TEMPERANCE METHOD Of TREATING EPIDEMIC CHOLERA 1849 ARMY MEDICAL IJBRARY A TEMPERANCE METHOD OF TREATING EPIDEMIC CHOLERA. BY A PHYSICIAN, Now in Successful Practice in the City of New York. WRITTEN BY REQUEST NEW YORK: 1349. Entered according to Act of Congress, in the year eighteen hundred and forty-nine, BY JOHN GOLDER, In the Clerk's Office of the District Court, for the Southern District of New- York. AN ESSAY UPON THE MEDICAL TREATMENT OF CHOLERA. Ever since the appearance and prevalence of the Epidemic Cholera in the city of New-York, the public press has teemed with speculative suggestions relative to the treatraeut and reputed cure of the disease in other climates, without due regard to the nature and condition of the numerous cases in this community* After an experience and practice of many years successful treatment of this Epidemic, we have been persuaded to publish the following statement of facts, if possib'e, to counteract some of the injurious influences of fugative reports from abroad, by a faithful detail of some facts in relation to the successful treatment and cure of several hundred patients within ihe bounds of our city and its vicinity. Among the remedies proposed, it has been often stated in some of the public prints that "stimulating articles were the most successful and proper in the cure of Cholera/ consequently a great, variety of highly exciting and injurious remedies have been injudiciously recommended. That there is an inclination to adopt these remedies by some, and the use of alcoholic mix? tures by many, is too obviou3 to demand proofs. In order to arrive at a general plan of treatment of such a disease at this time, it will be well lo examine and ascertain how those diseases affect, the body in the solids, in the' blood vessels, and vital organs, and what are the traces exhibited of disease on examination of bodies after death, and how the one prevalent disease compares with other and previous Epidemics. In this way we may ascertain what remedies or modes of treat, ment has been most successful on previous occasions in maladies similar to or approximating to the present one. In regard to Cholera, there has no doubt been more attention paid to one symptom — that of the evacuation from the alimentary canal — than it intrinsically deserves;, while the general effects on the bedy have been overlooked or passed by : for the matter of the evacuation from the bowels, in Cholera, seems to be an excretion produced by the virus of the disease operating on the 4 body, the irritation oF which generally locates on the inner surface of the alimentary canal ; the system makes an effort to ..expel the irritating and excreted matter by this outlet. s ίut there are many cases recorded of what are termed Cholera, when the patient had many, or all the other symptoms attending the disease, and died, who bad neither vomiting nor diarrhoea. Some such we have witnessed. The miasma or virus, which produces Epidemic diseases when it operates or the body, the first effects are to produce an increased action of the organism and an inflammatory condition. This is shewn by acute pain in various parts by an increase of the momentum of the blood and action of the heart and arteries, and an increased fulness of the pulse — generally a more than natural redness of the substance of the tongue, which is covered with a fcliin whitish scurf. During the Cholera of 1832, nearly every person in the locality of the disease had this kind of tongue. These aie symptoms of inflammatory affection, and those marks of disease have been presented in most mild cases of Epidemics in the forming or first stage. They are mentioned by Sydenham, Rush, Mann and <3ullup ; and in the Winter Epidemic it is stated "that the mild cases did not differ from an ordinary case of inflammatory fever.'' Similar facts are mentioned as having occurred in Cholera, during the premonitory stage; and when the attack is not severe, there is existing the usual symptoms of increased or inflammatory action. But when the attack is violent, the system, surcharged with a large quantity of virus, or morbidly exciting influences, the transition from the simple inflammatory or premonitory state is rapid; or if the case is suffered to continue a length of lime before suitable medical means are used, a more .active, depressed or congestive condition takes nlace, and some of the vital organs become affected w,nh compound inflammation. or congestion; they are overloaded or surcharged with blood and fluids. This condition was, in the sixteenth century, termed by Sydenham, oppression or depression; by Dr. Rush it was called debility from action, or over-violent action ; by Dr. Donaldson, compound inflammation, and by Dr. Armstrong it was termed Congestion, by which it is now generally known. Congestion is defined in the Lexicons as " a collection of blood or Huids in vessels or cells, more than natural. When they are over-distended or obstructed, and the motion of the blood through s the part is slow, and sometimes the pulse is nearly suspended." Therefore, in Epidemic diseases, as well as in some other severe .cases, the pulse is frequently slow, soft, compressible, dec. In 5 the description of the Winter Epidemic, sometimes called Spotted Fever, or Epidemic Inflammation of the Lungs, of 1812, 1813, this fact is often mentioned. A similar state takes place in Cholera, aad in this disease the pulse is often imperceptible* Similar facts are noticed by writers on Yellow Fever. In the great Plague of London of 1665, similar facts are noticed — in this condition of a patient the face is dingy or bluish, the skin is torpid or cold, the tongue loses its florid color, and is frequently very cold — it is brownish— the eyes have changed their lustre to a dim glairy hue, and indifferent expression — the breathing is obstructed and laborious. In describing this