ITS NON-AERATION--NON-OXYDATION.
In the preceding section we alluded to the suggestions and doctrines
advanced by the learned Dr. C. W. Bell, Physician to the Manchester
Infirmary, and late Physician to H. M. Embassy in Persia--and also
to Dr. George Johnson, of Kings College, whose views and doctrines,
relative to the Pathology, illustrative of the congestive character
and non-aeration of the blood, coincide with those of Dr. Bell. A
brief examination of their philosophy and doctrines will show very
conclusively the first direct impression of the poison--the gradually
altered condition of the blood, and the corresponding loss of nerve
power--the impeded arterial circulation and the general tendency to
congestion, as well as the altered condition and stagnation of the
blood, especially during the stage of collapse.
The question is asked, "What is the pathological explanation of this
remarkable train of symptoms?" and the answer is given, "The one great
central fact is this, that during the stage of collapse, the passage of
blood through the lungs, from the right to the left side of the heart,
is in a greater or less degree impeded." Very conclusive evidence as to
the existence of impeded pulmonary circulation during life is afforded
by the appearances observed in the heart, blood-vessels, and lungs
after death.
After adducing the evidence of this impediment from _post-mortem_
examinations, and affirming that the blood does not flow freely
through the lungs and pulmonary arteries, which are often filled and
much distended with blood, it is observed--"The most interesting and
conclusive evidence that arrest of blood in the lungs is the true key
to the pathology of choleraic collapse, is to be found in the simple
yet complete explanation which it affords of all the most striking
chemical phenomena of the disease, the imperfect aeration of the
blood, and the suppression of bile and urine."
And again, says the learned author, "It is obvious that the stream of
blood from the pulmonary capillaries to the left side of the heart
is the channel by which the supply of oxygen is introduced into the
system. One necessary consequence, then, of a great diminution in the
volume of blood transmitted to the left side of the heart must be,
that the supply of oxygen is lessened in a corresponding degree. This
position, probably, will not be disputed by any one who will give the
subject a moment's consideration. Nor, again, can it be denied or
doubted that certain results must of necessity follow this limited
supply of oxygen." * * *
"The blood in cholera is black and thick only during the stage of
collapse; in other words, during the stage of pulmonary obstruction and
defective aeration."
Again, in his explanation of the injection of the solution of soda
into the veins of the suffering patient, it is affirmed, "The benefit,
however, is of but short duration, for the primary cause of the
impeded circulation, namely, the poisoned condition of the blood,
being still in operation, * * * the stream of blood through the lungs
will soon again be obstructed, and the patient thus passes into a
state of collapse as profound as, and more hopeless than, before. It
appears, therefore, that the hot saline injection into the veins and
the operation of venesection, when it rapidly relieves, as it often has
done, the symptoms of collapse, have this effect in common, that they
facilitate the passage of the blood through the lungs, and thus lessen
that embarrassment of the pulmonary circulation which is the essential
cause of choleraic collapse. But whereas the _hot injections act_ by
removing the impediment which results from spasmodic contraction of the
arteries; _venesection acts_ by relieving over-distension of the right
cavities of the heart, and thus increasing the contractile power of
their walls."
Such are, in brief, the views of the learned Drs. Johnson and Bell,
whose works are very highly commended by their American editor to
the notice of the profession. These views, coming as they do from
the highest authority, fully sustain the doctrine that the earliest
impression of the disease is made upon the blood, and hence it becomes
altered and changed in its most essential life-sustaining principle;
for its oxygen becomes diminished, its consistency augmented, and its
flow through the lungs impeded. Through this channel the effect of
the poison soon makes an impression on the ganglionic mechanism, and
the nerve-power becomes correspondingly diminished, and the action
of the ganglionic nerves essentially deranged. But this is not all:
they exhibit in the clearest manner the congestive character of the
disease, and show the necessity of prompt and decided means to arrest
this tendency. Hence, they urge, in the strongest terms, the importance
of observing carefully this essential feature, and endeavor to exhibit
fully the condition of this vital fluid at a particular stage of
the disease, when bleeding, as recommended in their practice, is
required, and may be performed to the best advantage for the relief
of the partially congested blood-vessels, and to stimulate and give
freedom to the circulation. The passage of the blood, they affirm, is
impeded, clogged, and partially suspended. To remove this obstruction,
relieve spasm, and secure the prompt aeration of the blood, in hope
of arresting the progress of this disease, is ostensibly the object.
