be taken feveral times in the courfe of a u ay. When the Columbo can not be exhibited, or if it fails of fuccefs—The compound tindure of the bark, or the tindure of gum kino may be fubdituted, and a little of the common chalk julep, rendered cordial with vola- tile fpirits, peppermint and laudanum, occafionally in- terpofed. When the debility is great, laudanum fhould always be given in very fmall dofes, and at considerable inter- vals. From negleding this circumdance, numbers have been rendered worfe indead of better by its ufe. To render the recited remedies more effedual, the warm bath either general or partial, diould be em- ployed, and the patient's ftomach and abdomen rub- bed with fpiced-brandy, or a compofition confiding of Sp: Vin. Gallic 1bfs Sp: Sal Vol. Alk. Jii Ol. Caryoph: 31J two or three times a-day, and afterwards covered with foft flannel or mudin, fo long as the diarr- hoea continues, and the child's flrength appears to de- cline. When the child's countenance appears pale, fhrunk and depreffed, refembling one extremely fatigued, a ' declenfion of drength is always indicated. If to thefe circumdances, the dools are copious, watery and green, preceded by redlefsnefs, toiling of the limbs, rolling the head, and retching to puke, the cafe is dan- gerous and alarming. Under thefe circumdances two or three drops of laudanum fhould be added to every dofe of the chalk julep, with a due proportion of Vo- latile aromatic fpirits, or effential oil, and given every hour till it affords evident relief, and afterwards once in fix or eight hours till all danger of a return ceafes, ( 10 ) which will generally be the cafe before the end of the third day. The patient fiiould then be removed out of the hot and impure air of the city,.till the feafon be- comes cooler.—Unlefs this is complied with, a relapfe is always to be apprehended, (o long as the caufes which originally produced the difeafe, continue to exifh In fhort, we might with as much reafon exped to cure inflamed eyes occafioned by a fmoky room, without a change of circumdances, or fituation, as to cure the bilious diarrhoea, fo long as the heat and impurity of the air, which gave origin to the difeafe continue to operate. In cafes where great debility or prodration of drength is e ident, and the litle fufferer toffes his limbs and heai backwards and forwards, and retches to puke be- jfore every dool, which is generally watery, curdly, and of a greenifh colour : I have feen immediate benefit produced by fmall gliders of tepid warmth, made by infilling camomileflowers and cardamom feeds, or annis ieeds in boiling water. In thefe circumftanees*during tiie intcrmifiions from griping, the child diould take a tea fpoonful or two of the following mixture every hour till eafy, and afterwards, once in four or fix hours as circumdances may require. &: Magnef: Calcinat. '$]]. Gum Arab. 9i. aqu : com. ^i. cui. Add. vel. menth. vel. cinnam. gut i. fp. Sal. Vol. Alk. gut xvi. tind. theb. gut. vi. When the debility is great, and the acid in the primse via; copious, calcined magnefia, or lime water is preferable to chalk, occul. cancror. bol. arm. or any of the common abforbent earths, becaufe they are freed from ths carbo- nic acid with which the others are combined. The ufual dofe of aq. calcis for an infant, is from one to four drachms, diluted with common water. When the debility increafes, accouip.uiied ^vith in- fatiable third, wine whey, or thin milk punch fhould be given frequently in fmall draughts. The domach and bowels fiiould be rubbed at the fame time with warm camphorated fpirits and laudanum, or the volatile lini- men ( II ) ment, and covered with flannel; and if the nights and mornings are confiderably cooler than the red of the day. which is generally the cafe after the middle of Au- gud, worded dockingsor a flannel petticoat long enough to cover the feet, fhould be worn conftantly. Small blidering pladers applied to the limbs, and repeated occafionaUy,, frequently afford reiie , not only to the fever, but to the di;.rr! cea. As foon as the diarrhcea and third ceafe, the cold bath, either by way of fhower or itnmerfion, fiiould be employed regularly once a-day at leaf. V/hen the bath can not be conveniently applied la either or the ways juit mentioned, the whole body may be waflied by means of a thick linen cloth, dipt in cold water and brandy, and wiped dry after each warning with a warm napkin ; this occafions a glow on the fur- face, and in feme meafure, fuppliea the place of exerciie. By the ufe of the bath, a proper regulation of tiler, and frequent exercife in the open air, a relapfe may be genenlly prevented during the extreme heats of July a:ui Augr.it ; but for farther fecurity, as the feafen ad- vances, ar.d the nights ar.d mornings become cold, v. hile the middle of the clays continue ddtrcfilngly hot, it v ill be proper to let the infant wear a flannel fihirt, as v ell as a long flannel petticoat or worded dockings. I'lannel from its texture repels moidure, and has the property of retaining heat, whereas linen being fmooth and ccinprd, fufR-rs it to efcape immediately: hence flannel cleathing pveferves the warmth on the furface, and thereby prevents morbid determination to the in- ternal vifcera. Cafes of diarrhcea often occur during the hot feafon, that are not bilious, particularly in June and July. In thefe cafes, the alvine evacuations are generally mixed with more or lefs mucus ; the griping, though more f. vere is attended with lefs ficknefs, and lefs third, and the countenance is always more animated, and the func- tions in general more vigorous.