state as occurring in the Winter Epidemic of 1812, Professor Gallup, of Vermont r observes, "the pulsations shortly cease, coldness increases on the surface, the eyes become suffused, there is a lividness of the skin — the respiration is short, the heart beats slow and has to resign its umpire — it ceases to pei form its office. Respiration is now only a gasping, and the patient is folded in the arms of death ! This is what every practitioner who has seen much of Epidemic disease must have witnessed." Dr. Mann, Surgeon General of the Army, during the War of 1812-1815, in his account of the Winter Epidemic of that period, furnishes similar facts. If blood is drawn at this period it is dark and thick, and if the case has continued a length of time, the blood is black. It does not attract oxygen from the air while standing' in the vessel, while blood drawn from a healthy person, or from one not very sick, always does — this circumstance is noticed by writers on Cholera, and shews that the blood in such cases is deprived of vitality while circulating in the vessels. In such conditions of prostration recourse has ofteί been had to active stimulants, and frequently in excessive quantities, they have a tendency to increase the difficulty and aggravate the disease. And it is under their use, with free doses of opium, that those cases have been so very fatal! ! — Treatise on Epidemics. In a Lecture lately delivered by Dr. Griscom before the Free School Society of this city, it is stated that the lungs in every minute requires eight pints of air for the purpose of sustaining life, and that in health eight pounds of bleod passes through the lungs in a minute, when the blood becomes deprived of oxygen it becomes dark." But in cases of congestion of the lungs, or &• paralysed or diminished action of the heart, the circulation of the blood is slow through them, the quantity passing through them may be diminished one half or more, and as the breathing is verj slow, the quantity of vital air which passes into the blood is also lessened one- half or more. These statements will furnish. 6 an explanation of the reason why the sudden deaths take place which otten do occur in Epidemic Cholera, as well as in other Epidemic diseases. This explanation we are awafe may be objected to by assuming that the prostration and subsequent death is owing to the evacuation from the bowels, and that the fluid portion of the blood escapes in this way. This evacuation has no doubt a great influence in the result, but it may be remarked that very often prosration, collapse, and even death takes place when there is very little or no discharge from the bowels, and often not more ihan is frequently discharged by the operation of an active purge, death certainly would not be caused by such an evacuation. With such facts before us it will be well to direct the attention to some other cause than the Simple Diarrhoea, for the sudden deaths. We assume that they are generally caused by congestion of the brain or lungs, or both. The blood circulates so slowly through the lungs that it is deprived of oxygen, (vital air) and the patient dies from this cause. And as John Bell, in his Physio'ogical Anatomy expresses it "in congestion of the lungs the blood cannot circulate through them, and the patient falls down and suddenly dies In other Epidemics, when there is no evacuation from the bowels, death often takes place equally sudden. In that of 1812, persons were often attacked, congested, prostrated, and died in twenty-four hours. This condition of the system is also pointed out by Dr. Rush, and the remedy for it directed, which will be noticed hereafter. In the description of the Winter Epidemic, it is related that when the chest was affected the patient complained "of very little pain, but of a stricture, heaviness and obstruction to respira•tion .from an inability to dilate the chest." — " there was great prostration, and sometimes fainting — the moat common pulse met with was a frequent one, without much tension, feeling like an elastic tube partially filled with fluid." See SherrilPs History of it, and Drs. Mann and Gallup notices a similar state of the pulse in that disease. In Cholera, a like pulse is often attending. W hen this kind of pulse with other severe symptoms are present in the first stage of a case, it is a true indication of congestive disease, and more particularly so when thg lungs are the organs affected. In such condition of a patient there is another prominent symptom that is worthy of notice. The skin has a doughy feel — it is purple or bluish — and in severe cases, it is black. This black appearance of the skin has been mentioned as attending some fatal cases faere this season. This condition of the skin was very common in ihe Winter Epidemic, and sometimes in severe cases of remitting 7 fever, or bilious remitting fever, which occurs every year. They were very common in the Cholera of 1832, and we again observe them in the Cholera of 1849. In such a condition of a patient, opium and alcoholic articles, except as a temporary remedy, are always injurious, and if long continued, are pretty sure to destroy the patient. A great number of writers on Cholera have mentioned that the blood was carbonised or deoxydated, or, in plain terms, contained a large and poisonous quantity of carbon and a diminished portion of oxygen, and to this circumstance was owing the dark and black color of the blood and of the skin. The remedy indicated for such a condition would be (he same as should be prescribed for a person who had been immersed in a deep weir or cavern filled with carbonic gas — they exhibit similar symptoms. The remedies in such cases would be blood-letting, to give a more free action to the lungs, and to convey into the blood, through the lungs an increased quantity of oxygen. It was the state of depression which appeared to