However, they seem studiously to avoid the most logical conclusions of
their explanations, and justify a practice that can give no hope of
permanent relief, while every fact and symptom is ominously suggestive
of the wants of the system, which imperiously demands the aid of
electrified oxygen, ozone, or free caloric, for the oxydation of the
blood.
Says Dr. Reid, "I believe the true explanation of the arrest of blood
in the lungs to be this: The blood contains a poison, whose irritant
action upon the muscular tissue is shown by the painful cramps which it
occasions. The blood thus poisoned excites contraction of the muscular
walls of the minute pulmonary arteries, the effect of which is to
diminish, and, in fatal cases, entirely to arrest the flow of blood
through the lungs."
Says Dr. Wallis, "The phenomena which are exhibited when the
deleterious air has been drawn into the lungs are these: the great
gastro-pulmonary nerve is either wholly or partially paralyzed; the
consequences are the cessation of all its functions, either wholly or
partially. This great nerve is a nerve of function, and performs the
functions of digestion and respiration, and influences all secretions."
Dr. Maxwell, of Calcutta, uses the following language: "The development
of the stages of fever entirely depends on the changes the _leaven
has effected_. If this change has been such that the blood has become
too thick to flow through the lungs, then, as a matter of course,
the collapse stage is developed in excess; in other words, _cholera
asphyxia_ is exhibited. The blood, unable to pass through the middle
passage into the arteries, collects and swells out the veins, giving
that deadly or blue color to the skin. When the vomiting and spasms
come on, this mass of blood in the veins is squeezed with great force,
and hence the clammy moisture that is forced from every part during
these fits. There is no pulse, because there is no blood in the
arteries." "There are also lethargy and languor, and oppression in
breathing, caused by the blood being collected in the veins. These make
up the principal links in the chain of mechanical symptoms."
Dr. Bell, dwelling on this congestive character of the blood, and
endeavoring to point out the best mode of relief, observes, "When this
has reached to such a point as to oppress the action of the heart,
yawning first and then shivering, or a sense of suffocation and pain
in the precordia, are the indications of oppressed circulation, and
of the commencing effort of the heart to overcome the mass of blood
which is stifling it. If, by the application of tourniquets to the
limbs, or by _bleeding_, part of the blood which is rushing from the
extremities to increase this congestion is prevented from reaching the
great veins, the heart, excited to increased action, is enabled, by
this relief, more quickly to overcome the obstruction and restore the
balance of the circulation, and the paroxysm passes off. If not thus
mechanically aided, the heart, after a severe struggle to maintain the
circulation during the period of constriction, is at length relieved
by this nervous disturbance or spasm of the capillary circulation
passing off of itself, and then the heart and arteries, so long excited
by the struggle, maintain for a time their increased action after
the obstruction in the capillaries is removed, and produce apparent
febrile action. Presently this excitement subsides, the vessels become
relaxed, and sweat succeeds. The vessels continue in this state for
a longer or shorter period, according to circumstances, till they at
length recover their ordinary tone and action in the intermission. This
fever, however, is not fever properly so called, but reaction; and the
sweating not critical, or essential, but relaxation. The cold stage
is alone essential, and is the physiological cause of the subsequent
stages."
From the passages we have cited, it is quite evident that Drs. Johnson,
Bell, Parkes, Reid, Wallis, Maxwell, Massy, and many others, admit this
congestive character and impeded circulation of the blood to be the
result, or consequent of a primary affection of the blood, as we have
already observed in a former paper. The _term_ "Algide" is peculiarly
expressive of the diminished animal heat, and, as Dr. Bell represents,
it is the cold stage which is alone essential, and is the physiological
cause of the subsequent stages. It is the specific disease-poison, so
often referred to, that has been inhaled, the leaven that has effected
such obvious changes in the blood. The poison, virulent, and subtle,
and unknown, so marvelously active in its operations, that is exhibited
so prominently in all the works we have perused as the one great,
mysterious, and efficient cause which produces the disease called
cholera, and all the phenomena of its development. To its direct and
specific action, therefore, must be attributed all the phenomena of
the disease as the resulting subsequent consequences.