—Children whole gums are inflamed by teething, are mod frequently afleded with a diarrhcea of this kind; and my obfervations give me reaibn to believe, that the efFcds of teething, indead ( ^ ) of being the caufe of the bilious diarrhcea, is always a preventative, except the inflammation which the irrita- tion of the teeth occafion, before they pafs through the gum be fo great as to bring On indired debility. When therefore the gums begin to appear fwelled and red in cafes of bilious diarrhoea, it may be confider- ed a favourable circumilance.—From this circumdance it is vrry probable, that mercurial fridions would be beneficial in cafes of bilious diarrhcea, by inducing a fimilar fwelling and inflammation, and a general phlo- giftic diathefis. To promote the cure of the diarrhcea mucofa which if not caufed, is often aggravated by the irritation and pain of teething; thofe parts of the gums where the tecrh are ready to protrude, fhould be cut acrofs with a fcalpel fufficiently deep to prevent any farther irritation from the edge of the tooth. rl he irritation and pain occafioned by teething, ge- nerally renders the domach liable to be difordered by every thing the infant takes. When this date of the domach is attended with thin watery dools, and no fever, laudanum proportioned to the age of the patient is the mod certain remedy ; but when frequent incli- nation to puke is accompanied, or followed by mucous dools, and fymptoms of more or lefs fever, I have ob- ferved the lollowing method of treatment to be the mod efficacious. %,: PJagnefne : Alb : 31. Sal. glaub : epfom vel Rochcl: V)iv. Sach. alb. 3ij. Pulv. Gum Arab. 3k ()l. nicuth. pip. vel. Cinnam. gut i. Aq. Commun : ^ij. M. From two to four tea fpoonfuls may be given every two hours, till it occafions copious and liquid dools. At ni^ht from two to fix drops of the tindure of opi- um, commonly called liquid laudanum, fliould be given at bed time, in any thing agreeable. If the ilools appear to be mixed with mucus, or if the patient is troubled v lih tenefmu:., the fame n-tdi- cines are to be repeated every day in the fame manner, or at longer intervals, till they afford relief. If ( *3 ) If the diarrhoea fhould become liquid, or watery, and not accompanied with fymptoms of inflammatory fever, the following laxative abforbent mixture, is the bed remedy that lam acquainted with. & : Magnefise Alb. 31. Pulv. Rubarb gr. xii. Sach alb. 3ij. 01: Menth piper, vel. Cinnam. gut. j. Aq : font. %i. M. When this medicine is intended to carry off acrid, or irritating matter from the intedines, two, three, or four tea fpoonfuls, more or lefs, adapted to the age of the in- fant, fliould be given every hour, till a change in the colour of the dools, render its operation evident. The operation may be promoted, by a fimple decodion of bread and water, made palatable with fugar ; by fago gruel, or fowl broth, &c. The bread: may alfo be allow- ed. An anodyne at night, fuited to the age and drength of the little patient is generally found neceffary to pro- cure tranquil and refrefhing fleep, unlefs the complaint be attended with fever of an inflammatory kind. When the medicine is intended to corred acidity, calcined magnefia is preferable to the common kind, and may be employed in the fame quantity and manner, and when the griping is fevere, from half a drop to three drops of tind. opii. may be added to each dofe of the mixture, and given every hour till that fymptom is relieved, and afterwards three times a-day till the eva- cuations are fuppreffed. When this is accomplished, tone may be reftored to the domach, intedines, and the whole fydem by the ufe of tonics, combined with lauda- num, and given in proper dofes, and at proper inter- vals. 5, Tind. Kino. 5iij. vel Tind. Cort. Peru. Comp, 5vi. Tind. Opii gut iv. vel vi. Aq. font. %i. Or, §> Pulv. Alumen. Coccinel an : gr. viij. Tind. Opii gut iv. vel vi. Sach. Alb. 3i Tr. Lav. comp. 3i Aq. Com. |i M. A f '+ ) , A fmall tea fpoonful or two of either of the above, according to the age and drength of the patient, fhould be given three or four times a-day. Wine whey or brandy and water made weak, and fweetened with loaf fugar to be given in the intervals. In aid of thefe, great advantage may be derived from a proper regulation of the patient's diet, clothing, and exercife-in the open air, and from the daily ufe of the cold bath, when the drength will admit of it with fafety. When the debility and emaciated condition of the patient has rendered the cold bath unfafe, the hot bath has frequently been obferved to turn the tide of the difeafe. My experience does not enable me to determine pre- cifely the degree of heat which renders the bath mod falutary, but as all degrees below 96, decreafe the ftrength and fulnefs of the pulfe ; if the experiments of* Dr. Macard of Hanover are corred, it ought not to be much below that point. Pain of almolt every ; kind and decree, is mitigated by the application of warm water to the part, and even in internal pains ; this erred is produced by fyrnpathy, when the \0arm bath is externally employed, even if it be only to the feet. Dr. Darwin confiders a bath of 96 or r8° a falutary ftimulus, which fupplies heat rather than produces it, and rather fills the fyftem by increafed abforption, than empties it by increafed fecretion ; and may hence be employed with advantage in almolt all cafes of debility with cold extremities, perhaps even in anafarca, and at the approach of death in fevers. Removal to the high grounds of the country before the extreme heat commences, is the bed prefervative againd the diarrhcea of children, and after the difeafe has taken place, removal to the country is the mod cer- dn means of preventing it from proving mortal. * v.ec bis C^fcrxations in lac Am lytic Rr. lew for 1793.