induce many to use remedies of a stimulant alcoholic nature in former Epidemics, and it appears that a similar course has been erroneously pursued in Epidemic Cholera. Many conjecture that in such cases highly exciting and stimulating drugs and alcoholic libatiocs will goad up the vital energies of the system to increased and healthy action. A false and delusive hope. For by a free use of such remedies in the early stage of the case, the patient is generally more depressed, and the avenues by which life is preserved is closed up, and there is danger of expelling the vital principle by their use. There were two prominent me'hods pursued in treating the Winter Epidemic, very different in their effects, and generally equally different in their results. One may be termed the evacuating method, consisting of blood-letting , vomiting or purging, and sweating. The other a stimulating course, composed of calomel, opium, essences, bitters, wine, alcoholic drinks, sweaU ing, &c. These plans refer to the early stage of the case. Those again were modified by the opinions, notions and judgments of the prescribers. Similar methods have been pursued in Cholera. In tho accounts of the Winter Epidemic, by Drs. JWann, hovel, (Army Surgeon,) and Gallup, it is stated that under the stimulating method the fatal cases were about one in four to one-half.-^- Whereas by means of the evacuating course the cures were about eleven in hvelve to fifteen in sixteen cases. In the Medical and Philosophical Register, edited by Drs Hosack and Francis, in 1812, the evacuating remedies are re 8 commended for that Epidemic. Drs. Ackerly and Scofield y attached to the Army on Staten Island, in 1812, stated that by the evacuating and sweating plan about eleven in twelve recovered. Writers on this disease in noticing the small and soft state of the pulse similar to what often takes place in Cholera, recommends taking small quantities of blood at a time, and often to repeat (he operation. In Dr. SherriU's account of it as it prevailed in Dutchess county, the statements are, that by information gathered from the results of the stimulant treatment, ''one. third died, to about onehalf of all that were actively seized." Whereas by the effect of the evacuating course pursued by the author, il the fatal cases were one in eighteen." By the history of the Cholera, in all parts of the world, it ap« pears that from dissections made, it has been discovered " that the cells and the cavities of the brain were filled and stuffed with dark blood ; the lungs were filled and stuffed with dark blood; the vessels about the stomach were injected with blood; the villous coat or internal surface of the stomach and intestines were injected with blood or were red, shewing traces of inflammation or congestion.* Dr. Cruvilier, of France, who had charge of a large hospital, and made extensive post-mortem examinations, discovered " that the Cholera cases exhibited evidences of inflammation of the peritoneum, the stomach and intestines, and that the brain and its meninges were injected with blood." Among others it is stated by Drs. Donaldson and Abercrombie, " that simple inflammation of the internal surface of the stomach and intestines are attended with vomiting and diarrhoea of a serous watery nature — the skin is cold and the eyes are sunken in ; the fingers are withered and spasms supervene." One of the uniform symptoms in Cholera is, the stomach has in it pain, soreness, burning heat, uneasiness, nausea, retching or vomiting. The virus or miasma, or material, which produces Epidemic and malignant diseases, it is generally agreed is a poisonous or exciting matter floating in the air, which is conveyed into the system where it is insinuated into the fluids and solids ; it operates on the nerves and vital organs, producing derangement and diseased action. When it is suspected or ascertained that a foreign or poisonous matter is existing in the body, producing disease and endangering life, the general practice of medical procedure is to use means to abstract a portion of it, by some evacuating means, or to use remedies to neutralize and counteract 9 its poisonous and injurious effects. This method seems toapply very forcibly to the treatment of malignant diseases — the history of them, and the experience about them shews that the cases which are the most violent in the attack, if left to themselves or aggravated by injudicious remedies, change their type soonest from an inflammatory character and run into a prostrated and more malignant or gangrenous form. The plan of treating them, which in most or all instances seems to be the most successful, has included in it some means which in the early stage has abstracted or removed from the body a portion of the fluids, and with them a part of the virus or exciting material which has had an agency in generating and producing the disease. It is stated by M. Roche, of France, « that the miasma producing Epidemic diseases, whatever it may be, should be expelled from the system, and the body relieved from its poisonous and depressing effects by bleeding, vomiting, purging or sweating." From the Treatise on Cholera, by Drs. Bell and Condie, of Philadelphia, we make these extracts :—: — M In examination of those dead, from it the blood was uniformly dark, but grew lighter and more florid after bleeding. " There was a tendency to inflammation and congestion. "The brain and intestines and liver generally showed congestion. "In some instances there was no vomiting. "The lungs generally were gorged with dark blood; in some instances the lungs were almost like liver. ''The stomach generally showed appearances of inflammation or congestion. " The liver was gorged with blood. "In Russia the brain was found filled with blood — the vessels were turgid. " Along the spine the vessels were loaded with blood, and the lungs were gorged with black blood. "Treatment by blood-letting has been more successful than any other plan. M In all cases where the bleeding has been free and the oppression of the chest relieved, a recovery has ensued. " The German, Russian and Polish doctors bled, and our experience is in favor of it. 44 Opium has been used, but large or free quantities of it is injuriou — it increases the eoίgestion. 