It is also further evident, from the pathological facts and arguments
adduced in support of this theory of congestion, that the abnormal
condition or state of the blood-vessels is the result and the product
of the activity of the primary or final cause, and must be regarded
in relation to it as cause and effect. On this principle alone, the
thickening of the blood, the contraction of the left ventricle of the
heart, and of the capillary and pulmonary arteries, assigned by some as
the cause of choleraic collapse, must be accounted for. These effects
are not and cannot be from a process independent and outside of the
primary disease action, but are the result of such primary action.
Again, it is evident, from the views and doctrines cited above, that
the disease is decidedly congestive in its tendency and character from
its very commencement. The impeded flow of the blood--the comparative
emptiness of the left ventricle of the heart and arteries--and
the excessive loss of temperature, all indicate a rapid process of
congestion attending the progress of disease. This is one of the
peculiar and prominent features of cholera, and is strikingly exhibited
in the morbid appearances observed in all those instances where death
has occurred within a few minutes from the first indications of attack.
When the attack is violent, the process is rapid; when mild, it is
slow; and even in the collapse stage progresses tardily. In either case
it is the direct resulting consequent of the primary cause. How else
can the violent attacks, suddenly terminating in death, be accounted
for? To what other principle can this altered condition and stagnation
of the blood be attributed? The evidence confirmatory of this position
is abundant and conclusive. Many instances of the apparently rapid
action of the cholera poison are related by Dr. Milroy, in a historical
sketch of the epidemic of 1817; and at Kurrachee in 1855 and 6, it is
said, that within little more than five minutes, hale and hearty men
are seized, cramped, collapsed, and dead!!
When the disease broke out at Teheran, in May, 1846, Dr. Milroy states
that those who were attacked dropped suddenly down in a state of
lethargy, and at the end of two or three hours expired, without any
convulsions or vomitings, but from a complete stagnation of the blood.
In the paper before us, it is stated, that "in a great majority of
cases in which death has occurred during the stage of collapse, the
right side of the heart and the pulmonary arteries are filled, and
sometimes distended with blood; the auricle being partially, and the
ventricle completely and firmly contracted. The tissue of the lungs is,
in most cases, of pale color, dense in texture, and contains less than
the usual amount of blood and air. There is something surprising in
the contrast between the almost constant occurrence of this extremely
anæmic condition of the lung, from which scarcely even a few drops
of blood flow when the tissue is cut, and the hyperæmia of most
of the other viscera." This impeded flow of the blood through the
lungs, resulting, as it must, in a very scanty supply of blood to the
arteries, in connection with the corresponding fact of the increased
expansion of the veins, filled with black, and thick, and stagnant
blood which, by the action of a powerful poison, or malignant disease,
has become disorganized and unfitted for circulation, furnishes
indubitable evidence of one prominent and characteristic feature of
cholera which we term congestion, and to which we alluded in our
remarks when the question under consideration was first introduced;
in this view we are happy to find ourselves, on a more thorough
examination of the subject, ably sustained by eminent pathologists
and authors, who have arisen during the half century last past, and
whose works are said to embrace all that is known and reliable on the
character and treatment of Epidemic Cholera.
It is worthy of notice, before passing from this part of our subject,
that according to Dr. Bell's _views_, the blood is forcibly sent into
the great central veins, and there stopped in its course without any
attempt to account satisfactorily for its singular arrest, at that
point--Dr. Johnson comes to his relief, lifts the veil, and explains
why it is kept there and cannot get any further. If the road, he tells
us, had been clear and uninterrupted through the lungs, the blood would
easily have got round to the left ventricle, and have again gone its
round, but it is stopped by the spasmodic contraction of the minute
branches of the pulmonary artery, which will not even allow the blood
to enter the pulmonary capillaries, as shown by the remarkable anæmia
of the texture of the lungs.
