PREMONITORY SYMPTOMS.

"In general it has been found that slight oppression of the breathing, with a soft and somewhat accelerated pulse, a degree of mental depression and inaction, anxiety of countenance, giddiness and some muscular debility are the earliest indications of the disease; the abdomen almost invariably feels distended, and is affected with slight transient pains; the urine is scanty and pale. These symptoms are usually followed by a moderate diarrhoea, the discharges being natural, consisting of the usual ingesta: the character of the discharges, however, (if the diarrhoea continues long enough uninterrupted by other violent symptoms,) gradually changes; and they have, in some instances, assumed precisely the choleric character before any vomiting, cramp, or collapse had unequivocally declared the nature of the disease. Two other symptoms remain to be mentioned, which are of very frequent occurrence, and which, in conjunction with those previously noticed, may be considered almost diagnostic. We allude to slight cramps affecting the fingers and toes, or prevailing still more generally, and coming on during the night; and to a numbness, and feeling of inability to move the limbs, approaching to paralysis; it is not a real inability, as a strong effort is sufficient to dispel the illusion. But the sensation recurs; and it is fortunate for the patient if it create sufficient alarm to induce him to seek, without delay, medical assistance.

After the duration of the premonitory symptoms for a period varying from a few hours to as many days, the disease manifests itself in a manner which, once witnessed, can never be forgotten."

The stage alluded to is that of collapse, of which we need not repeat the portrait. Of the treatment, too, we need not speak, since the subsequent experience has shewn the inefficiency of almost every remedy enumerated by our authors. The same experience, indeed, has proved that many of them are not merely inefficient, but that they are actually injurious. We mean the large and repeated doses of stimulants.

For

In respect to the mode of propagation, our authors are contagionists of the very first class of the brightest water. although many of our stanchest advocates for that doctrine have acknowledged that the laws of choleric contagion were obscure, while others of them have lowered the de

gree of contagion almost to minim, yet Messrs. Haslewood and Mordey see nothing but contagion, and that as plainly working as one of the steam engines in a Sunderland colliery!

"From the facts above stated, which in conformity with the great preponderance of testimony from the Continent, and especially with that contained in the very interesting letters of Dr. Becker, concerning the facts observed at Berlin, we can no longer doubt that the disease propagates itself in strict accordance with the known laws of contagion.

This view of the subject suggests at once the necessity of precautions being used to stop the progress of the malady."

Thus, it only wanted the cordons, the red crosses, the total seclusion and sequestration of the sick at Sunderland, to stop the epidemic! God help you, good easy gentle

men! Ye have been at least twelve months too late in publishing.

II. DR. KEIR (OF Moscow) ON CHOLERA. THIS gentleman, who has grown gray in the practice of his profession, and who is also a contagionist, is very far from being so po3itive in his opinions as our brethren of Sunderland above-mentioned. The following extract is interesting.

"Although some of the medical men of this city are of opinion that cases of this epidemic had begun to appear as early as August, still no case of the disease, as far as I have been able to learn, came to the knowledge of the medical police, or was recognized as Cholera, till the evening of the 14th, (26th) September, when Demetry Michaeleff, a doorkeeper, residing in the quarter of the city called the Sretinka, near an open canal, which was under repair, and being covered over this last Autumn, 1830,

was attacked with it. The ground through which this canal runs is apparently for some depth a black loam, and though open for a considerable space in the neighbourhood of the doorkeeper's dwelling, has for many years past been a waste, on both sides of the canal, not unfrequenlty boggy, and a receptacle for the impurities of the neighbourhood. The water running through this canal empties itself into the river of Moscow at the distance of about nearly three versts from the doorkeeper's dwelling, and the ground rises gradually by a considerable acclivity from this water-course on either side of the canal, in nearly an easterly and westerly direction, till it is intersected by the Sretinka street on the east, and the Tverskaia on the west, both situated at a considerable elevation above the level of the canal, and in the most elevated ground in Moscow.

I have been thus particular in describing these localities, because here one of the first, if not the first case of the disease was met with, and because it was in the hospital attached to this quarter, of which I was inspector, that I had my principal experience of the disease."

"After an interval of a few days the disease began to shew itself in different parts of the town, at a considerable distance from the doorkeeper's dwelling, and without there being any suspicion of communication between him and others affected by it. It now became more widely extended, and proceeding with rapid strides affected persons of all ages and constitutions, from five to above seventy, but more particularly the lower classes from fifteen to sixty."

The following is Dr. Keir's very moderate creed.

"At the same time that I admit the communication of the disease from one person to another, under particular circumstances, as in the wards of an hospital, or in a small ill ventilated room, and a fortiori, if other depressing causes are at the same time in action, and while I think it probable that it was imported to Moscow either from Nijney Novogorod, or Saratoff, still it must be granted, that the agency of an epidemic

"To have produced it, some very widely extended cause must have been in action; what that cause may have been, or how produced, I know not; but judging by its effects, and the character of the disease, it seems to be a poisonous agent or miasm, possessed of considerable specific gravity, by which it is disposed to lodge more particularly in the lower strata of the atmosphere, perhaps proceeding from the bowels of the earth; hence one reason of its tendency to affect more especially those who live on rivers and canals, in low situations, cellars, ground floors, &c."