44 Calomel was very little used in Russia, Poland or Germany ; many denounced it as injurious. 10 "In seven hundred and forty- five cases, in which no calomel was used, only seventy- five died. " Purgatives have been used very extensively, and in many cases with great advantage. " Experience shows the utter inutility and injurious effects of stimulants during the stage of congestion or collapse. They do more hurt than good. "By the use of brandy thirty-two out of thirty-four have died." Professor Chapman, of Philadelphia, in a letter published in 1832, bears testimony to the good effects of blood-letting. In 1832, Dr. Francis, of this city, published a letter on the Epidemic, in which he recommended blood-letting. In the same year Dr. Reese issued an essay on the subject in which bleeding was recommended. About this period Dr. Ferris published an essay on Cholera, in which blood-letting forms a prominent part of the treatment. According to the best of our recollections the statistics furnished in this treatise was about eleven out of twelve cases recovered. Dr. Corbin, Surgeon to a British Military Hospital, in Asia, 65th regiment, says, — "believing as I do the disease Cholera to be incipient inflammation, it follows that blood letting is the first remedy, indeed it is the most important, but requires many limitations in its use." '' There is a depression of the powers of the system. Blood-letting and other means set those organs free, and restore energy to the system. If a rugged, middle-aged man be attacked, sixty ounces abstracted is not too much." " Spasms and burning heat at the stomach all subside by this remedy." The Bombay medical board approves of this treatment; they say, — '' The practice adopted in the 65th regiment clearly proves that in Europeans, blood-letting is the sheet-anchor of success." Dr. Taylor, in Asia, reports — "'Seven thousand ftur hundred and fifty-nine cases treated, of ivhich four hundred and fifty-one died, lhat the greater number, if not all of the deaths, were patients to whom brandy was administered.' 1 In about the year 1500, an Epidemic sweating sickness prevailed in England and other parts, which has been compared to Cholera, only in that the serous discharges or sweat was discharged by the skin, as described by John Kage, "The symptoms were a sudden sensation of heat and vapor running through the parts affected — internal heat— great thirst, and profuse sweating. It carried off patients in two or three hours sometimes. In was the most deadly to persons in good vigorous health. In it they had violent pains in the head, stupor, delirium, excessive drowsiness, and sweating. This disease was inftammatory, 11 and bleeding and purging (and sweating means) were the only successful remedies." From the London Medical Journal, — Dr. Langue, of France, states " that there were many cases in which, like the sweating sickness, of about fifteen hundred, the serous discharge was from the skin instead of the bowels.*' Dr. Shaffer, of Germany, records— "that the sudden deaths that often takes place, particularly in Epidemic diseases, are owing to a palsy (or congestion) of the lungs." This condition frequently occurred in the Epidemic of 1812, and as often took place in the Cholera of 1832, and sudden deaths was the consequence. "In 1831, the Cholera broke out in Egypt. The mortality seemed to threaten to sweep away the population, so that scarce one recovered. At length M. Clot Bey, physician to the Pacha, adopted blood-letting, which he often repeated, bleeding freely, &c, Copious drinks were given, with some opiates and warmth to the skin Great numbers were saved by this method. The people used those remedies themselves with great success. A colonel of a British regiment stationed in that region, whose surgeon got frightened and run away, took the treatment in hand Himself, and saved almost all the soldiers attacked with Cholera, by bleeding them himself." In the New York Morning Star, of Dec. 12th, 1848, there is published an extract of a letter from John Backer, Esq., formerly consul-general in Egypt, from Great Britain, the consul says — " as soon as vomiting and diarrhoea commenced, he placed the legs of the patient in very warm water ; threw in six or seven handfuls of salt ; caused the legs to be rubbed freely ; opened a vein in both feet, and allowed the blood to flow in the warm water twelve to twenty minutes ; kept the water at the temperature as at first, by this the animal heat will be immediately restored and felt; the patient at once asks for nourishment, and will be ready to resume his labors in a day or two. With a fair trial of this remedy all recovered. If the blood does not flow from the feet, try the arm, and the remedy invigorates instead of debilitating." Dr. Wilson, of Belfast, Ireland, states — "that in the hospital, calomel was given in large doses, with opium, so as to produce salivation, (if the patient lived long enough.) That under this treatment three times as many died as there did in the town where little or no calomel was used " Dr. Langford, of Manchester, England, "gave small and repeated doses of tartised antimony, so as to produce moderate vomiting, which was long continued. By this course the congestion 12 of tke lungs and heart were relieved, the pulse soon became more free ; the vomiting and diarrhoea soon ceased. Three out of four recovered by this treatment." The editor of the London Medical Journal recommends a similar course. In Dr. Sherrill's