In this connection may be introduced an opinion as to the cause of
the disease and some of its phenomena, which has obtained at least
some celebrity, and attracted the attention, if not the careful
consideration of the profession. It will account, in part, if founded
in fact, for the physiological condition under consideration.
It is said, some have observed a chemical change in the constitution
of the atmosphere, and have attributed the cause of the cholera to
the loss or diminution of its ozone--a principle which is understood
to represent what is very properly termed electrified oxygen. Ozone
is, therefore, the vital element of the air. It is said that oxygen
cannot be assimilated or combined with the blood except when it is
in an electrified state constituting the peculiar property or state
of ozone. In this state it produces vital electricity of the blood,
_which is the life_. The brain is considered and represented as the
reservoir of this vital electricity, and the nerves are the telegraphic
wires or conductors of it. As a necessary consequence, all acts of
material and intellectual life depend upon this double cause. The
absence, then, it is affirmed, of this principle, termed ozone--or
electrified oxygen--from the atmospheric air in certain localities
and the consequent non-aeration or non-oxydation of the blood, may be
considered as an efficient cause which will account for some of the
most striking phenomena of the cholera.
Whether this electrified oxygen, or ozone, is identical with free
caloric, it is unnecessary for our purpose at present to determine. It
will be admitted that oxygen is the source of animal heat, and when
introduced into the system generates its free caloric, which is an
essential life-sustaining principle.
Dr. Massy, after describing a severe and advanced stage of cholera,
observes, "The treatment of this case depends in the first instance
on bleeding, and largely, if the patient's pulse is good, giving at
the same time twenty grains of calomel with one of opium. This, he
thinks, will be found the best practice. After twenty minutes, he gives
ten grains more of calomel and half a grain of opium. He considers,
however, a reliance on opium in this form of cholera most faulty--but
observes, as you draw blood, stimulate, give punch, brandy, or wine
and water, or carbonate of ammonia. Apply friction, with stimulating
and hot liniments to the extremities, warm sand-bags to the feet,
sinapisms to the calves of the legs and pit of the stomach; for, if
you can once raise the pulse, the chances in favor of recovery will be
vastly increased." The practice of bleeding and stimulating at the same
time is deemed of vast importance. Dr. Bell coincides in this view, and
devotes much space to the necessary instruction as to the time when and
under what circumstances to bleed and to what extent, endeavoring to
show the advantages arising from a strict observance of certain rules
in carrying out this practice.
We have thus traced, _in extenso_, the views and doctrines of eminent
surgeons and authors on the changes of the blood, and especially of
the impeded circulation, to show, if practicable, the inconsistency of
the more common and prevailing practice, and its utter inadaptation
to the pathology and phenomena of disease. On the latter there seems
to be little or no discrepancy--on the former there is a great
diversity--as there has been no general principle established and
laid down as the basis of treatment and cure of cholera. It has
often been observed there is no disease on which so many different
modes of practice have prevailed, some purely experimental, others
empirical--and all without discovering an antidote to the poison, or
any efficient mode of relief. The cause, or the poison producing the
disease, still remains undiscovered. The direct mode of suspending
and removing it, or counteracting its power and neutralizing its
effect, and subsequently eliminating _it_ from the system, remains
still in doubt. What course, then, should the epidemic cholera again
prevail in our midst, shall we pursue? Shall we rest satisfied with
the diversified modes of treatment now prevailing? Or guided by the
light of reason, science and experience, endeavor to adopt a general
principle of practice, and exhibit and establish an efficient and
judicious system, consistent with the pathology and the phenomena of
the disease? Does then the practice, the prominent features of which
are given above, accord with the indications required? In short, does
the exhibition of bleeding and calomel and opium, accompanied with
sinapisms, and hot, stimulating applications to the surface, meet
the pathological condition and the phenomena of the disease? We have
seen that the rapid changes in the blood, and the consequent direct
tendency to congestion, are the proper and distinguishing features of
the disease;--and hence the diminution of animal heat and general loss
of temperature and their consequent effect, impeding the circulation,
