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In the western and northern portions of the county, which, as also observed, are flat, the streams are more sluggish, smaller in size, less abundant in number, and dry up much earlier; the springs are also less abundant, and fail much earlier in time of drought. Many families in these parts of the county have to depend upon wells for their supplies, in which they pretty certainly procure water at the distance of thirty or forty feet. In these flat portions of the county remittents and intermittents were in former years more prevalent than in the southern and eastern parts of the county, except the particular localities on or contiguous to the low lands bordering some of the streams or watercourses. But for the last nine or ten years these forms or types of fever have been becoming less and less prevalent in all parts of our county. As far back as seventeen years, and even ten years prior to that time, our county was visited annually with bilious, remittent, and intermittent fevers; but as the country has been drained, and more of the woodland cleared and reduced to tillage, this form of disease has become less and less prevalent. I will here mention that, during the year 1835, I witnessed two cases of intermittent fever in this county, each one of so rare a type as not to be found in any modern work on the practice of medicine. They are noticed with some speciality by Alibert on Intermittents. One of the cases was the syncopal, and the other the apoplectic form of intermittent. That season was extraordinary with us for the malignant form of fever that prevailed, as both of the cases above alluded to proved fatal, and so did many of the cases of remittent, owing mainly to their congestive character.
As the above-mentioned forms of fever have been, as it were, gradually disappearing, the enteric or typhoid type has taken their place. However, this expression needs some qualification, as I cannot say that, as a general rule, the localities which were formerly most exposed to intermittents and remittents have been most severely visited with typhoid fever; for I recollect some instances in which families have suffered most seriously with enteric or typhoid, at places where they had resided for twenty or twenty-five years previously with entire exemption from intermittents and remittents. Indeed, as a general rule, I think the most hilly and best - watered sections of our county suffered most seriously during the first years of the prevalence of typhoid fever with us. But it gradually extended its area until no neighborhood can be said to be exempt from a liability to its ravages. In consonance with this change in the type of our fevers, the character of our diseases generally has changed, or I might say that a change had taken place generally in the degree of vital force, as the character of all cases of disease differs
now from former years. The change has been from the sthenic to the asthenic, as cases bear and really require the earlier resort to tonics than formerly, and of course will not bear, neither do they require, the same amount of depletion. To this general rule there are still some marked exceptions; for with us it was notorious that during the winter of 1851-2 our pneumonic diseases were so generally accompanied with a typhoid form of fever as to receive the appellation of typhoid pneumonia, and, of consequence, to bear direct depletion badly. Still, during the month of March, 1852, I met with a case of pneumonia of such severity, and with so full and hard a pulse, as to require, and tolerate as well, the very free and several times repeated abstraction of blood by the lancet, as well as the most liberal exhibition of tartrate of antimony for five or six successive days, as any case that I ever saw in my life. The patient was some fifty-five years of age, a teacher by occupation, and habitually subject to serious bronchial irritation. I am satisfied that under the influence of a less active depletory course death would have been inevitable.
I presume the change above alluded to has been general, but to what cause or causes this difference in the type of disease is attributable I cannot tell. The three years, 1850, 1851, and 1852, were unusually dry in the middle portions of the State; and the winter of 1851 and 1852 was colder than usual, as in the month of January, 1852, the mercury fell lower than at any time since January, 1832. In the former
year it fell to 18° or 20° below zero; and in January, 1852, to 8° or 10° below zero. The prevalent form of disease immediately succeeding this very low temperature of the winter of 1851-2 was typhoid or adynamic fever, with pneumonic complication, which was quite fatal in some of the adjoining counties, but was not attended with much fatality in this vicinity. I think the colored population suffered more, in proportion to numbers, than the white. During the months of February and March pneumonia typhoides was quite prevalent. During April and May whooping-cough was quite prevalent, with some rubeola, with still an occasional case of typhoid fever. A few cases of dysentery occurred as early as March, but it did not assume the character of an epidemic form until the latter part of June, and then did not embrace the whole limits of the county, but prevailed to a fearful extent in the south-eastern, southern, and south-western parts of the county, and to some extent all over the county. I have no means of ascertaining the number of cases that occurred in the county, or the number of deaths from it, but the latter must have swelled to several hundred. It became the prevailing form of disease through the summer and autumn, even as late as the cold weather of November. Although dysentery was the prevailing epidemic, yet the different types of fever were seen also, as I saw in the same family, and at the same time, dysentery, typhoid and intermittent fevers; and during the same period, and within a mile of that place, I saw in another family well marked bilious, remittent, and congestive intermittent. With the majority of our cases of fever there was great tendency to excessive action of the bowels, and in other cases of full development of all the symptoms of typhoid fever, we had as an accompaniment well-marked dysenteric irritation. These were the worst cases, and nearly all of them ended fatally. The sections of the county in which dysentery was most prevalent included the most broken or hilly parts of the county, and of course the portions best supplied with springs and free running streams. A few families in the level sections of the county suffered with dysentery severely, but its prevalence there did not become general.