treatise on Cholera, it is stated — " In many cases where blood had been obtained freely, the vomiting, diarrhoea and spasms soon ceased ; the patients have got up iv twenty four to forty-eight hours, and walked off." In this work we find an important maxim on the treatment of collapse. It is as follows — "When a case of Cholera progresses moderately, the patient sinks regularly down into a state of low depression or collapse, when by a judicious use of the means recommended here, (bleeding in small and repeated quantities, and vomiting moderately) the superincumbent load is removed from the brain, lungs, nervous system and vital organs. The blood receives an increased quantity of oxygen, the heart and arteries regularly react, the pulse grows firmer and fuller, mirks of increased action are exhibited, a diffusive warmth pervades the skin until full re. action is restored, and a plain case of fever or recovery to health takes place.'' In this work, on the uses of bloodletting, there are these important aphorisms : *' It ought to be used early after the attack, before the blood assumes an acrid, hot, gangrenous tendency, and before conges* tion takes place." "It lessens and regulates vehement excitement, and prevents the vital organs being affected with fatal obstructions." " It removes a disposition to faint." "It removes pains and spasms." "It reduces the force of the pulse in acute inflammation." "It incieases the fulness and firmness of the pulse in depressed congestive states of the system." " It checks vomiting, and is the most efficient remedy for thai symptom in Cholera." " It restrains and checks the diarrhoea." 11 It disposes the patient to sweat, more than any other remedy." " It removes stupor and delirium in the first stage of the case.'' " It induces sleep.'* , " It increases the strength and the powers of the system, by removing the pressure and prostrating influence of the disease." In Dr. Rush's Medical Observations and Enquiries, vol. iii., History of the Epidemic of Philadelphia, of 1793, it is stated — il I was led to the use ef bleeding by the slow and depressed pulse in which I had used it in other cases." " Rivereus describes a pestilential fever of 1623, which carried off half of all affected by it. After trying various expedients, he 13 drew three ounces of blood — the pulse rose after it — afterwards he drew in a few hours, six ounces, with the same good result. Then he gave a purge, by which he rescued the patients from the grave. v Bleeding raised the pulse when depressed — a slow depressed pulse I had raised by bleeding." "In states of great depression, the bleeding ought to be small, and often repeated- Large bleeding, in such states of depression, may produce a collapse, and prove injurious." &c. In this work ''statistical statements are given, shewing the various success under the evacuating plan, and by the stimulating method, from which we extract, under the direction of Dr. Rush, by using the evacuating remedies (it is well known that Dr. Rush used blood-letting and purging) the deaths were only one in a hundred." " Dr. Griffith, by the same method, cured forty- nine in fifty cases." " Dr. Pennington, by the same, in forty-eight cases, lost none," "Under the use of stimulants, sweating means, &c, two out of four, or one-half, died." <£ In the hospital at Bush Hill, in a salubrious location out of the city, by the use of bark, wine, calomel, opium, and alcoholic remedies, one-half died. By the use of those remedies, whole families were swept off." In Dr. Donaldson's account of Epidemic Yellow Fever, which prevailed in New York, in 1822, it is stated — " That by the free use of evacuating remedies, bleeding and purging, twenty-two cases in succession wore cured. That by his neighbors, the doctors, who used the stimulating or calomel and sweating remedies, one half of the cases were fatal." In Dr, Sherrill's account of the Cholera, as it prevailed ia Dutchess county, in 1832, a statistical list is given, treated by blood-letting and other evacuating means which shows that nineteen in twenty cases were cured. Also, a statement showing that under the stimulating remedies, nineteen out of twenty cases were fatal. By another statement, furnished by a different source, it appears that three out of four were fatal. Blood-letting in such cases is not indicated to restrain increased arterial action, nor to check or cure acute inflammation. Among other effects it is indicated for a greater or more noble and exalted consideration. It is to remove the over fulness and torpor of the vessels about the heart, lungs and other vital organs by which the blood is enabled with more facility to pass through the lungs, there to receive an increased quantity of vital air, which, in the primeval state of man's existence, God breathed into his lungs, conveying the "breath of life," and animating 14 humanity. Here the oxyge unites more freely with the blood, This furnishes the best excitant or stimulant that can introduced into the body. By this process the carbon is expelled, and the blood becomes more florid. Animal heat is generated and diffused throughout the system. The purple or blueness and cold" ness gradually leaves the skin, and a returning natural warmth pervades the body. To rely in such cases on external heat exciting and torturing appliances, shows the futility and uncertainty of producing those effects by external means. It is applying remedies at the wrong end of the nerves and of the blood vessels, and in a great majority of cases the above remedies will terminate the case favorably. TREATMENT. From the views and maxims thus far presented, the treatment to be recommended m^y be in a measure anticipated. If the case is not checked or cured by the premonitory treatment, and the disease advances to a severe or collapsed state, great benefit will be derived from