depressing and prostrating the nervous power--impairing and paralyzing
the respiratory organs--suspending the functions of the liver and
kidneys--enfeebling the action of the heart, and causing the capillary
vessels of the mucous surfaces to pour off the serous fluid from the
blood, and every muscle and tissue of the system with great rapidity,
essentially constitute the phenomena of the cholera;--and that the
constantly increasing augmentation of the poison and its intensified
effects, measure the malignity, the violence, and the rapidity of the
disease. Is there, then, any tendency in bleeding to arrest this rapid
process of disease so disorganizing, depreciating, and enfeebling to
the vital life-sustaining fluid, the blood? Can abstracting a portion
of it, however large, suspend the poison, or its activity, or even
check its progress in its rapid course and fatal termination? Can it
have, under its depressing and depleting process, any tendency or
power to relieve the congestion that is taking place, or change in any
good degree the poisonous principle which is now generally admitted
to exist in the blood, and to be the sole and efficient cause of its
altered character and condition? The poison, once introduced into the
blood, like the leaven hid in three measures of meal, will continue
its activity, increasing its energy, and multiplying its forces, till
the whole circulation becomes affected, and its life-sustaining power
is destroyed and utterly lost, unless, by the exhibition of some
remedial agent, it shall be promptly arrested in its progress, and
suspended and eliminated. Again we ask, Will calomel fulfill any of
the indications required? Has it any influence or power to arrest this
disease, to quiet the nervous system, relieve the cramps, or restore
warmth to the body? Its specific action, so far as known, can have no
tendency whatever to relieve the system in any essential particular,
or stay the progress of disease, or delay its inevitable result, if it
remain unsubdued by the action of other remedies. Its action upon the
liver, however prompt it may be, is only of a secondary importance. The
primary cause must be overcome, its activity and energy suspended and
the system generally relieved, or there is little hope in the case.
Here we may ask, Will opium aid, or give the relief so urgently
demanded? However serviceable as an astringent and anodyne in the
premonitory stage of the disease, it cannot be exhibited in the second
stage to so good an advantage, as its direct influence is to aid and
promote congestion in those cases, where a tendency of this kind is
already in existence. Hence, its continuance in the true or collapse
stage of cholera is now generally considered faulty.
Once more: The auxiliaries employed in aid of the leading remedies
already noticed may be summed up in the language of the celebrated
Dr. Massy, in his instructions and directions on the subject of the
treatment now under consideration. He observes, "But, as you draw
blood, stimulate, give punch, brandy, or wine and water, or carbonate
of ammonia. Apply friction, with stimulating and hot liniments to the
extremities; warm sand-bags to the feet, sinapisms to the calves of the
legs and pit of the stomach; for, if you can once raise the pulse, the
chances in favor of recovery will be vastly increased."
To these directions there can be no special objections, except in the
first instance in which he, indirectly, commends the use of means
tending to deplete and depress the system, already brought by disease
to the very verge of utter exhaustion. Remedies of this tendency
are contra-indicated, and cannot, to say the least, be employed to
advantage.
Depressing remedies generally, instead of checking, or counteracting
the disease, will inevitably aid and hasten its fatal termination.
Stimulants, such as are prompt and diffusive in their character, must
be regarded as essential, and may be employed to great advantage. It
will be found, however, exceedingly difficult in most cases, even
where there is no depletion from bleeding, to keep up the waning
powers, and carry the patient, through this formidable disease, to
a favorable termination. Of the utility of warm applications to the
surface generally, there can be no question; yet, our main reliance is
on internal remedies, as has been already shown: the lost temperature
of the body must be restored, the production and diffusion of heat, or
caloric, must be internal through the administration of remedies, that
will promptly and kindly produce this result.
What are, then, the remedies? We have ventured in this discussion
to recommend the internal use of chloroform, and believe it will be
found in combination with other prompt and diffusive stimulants,
specially adapted to meet this condition. In this recommendation, we
feel ourselves fully sustained by the result of various experiments
heretofore made, and the recent trials of its use, as an internal
remedy in the various stages of the disease.