From the source in question we cannot expect any interesting information on the subject of treatment. Dr. K. is an advocate for mercury in the epidemic cholera.

III. MR. MORRAH ON SULPHATE OF COPper. THIS gentleman, who we know to be a very intelligent practitioner, was induced to try the sulphate of copper, in a scruple dose to a cholera patient. It remained a quarter of an hour on the stomach, and then acted. After its operation was over, the skin became warmer, the pulse more distinct, and the spasms mitigated. Two grains of calomel and a table-spoonful of beef-tea were given every half hour. At night three drops of croton oil, which acted on the bowels, and appeared to improve the secretions. The patient slowly recovered. Some other successful cases are related by Morrah in the Medical Gazette.

IV. DR. TWEEDIE ON CHOLERA. In the Medical Gazette Dr. Tweedie remarks that in his opinion the epidemic may

be stopped at any period anterior to collapse by efficient doses of opium. He properly observes that some secretions are more easily stopped than others-that the biliary secretion will be impeded by a dose of opium, which will have little or no effect on diarrhoea-"but that if a sufficient dose be given to stop every secretion, there has not, so far as he has witnessed, been any but the happiest result from it." Dr. T. observes that there is no necessity for giving aperients for a day or two after the diarrhoea is checked, as the bowels will generally act spontaneously, if let alone. In the stage of collapse he has seen no remedy that deserves especial praise. "The saline treatment has increased involuntary purging, and done harm; or the powders have been immediately vomited, and did no good." Excessive opiates have quieted the sufferings, but have done.no good. Stimulants, in excess, have appeared injurious. In moderation, "they are not injurious." The few who have recovered from collapse, have done so under frequent doses of calomel, with or without small doses of opium, according to the degree of purging, &c. Cold water or other cold drink is allowed ad libitum, and its repeated rejection is no objection.

MR. STEWARD.

The above gentleman, who had charge of the Droitwich Lunatic Asylum, administered brisk doses of tartrite of antimony (three grains) till the stomach became quiet, which it usually did, and afterwards, the same quantity of the tartrite, with one grain of opium every hour. "In no case thus treated from the commencement, did the sickness rest beyond four doses." Very often both the vomiting and purging ceased; but where the latter continued, rhubarb and magnesia with laudanum were given, followed by calomel and capsicum.

In the Lancashire Lunatic Asylum, the medical officers have combined the saline treatment of Dr. Stevens with the cold water of Dr. Shute, and the mercurial treatment of the India practitioners, with success, according to their statements. Mr. Lang

ford, of one of the Manchester Cholera Hospitals, has practised the antimonial treatment, on the principle of inducing the tolerance of the medicine.

DR. AYRE.

This intelligent physician boasts, and we hope with reason, of the "eminently successful practice" which he has pursued in cholera-all the cases being treated on the same plan, and all by one remedy. Our readers are aware that Dr. Ayre pursued the mercurial practice, and he now offers to prove his success under the inspection of any competent commission.

MR. HICKMAN.

This gentleman, who had served several years, and treated cholera on a large scale there, has addressed the Central Board of Health, stating his conviction that "all our hardly-earned pathological, physiological, anatomical, and therapeutic experience, has been laid aside, in order to seek for new modi medendi, which have been blazoned forth to the public only to suffer defeatnay, more, have by their failure increased the dread, and aggravated unnecessarily the feelings of the public respecting this vampire in the shape of disease." Mr. H. then gives a brief outline of his own mode of treatment, which we transcribe from the Lancet.

"1st. When in the form of bilious diarrhoa:-In this stage, avoiding as much as possible all known lædentia, and employing, in an equal degree, all known juvantia. I have trusted entirely to the conf. opi in doses gr. xxxvj. in aquæ pimenta 3j. to adults, repeated at well-timed intervals, watching the patient attentively. The suc cess attendant on this treatment has been most signal.

2d. In that of rice-water evacuations:In conjunction with the above, I have employed doses of calomel and camphor, gr. iij. of each in the form of a powder.

3d. In the stage of collapse:-Here I have relied (cæteris paribus) entirely on full doses (j.) of calomel, with moderate quantities (gr. j. or gr. 4) of opium, mercurial

inunction and calomel and camphor gr. iij. of each every half hour, or every second, or every third hour, combining with each powder as reaction became established one grain of pulvis calumbæ, which I consider highly valuable."

Mr. Hickman protests against the employment of a farrago of medicines, poured into a stomach, already highly irritable, with deadly and empirical velocity.