blood-letting, vomiting, purging or sweating. In all the acccounts of Epidemic disease where some one of those means have been used to a considerable extent, the result ha& been the most successful. And in regard to the Epidemic Cholera, as far as the history of that affords us light on the subject,, the observation well applies to this disease. Where some of those indications have been used or combined, the best success has attended. During the premonitorj stage, the most suitable and successful remedies are those which relieve inflammation and the irritable state of the internal surface of the stomach, such as aconite, antimonial tartar, camphor, Ipecacuana, blood root, (sangu naria canadensis) veratrum, &c. These should be repeated three or four times a day, or oftener, according to the severity of the pain, burning and uneasiness of the stomach and bowels, the vomiting or diarrhoea, if those symptoms are very severe, the doses may be given every hour. The remedies should be given in small doses. These remedies ought not to be combined or mixed together. Give each by itself alone until it has a fair trial, and if it does not check and quiet the symptoms, another may be tried, or one may be alternated with another to advantage. The aconite may be alternated with camphor, with great benefi 1 , in moderate cases, two or three hours apart. But in severe eases, the medicine should be repeated oftener, even every half hour. For in this stage where there is diarrhoea, aconite and camphor 15 is allowed to be the best. If the case is not arrested by some of those remedies, or others which may be used, and should hare advanced to a severe, fully formed case, as above stated, great benefit will be obtained by taking blood. The quantity should be regulated by the severity of the case, and the condition and vigor of the patient. Ten to thirty ounces have been taken with benefit. The severe symptoms will generally b© moderated or cured by this operation. But if the severe symptoms continue, and do not yield to the means used, vomiting will be of great service if the case has advanced to a more severe form, and what is termed the state of collapse, and this state often is directly formed after the attack, then a different set of remedies are required. The state of collapse, as it is termed, seems to convey an erroneous idea, and on that account it is an improper term. In the advanced or sinking state of Cholera, the vessels at or neaj the skin are diminished in their fulness, and contain less than a usual quantity of fluids, and at this time they are in a state of emptiness or collapsed; but by turning the attention to the internal and vital organs, the blood and fluids will be found there distending and clogging them up. The heart beats very feebly; the arterial action is diminished ; the pulsation at the arm is slow or imperceptible. The examinations after death have found all the internal and vital organs filled and stuffed with black blood. As far as the purposes of life are concerned, instead of being collapsed, there is distention or congestion. This state has generally been attributed to the serous portion of the blood running off by diarrhcea, and much ingenuity has been used to try to close up the mouths of the excreting vessels of the bowels to stop the running off. This course does not furnish a remedy, and is very apt to fail. Generally, we have noticed when collapse takes place, the evacuations from the stomach and bowels have been checked, or have ceased. The state of collapse, as it is termed, has by many, perhaps the majority, been considered an incurable or a fatal condition. Our experience has been very different from this, and the result of the plan of treatment herein detailed, shows the fallacy of such an opinion. When this state has taken place — with a compressible or imperceptible pulse — the face dingy or blue— the eyes sunk in — the skin cold with vomiting or spasms — the better way to proceed is to immerse the arm, to above the elbow, in a tin pan of ten or twelve quarts, or other vessel, with water as hot as it can be borne, and the patient will bear it much hotter than common warm water. The arm should be rubbed briskly. As soon as it can be, a vein should be opened, and four to six ounces of blood taken. The quantity should be 16 small. The blood, in such cases, is very thick and dark — it runs very slowly — perhaps merely trickle down the arm — but by perseverance, and keeping the arm in the water, three, four, or six ounces may be obtained. In such cases it is not easy to catch the blood in a vessel ; it is as well to let it run into the water, and to judge of the quantity and effects ; — there is very little danger of getting too much. During this period, hot and exciting applications should be made to the skin, and substances, such, as a rag wet in hot vinegar or camphor, emitting oxygen, held to the nose :but avoid wetting the face with anything ; this is always injurious, for the evaporation carries off the heat, and with it, the vital air, is diluted and rendered more impure for breathing, the heat of the face is diminished to the injury of the patient. To carry out this part of the treatment, we have stood by for half hours in succession, and when we have succeeded in carrying out our intentions, we have uniformly been compensated by the recovery of the patient. The leading object in cases of collapse, is to bring about re- action of the heart and arteries, and to introduce an increased portion of oxygen into the blood ; therefore great care should be taken to remove and keep away from the patient all articles which ma) vitiate the air, and add to it such as increases the quantity of oxygen. A cloth wet with hot vinegar and held to the nose, is one of the best for an emergency, or by pouring vinegar on a hot iron, and that held near the face, is still better ; but the face ought not to