The earliest record of the use of chloroform in cholera is probably
to be found in the London _Lancet_ for November, 1848, in which Dr.
Hill reports a case of its successful use by inhalation. He placed
the patient in bed, covered with warm blankets, and applied friction,
stimulant liniments, and heated bags of bran to the surface, and kept
the patient under the gentle influence of chloroform, till the more
urgent symptoms entirely subsided. At intervals brandy-and-water, and
thin arrow-root or milk was given. All other medicines were avoided.
Though the urgent symptoms returned at first, as the effects of the
chloroform passed off, they were easily controlled by the repetition
of the inhalation. By persevering in its use, reaction set in, and the
patient became convalescent.
Other cases, afterwards, were treated in the same way, with a similar
result. Some, however, required the gentle use of chloroform by
inhalation, at intervals, for twenty-four hours; after which, none
seems to have been administered. For aught that appears these cases all
recovered.
Another very interesting case is related by Mr. Brady, who observes
that an elderly lady was seized with slight diarrhoea, which, on
the following morning, had become very profuse: excessive vomiting
supervened, accompanied by spasms in the calves of the legs, fingers
and toes. Under these urgent symptoms, the usual remedy, brandy, was
administered without avail; the dejections became incessant, and the
spasms increased in intensity, presenting the features of a decided
case of malignant cholera. In this condition, the physician was called
in haste, as it was believed and affirmed the patient was dying.
In describing this case, the physician observes: "On my arrival, I
found the patient presenting all the symptoms of malignant Asiatic
cholera, in an advanced stage; the features collapsed and ghastly;
extremities and tongue cold; burning sensation in the stomach and
oesophagus; pulse rapid and scarcely perceptible; voice diminished
to a whisper; stomach exceedingly irritable, and the dejections from
the bowels presenting the characteristic rice-water appearance; and
all the voluntary muscles of the body were affected by spasm, so that
the patient actually writhed in agony." Ordered the following: Rx.
Chloroform dram j; Ol. Terebinth. ounce j; aq. Dist. dram iij. M. And
gave immediately a large tea-spoonful, in a wine-glass, of dilute
brandy; and applied sinapisms to the calves of the legs and abdominal
and thoracic surfaces. Thirst was relieved by drinking plentifully of
water nearly cold. Though the stomach was irritable, the chloroform was
retained, as well as the fluid drank after it, and was followed by no
dejection. Half an hour after, two pills were administered, composed
according to the following: Rx. Calomel gr. v; fellis. bov. inspis.
gr. x; Ft. Pil. ij. Half an hour after these were given, vomiting
ensued, but soon subsided; the diarrhoea had apparently ceased; the
cramps had diminished in frequency and severity. A second dose of
chloroform, now one hour after the first, was administered, and soon
after this two more of the pills, both of which were retained, and gave
decided relief. The pulse rose in power and became slower, the spasms
less frequent, and, in an hour after the second dose, the patient was
bathed from head to foot in a warm perspiration, and expressed herself
comparatively free from all uneasy sensations. The attack had been
completely subdued, leaving behind a good deal of pyrexia and debility,
from which she rapidly recovered.
Here it is worthy of notice, that in this case, severe as it was, only
two doses of the chloroform mixture were administered, each containing
about six minims of chloroform and forty of turpentine; the pills
would naturally tend to perpetuate rather than relieve the nausea and
vomiting, and in one hour after the administration of the second dose,
all the urgent symptoms were assuaged.
In another case, the attending physician reports that, after giving
calomel, combined with opium, which was immediately rejected, the
following mixture was ordered: Rx. Chloroform vj minims; brandy dram
iij; water ounce iijss, one-third of which was given immediately,
and was thrown up in half an hour; a second dose was then given, and
was retained. The vomiting and diarrhoea ceased; the spasms became
less severe. In two hours after, gave the remaining third part; and
during the next six hours, administered in two doses six minims more
of the chloroform, with the most decided benefit, and the patient soon
became convalescent. To the extreme tenderness over the region of the
epigastrium flannel soaked in spirits of turpentine was applied; and
as no urine was secreted, I am firmly of the opinion that the usual
remedies would not have met this case. "I candidly confess," says the
physician, "I had no hope of success from its severity; and, but for
a knowledge of Mr. Brady's case, I believe I should have lost my
patient."