The symptoms, as I witnessed the disease, did not differ much from those enumerated by authors, or from what I have witnessed in former years. Many of the cases commenced with diarrhoea, which, after a few hours' continuance, was succeeded by tormina and tenesmus, with abdominal tenderness, sometimes general, but more frequently to a greater extent in the left iliac region, with very frequent mucous and mucosanguinated discharges. A peculiarity that I frequently witnessed was, that the evacuations were more copious, and more sanguineous than I had heretofore observed them. In mild cases there was but little disturbance of the circulation, but in the more violent the pulse was corded and tense, generally of little volume, and ranging from 110 to 140, according to age, sex, temperament, etc. With many there was a white furred tongue, with red edges, which soon became dry, with considerable thirst and restlessness. Some cases were attended with general hot skin, others with heat only partially diffused, others with but slight elevation of temperature. In some of the cases the alvine evacuations were different from any that I have seen heretofore, viz., resembling somewhat new or fresh cider, or cider and water. This was the worst form of the disease.
TREATMENT.-Regarding it as settled that dysentery was an inflammatory disease, and finding the symptoms generally, I may say universally present in all serious cases that are attendant upon inflammation, I regarded it as inflammation of a greater or less extent of the mucous membrane of the bowels. Entertaining this view of its pathology, I did not hesitate to use the lancet freely when called early to a case, unless the general prostration utterly forbade it; and whenever I met with
cases requiring it, and the other circumstances present admitting its use, I always found a marked mitigation of the symptoms ensue, especially if the bleeding was carried to approaching or complete syncope. In some cases I used the lancet the second time, and I am certain that I have no cause to regret its free and timely use; but on the other side I could not say as much. After the abstraction of blood by the lancet, I frequently applied cups over the tender portions of the abdomen. This application in two or three days I would follow with a larger vesication, and this with emollient poultices. If the evacuations had been free, we gave early anodynes very liberally, with or without mercurials, being governed by the state of the hepatic secretion, as I saw cases where the liver performed its function with tolerable regularity throughout the disease. Under these circumstances I could make no calculation upon
beneficial results from mercurials. I gave morphia in combination with ipecac and acetate of lead, or half-a grain of sulph. cupri instead of acetate of lead; in others tannin as the astringent; and anodyne enemas, or, what we found to allay the tormina and tenesmus much better, opiate suppositories, containing five or six grains each, with the free administration of mucilaginous drinks; and as soon as the violence of the disease was somewhat abated, I used very generally the ol. terebinth, in doses from six to ten grains every three hours, in the form of an emulsion. This remedy appeared to aid in overcoming the disease of the mucous membrane, as well as aid in supporting or sustaining nervous energy.
And some support of this kind was evidently necessary, as numerous deaths occurred from very sudden and entirely unexpected prostration. In cases of a protracted character I frequently, during the latter part of the second week or beginning of the third, resorted to a few one-grain doses of sulph. quinine, and in other cases combined pul. camphor with the anodyne, astringent and diaphoretic medicines being administered. These articles appeared to exert a salutary influence in maintaining the tone of the system. There was one particular noticed by myself, as well as others, in reference to the dysentery of the last season, viz., our patient bore, and actually required, a larger amount of opiates, whether morphia, opium, or tinct. opii was given, than I have ever seen in any other epidemic of this disease. Less than from six to ten grains of opium, distributed through the twenty-four hours, in addition to the constant use of opiate suppositories, would not make any apparent impression on the disease; and as much as two grains of acet. of morphia, and in addition an opiate suppository, were sometimes administered at once.
I heard it remarked by one of our oldest and most respectable physicians, that if he had done any good in the disease, it was by the lancet, and very
liberal use of anodynes. Some adopted the theory of congestion in the portal circle; they, I think, depended too much upon the mercurial treatment. Others, falling in with a popular prejudice, proscribed mercurials entirely. Both, as I think, were in error. The exhibition of mercurials, with sanguine expectation of relief, was not, I think, wise, when many severe cases of dysentery existed without suspension of the biliary secretion. And on the other hand, with the universally acknowledged importance of the hepatic function to a healthy equilibrium between the different organs and functions, to proscribe or even omit the only class of remedies capable of a specific and certain excitation of this important function was equally unwise, especially as it was manifestly deficient in many cases.
Whenever I found this deficient action existing, I gave every second night from ten to twenty grains calomel, with two, three, or four grains of opium, or its equivalent in morphia, with as much ipecac as could be borne without vomiting, and the free bilious evacuations which would pass off in fifteen or eighteen hours were generally followed by a brief abatement of the dysenteric irritation. Aqua camphoræ, with acid nitric and tinct. opii., in the form of Hope's camphor mixture, answered well in many cases during convalescence. The duration varied from two to four days to as many weeks.
I may remark in reference to the use of enemas of different character, that I used quite a variety of astringents, such as sol. of tannin, sol. of acetate of lead, of sulphate of zinc and of copper, nitras argenti, logwood, sol. of the extract, mucilaginous, and anodyne, and I am not satisfied that any good resulted from any of them, or from all combined; for the tenesmus and irritability of the rectum was so intense that it was rare for any of them to be retained long enough to accomplish any good; hence opiate suppositories were more applicable. I will here remark, in conclusion, of the treatment, that from previous observations extending through the last five years, of cases of dysentery, I indulged no sanguine anticipations of benefit from mercurials, as I had observed their effects closely, and seen but little benefit resulting in the last four or five years from them, much less than in previous years.
I cannot say that the epidemic was influenced in its prevalence by atmospheric changes. The greater part of the time of its prevalence the weather was moderately warm and very dry; but as autumn advanced the weather became cooler, and the season quite wet: still the epidemic did not appear to be checked by the change. I do not think it could have been owing to geological formation, as it prevailed in every variety of locality, but most in the hilly portions of the county. I have no conjecture to offer as to what cause gave rise to it, or what particular