be wet; rub that with a hot, dry flannel; every other article of a diffusible, stimulating nature, except it contains oxygen, should be kept away. In addition to the use of vinegar, there are a variety of ways by which oxygen may be obtained and used to advantage ; but these agents may be better used in hospital rooms and wards devoted to such cases. Professor Brusais, of Paris, Professor Chapman, of Philadelphia, and Professor M'Naughton, of Albany, have recommended blood-letting after re-action had taken place. Should the abstraction of blood be delayed to that period, it may be expected that in the majority of cases it would forever be 100 late ; for it is the partially unloading the vessels at the heart, and giving an opportunity for the remaining blood to pass more freely through the lungs, and there to receive an increased quantity of vital air, which enables the system to re-act. In some cases of great prostration the blood is almost deprived of vitality, and it is black — or as Dr. Rush terms it, in similar conditions, "dissolved," so that it remains in the vessels unchanged by the air. 17 We have seen it when it remained like black molasses, It neither formed coagulum nor serum, nor attracted the least oxygen from the air, yet by getting vital air introduced into the Juno-s, the blood became florid, and the patient recovered. During this period, some nauseating and vorriting medicine may be used to great advantage, and those of an exciting or stimulating kind are preferable to antfmonials or pieparations of zinc ; one of the best is ipecacuanha and blood-root, equal parts, say 20 grs. of each, put to half a pint of hot water, and give a table spoonful of the infusion frequently, so as to produce gentle vomiting ; then give it in small doses to encourage sweating. In this way it is a powerful agent for this purpose. After a few. hours, if the coldness or blueness of the face continue, with other severe symptoms, more blood should be taken. We have repeated the bleeding three, four, or six times in this small way, and the patient has continued to improve. The pulse gets firmer — the' blood more florid — the breaihing becomes more free, and convalescence begins, and in nearly every case full recovery ensued. A 11 the blood that is taken had better be drawn within twentyfour hours. After those evacuations, if there is a good deal of uneasiness and pain, some medicine had better be given to sooth and quiet these symptoms, and now there is no objection to opiates. The patient often has great pain and heat of the stomach, with excessive thirst When this is the case, ice bad better be given. But it is often difficult or impossible to obtain ice. Then let the patient drink often a little cold water. It will be very orateful. It may, in part, be thrown up, but that is not an objec* tion, for it comes in contact with the initable and inflamed stomach, and thereby allays the burning heat and inflammation of the stomach. After a while, the water will be retained. Brussais states, — " That now, thank God, with great benefit, we give those patients freely of cold water." We have also given it freely, and with uniform benefit. The following case was related to the author by a medical person, who saw it: — In 1832, when the Cholera was raging with great violence in a puhlic institution, (a poor house,) there was a stout colored man, a violent maniac, confined in a cell, who took the disease. Those who had the management of the place determined, as he was a troublesome fellow, they would do nothing for him, and let him go. A benevolent attendant answered his calls for water, to allay his burning thirst, gave him a bucket full. He drank it freely, and discharged it as freely, up and down. This was used up, and another bucket of water was given him, which was disposed of in the same way. In this man. ser he cured himself. If a person attacked with Cholera, would % 18 pursue this course, instead of being subjected to medical prescriptions, composed of opiates, pepper and brandy, they would stand a much better chance for a recovery. A very great error exists in putting chloride of lime about the patient, or to have it in the room. We have seen them gasp aed struggle for breath by inhaling this poisonous gas. Chloride of lime may destroy miasma and infecting air, and kill animalculse, when spread in the gutters ; but when brought about a patient, in such a sinking condition, it has great influence to terminate human life. In the depressed stage, when the circulation is languid, and the skin coljl, heat and friction may be applied to the skin. Under proper regulations, this will be of great use. But in the state of low collapse, the rubbing ought to be used cautiously and moderately. Rough, violent rubbing, as has often been practised, may do great injury. It ought to be borne in mind, that in this condition of a patient, the blood is very much deprived of its oxygen, and the principle of life is held to the corporeal mass by a very feeble tenure, and by rough handling and rubbing, it may be expelled, besides it is not by external remedies and local agents that the main good is to be obtained. It is chiefly by the judicious use of the internal and general means here pointed out that the recovery is to be effected. It is advisable to let the patient be kept quiet, and avoid such things as may exhaust the vital property, or to use up the oxygen about it. It will be best %o apply hot, wet, exciting articles to the skin, after a while, particularly when sweating takes place. Those should be changed for dry, hot applications. Purgatives. — A great variety of drugs have been recommended and used for this purpose, and although they have been. objected to altogether, in many cases, they have been used to great advantage as they change the matter of the bowels from the watery nature to a more feculent bilious kind, which