Dr. Davies reports a case in which he used chloroform fifteen hours
after the seizure with relief, but not with success, and observes that,
in a number of cases occurring in the hospital, there were 22 cases in
which, as severe symptoms came on, the chief remedy was chloroform,
administered internally, in doses of from seven to ten minims every
hour, half hour, or quarter of an hour, according to the severity of
the symptoms. Of these 22 cases, 8 terminated fatally, and 14 recovered.
Again: "Out of 9 cases of cholera, and 13 of the worst cases of
diarrhoea occurring in my own practice, and treated with chloroform,
_one died_. All these were in the better ranks of life. In some of
them, the warm bath (salt water) was used as an auxiliary, and the
diet consisted of nothing but cold milk and water, with some carbonate
of soda, _ad libitum_. The fatal case was that of a drunkard, who,
probably, did not take the remedy. These cases varied in severity,
from sickness and diarrhoea, and mild collapse, to sickness,
diarrhoea, severe cramps, and great collapse, with almost clear watery
evacuations, passing away involuntarily * * * Of 14 cases of cholera
treated by Mr. Towers, Medical Resident of the Infirmary, many of
them under my own observation, _one died_. The fatal case was that
of a woman aged 63, who was previously suffering great depression,
consequent on extreme destitution."
Again, says Dr. Davies, "It will probably be remembered that, in my
second report, I expressed a very favorable opinion of chloroform in
this deadly malady. I considered I had strong grounds for so doing,
after observing the large proportion of cases which recovered under
its administration. From the history of this last visitation in the
county prison, however, the fact turns out, that, under some uncertain
circumstances, the use of chloroform will not prevent the proportion of
deaths being considerable. I have reason to believe that it was, from
over-anxiety, given in too frequent doses in some cases, and that it
thus rather added to the coma, which is one of the characteristics of
the malady.
At the commencement of the outbreak, the doses were repeated every
hour, or every two hours, and it is to be noted that the first seven
cases _recovered_.
As the cases multiplied, the remedy was given every half hour, and, in
some instances, every quarter of an hour; the result was that the next
six cases died. Whether these cases had anything in them inherently
more fatal, it is difficult to tell. The symptoms at first were about
equal, and the differences did not show themselves until towards the
end. There was next a recovery of seven cases in succession; in these
the remedy was administered less frequently, but subsequently two
deaths occurred under the less frequent administration.
The chloroform was administered also by inhalation, in some of the
more severe cases of cramps, with the effect of affording relief in
every instance. The inhalation was not carried so far as to produce
insensibility. Although I am still of the opinion that chloroform
properly regulated is the remedy of all others hitherto tried to be
depended on, yet it cannot be considered a specific for cholera."
Mr. Steadman reports a very interesting case treated by chloroform.
He observes, "The spasms were universal and extremely violent, as if
knots were being tied in the bowels, countenance livid and cold, voice
feeble, and all medicines rejected. In this condition gave chloroform
combined with 'aquæ vitæ' and distilled water. The first dose had
a partial but most satisfactory effect. In two hours after, as the
symptoms manifested a disposition to return, gave a second dose, which
entirely controlled all spasms, vomiting and purging. The patient was
ordered cold rice and mucilaginous drinks, and had the chalk mixture
with nitric ether prescribed. A dose of oxgall (gr. x) was given in
course of the day, which produced the desired effect. In two days the
patient was declared convalescent." The daughter, who had nursed the
mother in this case, was seized soon after in a similar manner, except
the dejections were more abundant and frequent. The mother having some
of the chloroform mixture left, gave it to the daughter without advice
or hesitancy, and obtained the same magic results. The first dose was
only partial in its effect, but the second completely subdued the
disease.