V. MESSRS. TWEEDIE AND GASELEE ON CHOLERA.

THESE gentlemen have written a joint pamphlet on the epidemic, which is deserving of attention. Mr. Tweedie having been resident medical officer in the cholera hospital, in Abchurch-lane, has had ample opportunities of studying the disease, and observing the effects-therefore his remarks are valuable. The authors are ultra-con tagionists-their belief is as deep as the ocean, and, if they had been Romans or Neapolitans, they would have believed in the liquefaction of the blood of Januarius much more firmly than in their own existence. But we shall pass over this part of the subject, and see how this deep and solemn faith in contagion tallies with the "precautions" which our authors recommend against catching the disease. Respecting "protecting belts, anticholera medicines, spells, charms, and bags to dispel infection," our authors seem doubtful whether they are useful or injurious; but

"The only precautionary measures which we would recommend, are temperance, cleanliness, and avoiding, as much as is consistent with duty, unnecessary exposure to those who are diseased."

ceded by an irritable condition of the bowels or actual diarrhoea, varying in its intensity and duration from one hour, to two, three or more days; occasionally even a longer period; prior to which anomalous feelings may have been experienced in the abdomen, especially a griping pain in the epigastric and umbilical regions; and a state of constipation may even have pre-existed, but frequently mere diarrhoea is present, and the ease with which the bowels are evacuated, and the freedom from all pain, deludes the victim into a belief that his ailments do not require attention, and that 'all will soon be right.' Occasionally the complaints first attract notice, from nausea and sickness coming on, and in other cases the patient experiences, at first, an acute attack of pain, either in the stomach or colon, or is seized (though more rarely) with cramps in the extremities. The diarrhoea, in some instances, is soon followed by vomiting; in others, they both commence together. It is in these early stages that the complaint is certainly remediable under judicious treatment, variously adapted to the form of attack, the length of time which it may have existed, the rapidity of the progress which it has already made, and the condition and powers of the patient."

The authors divide the treatment of the premonitory symptoms into three parts— that necessary for the tormina-the feculent diarrhoea-and the serous diarrhoea. For the first, a proper evacuation of the bowels, followed by carminatives and anodynes, is sufficient. For the feculent diarrhoea, the same remedies will generally apply as if the epidemic did not exist, except that greater attention is necessary to check the disease in due time. An emetic is often useful in this stage, after which, opiates and astringents will usually be proper; though the retention of vitiated secretions will often require warm, but efficient purgatives, combined with, or quickly followed by, light anodynes. Many cases, however,

"The disease, as it has occurred to us in this metropolis, is almost invariably preVOL. XVIII. No. 35.

must be stopped as quickly as possible, without regard to bad secretions, since the danger of collapse, by draining off the fluid 24

and saline parts of the blood, is greater than any other danger. Opium, of course, is the sheet anchor in such cases. The authors of the volume before us give two grains to an adult, in the form of pill, for the first dose, and half a grain after every motion, till the discharges are restrained. Sometimes they combined a few grains of calomel with the first dose, but are not certain whether it added to the benefits of the opium alone. The purging being stopped, there is no need of soon opening the bowels again. A couple of days may be allowed.

When the serous diarrhoea has become associated with cramps and sickness, the most decisive treatment is necessary, in order to prevent collapse.

"To stop the discharges and stimulate the flagging powers, are now the immediate indications, and any means which risk the continuance of the purging are less preferable in proportion to the degree of such hazard. It has been said that the object is to stop the discharges, and nothing will effect this more, nay, so speedily, as opium in full and efficient doses.

The patient should be placed in bed between warm blankets and two grains of opium given, and followed immediately by a draught of the following nature:

Sp. myrist. vel. sp. junip. comp.
Sp. ammon, aromat

Vin. opii.

Misce.

3x.

ōj. mxx.

It is hardly necessary to remark, that the "saline treatment" of Dr. Stevens is regarded by our authors as unnecessary in the early stage, and inefficient in the collapse of cholera. Under the head of collapse, our authors make many sensible and modest observations. They deplore the conflicting opinions and practices which have been published and urged, to the manifest injury of the medical profession. They justly observe, that too much is usually attempted in the stage of collapse. "Remedy has followed remedy, and dose has accumulated upon dose, in a manner more creditable to a sense of anxiety for the sick, than was consistent with sound professional judg

ment."

"In natural recovery from collapse, the warmth gradually returns to the features and extremities, the vomiting ceases, the purging diminishes, the cramps subside, the circulation is restored, the secretions of health return, and the individual gets well, sometimes immediately, and at others with the interruption of consecutive symptoms.

The design of medicine should obviously be to bring about these very desirable results. The indications of cure are at once simple and manifest, and not the less cer tain because human art is in a majority of instances totally incompetent to accomplish them. The indications of cure are simple, so ought to be the measures adopted to fulfil them; the only difficulty is to know what are the best means by which this is to be done. It is very far from our inclination to attempt to solve this knotty problem. We do not venture to affirm, that such and such only is the 'sine quâ non' of treatment; our sole object and desire being freely and