is very favorable. For this purpose, calomel has held a prominent place as a purgative. If it does not interfere with other remedies, it may do yery well. But to give calomel to be relied upon, as it has been in a great number of cases, to saturate the system with it to produce salivation, it has proved a failing and injurious remedy. A better article for a cathartic, if that is determined on, is calcined magnesia, epsom salts, and rhubaib, well mixed together, and given in water, in small and often repeated doses* 19 Or. Stevens, who practised a long time in the West Indies, and some in this country, who had great experience in such diseases, states. ** That when oxides are given by the stomach, the blood becomes more dark — and when alkalies are used, the blood is more florid." For this reason Dr. Stevens recommends aiticles containing alkalies — such as neutral salts for purgatives. If the result of his experiments are correct, there will be a serious objection to the use of mercury in such cases. Calomel is a partial oxide of mercury. It seems to be aa erroneous idea to use calomel with the intention of salivating in diseases of such rapid progress as the cholera, to expect a cure from that effect. For generally the patient dies before that caa be produced, unless the prescriber could prevail on the fell-destroyer to stay his fatal grasp some six or eight days, so as to give time to saturate the system with mercury, even if that secured a safety. But sad experience does not prove that to be the case, for where it has been used to salivate, the patients have generally died. Again, observing practitioners must have experienced that it takes longer to produce a mercurial effect on a patient affected with a congestive state than it does on one with only simple or ordinary disease. Dr. Wilson, of BeHast, says, "I cannot see on what principle calomel is used." J)r. Sterling, of England, says, " Calomel has been used in all places — yet the patients have died." Dr. Leo, of Russia, says, '' for Cholera, calomel irritates the alimentary canal, and aggravates the disep.se." Opium. — As this is a medicine which has been used very ,-much, for good or for evil effects, it is worthy of a short .examination, for we have no doubt to balance the good it may have dorae. It has caused great mischief and many deaths. When the pain ,and spasms are great at first, it seems necessary to use some means temporarily to quiet the urgent symptoms; and opiates first suggest themselves to (he mind, so as to gain a truce. But it is very injurious to continue to use opium in any considerable quantity, unless the blood vessels are first evacuated and relaxation produced. Opium, in free or continued doses, produces congestion, and those symptoms accompanying that state, and those attending a state of collapse. If blood is drawn, that effect will be in a measure prevented. Therefore, without evacuating the system, opium may, and no doubt, has rendered many, very many cases fatal. Saying nothing of alcoholic remedies, wiiibii 20 are more or less combined with it. In illustration of this part of the subject, we introduce some extracts fromThars' work on lhe trials of opium, given to persons in health, in order to ascertain its true medical properties. Some of the symptoms are : ''Stupefaction — loss of consciousness- — dullness of senses— •'confusion of intellect — eyes glistening and inflamed, sunkem, "distorted — face pale — blue, disfigured, cold — ideas cloudy, "gloomy — vertigo — head pressed in — breathing tight, heavy — & congestion in the chest — oppression of breathing, short, diffi" cult — respiration short — -slow — congestion- — sighing — constric" tion, suffocating sensation — -intermittent breathing — pulse slow, " small, -congestion in the lungs cold sweat on the face — blood '' decomposed — diarrhcei water} ." Let the reader compare these symptoms with those presented in congestive diseases, and those which occur in severe or collapsed cases of cholera-. Although in the commencement, or early stage of such severe cases ot disease it is injurious to use stimulating and highly exciting articles, and fatal if they are continued any length of time, yet in the advanced stage, when proper evacuations have been made, the inflammatory or congestive nature of the case removed, and direct debility has taken- place, typhoid symptoms are approaching, or have set in, then it will be proper and necessary, to use cordial, supporting and stimulating remedies. During the present Epidemic we have had nearly one hundred cases in the premonitory and more advanced stages. Manyof them had copious rice-watery evacuations and spasms All 1 have recovered. One case was in a state of collapse when we fiifst saw it. To illustrate the notes of this, are recorded : June 2d, 4 P. M. — M. O. N. has had diarrhoea and vomiting. about twelve hours. Now those symptoms continue of a rice watery appearance — spasms severe--skin cold — face purple — - eyes sunken — tongue very cold and blue — pulse soft and small ¦ — breathing obstructed and labored — pain of the stomach — ex. cessive thirst. Gave camphor and cold water and ice freely. — • Hot bricks were applied to the feet and legs. In four hours the vomiting ceased, and the diarrhoea lessened. In sixteen hours the other symptoms continued, and those of depression increased — - the pulse was scarcely perceptible — twelve ounces of blood was taken, which was very dark and thick — the diarrhea and spasms ceased — the pulse rose, became firmer and fuller — veratrium was given — the blueness gradually left the face and tongue — the tongue soon became warm, and a general warmth gradually returned to the skin — the breathing was more free-convaelescnce commenced — on the 4th, he was free of disease — on the sth> walked the room — on the 6th. was out doors. NATIONAL LIBRARY OF MEDICINE NLfi 02Tfl3M7T 3