Such are the results of some of the experiments which have been made
by the administration of chloroform; and, so far as appears, the first
cases treated by inhalation were severe malignant cholera in the
advanced stage, all of which recovered. So, also, those treated by the
remedy used internally, combined with a prompt and decided stimulant
like the spirits of turpentine, or aquæ vitæ and brandy, recovered.
In all these cases the remedy appeared to meet the urgent demand, to
remove the impediment to the circulation, to relieve the nausea and
vomiting, and purging and cramps, and restore, in a very short time,
the general action and normal tone of the system. Still we must admit,
that some cases, treated by its internal administration, and also by
inhalation, proved, on some accounts not satisfactorily explained,
unsuccessful. Were these cases given in detail, it would be much easier
to detect the cause of failure, or its questionable use in such cases;
but we have only the bare fact that they were thus treated, without the
manner or character of the combination, if any were made, being given.
Hence Dr. Davies, under whose direction these cases occurred,
remarks, in view of this result, "that _no reliance_ could be placed
on chloroform alone." The correctness of this opinion cannot be
questioned, for the experiments we have cited all show the necessity
of a prompt and diffusive stimulant in aid of its action, to render it
sufficiently prompt and powerful to meet and overcome the disease in
the more rapid and severe cases. Chloroform, properly combined, offers
the best hope of relief, and is, without doubt, the most perfectly
adapted of any remedy known to the pathology and phenomena of the
disease. There is no remedy, when properly combined, so capable of
meeting all the indications required as this, and none that can be
administered with more certainty of success.
In conclusion, we may, with much propriety, refer again to the
pathology suggested by the authors cited above, and inquire whether
the action of chloroform as a remedy in these cases be consistent? and
whether as such it has that curative influence, or direct controlling
power, to arrest, suspend, and cure the disease, so imperiously
demanded? We have seen that, according to the opinion generally
prevailing, the first impression of the poison is made upon the
blood, and through it upon the nerves, especially those which, from
their anatomical position, bear the most intimate relation to the
blood-vessels. Through this channel the first invasion appears to be
made on the ganglionic, the nerves of circulation. These nerves are
distributed chiefly to the viscera and blood-vessels, and are at least
very early involved and essentially disturbed, for their healthful
action depends in no small degree on the aeration or oxydation of
the blood. Says an eminent author, "The action of every ganglionic
mechanism depends on the existence of certain physical conditions,
among which the most prominent and important is the due supply of
arterialized blood. If this be stopped but for a moment the nerve
mechanism loses its power, or, if diminished, the display of its
characteristic phenomena correspondingly declines." Hence the loss
of power in these nerves, and their deranged action, the contraction
of the capillary and pulmonary arteries, the impaired and impeded
circulation and all the phenomena arising therefrom.
Again, the great pneumogastric nerve, which is composed of both motor
and sensitive filaments, has a very extensive distribution in the
upper part of the abdominal cavity. It supplies the organs of voice
and respiration with motor and sensitive fibres, and the pharynx,
oesophagus, stomach and heart with motor influence. This very important
nerve, through the primary action and deteriorating process of the
cholera poison, becomes early involved, and its functions greatly, and,
in fatal cases, permanently deranged. The evidence of this disturbance
and loss of nerve-power is too obvious to be overlooked or disregarded
in the treatment of this disease.
In confirmation of this, we may, with great propriety, adduce the
testimony of Dr. Wallis on the loss of nerve-power, and the process
through which the result is produced, who observes, that "the phenomena
which are exhibited when the deleterious air has been drawn into the
lungs are these: the great gastro-pulmonary nerve is either wholly or
partially paralyzed, the consequences are the cessation of all its
functions either wholly or partially. This great nerve is a nerve of
function, and performs the functions of digestion and respiration, and
influences all secretions."
Hence it appears the nervous power generally, as before observed, is
very early and essentially impaired, and to such an extent that there
can be no rational hope of relief, unless some remedial agent can be
found that will exercise such a controlling influence and power, as
shall be adequate to restore the tone of the nervous system.
Hence, we are forced to the conclusion that the prominent, leading,
and most urgent symptoms requiring special attention, are "the Algide"
or loss of temperature, the loss of nerve-power in the ganglionic and
pneumogastric nerves and their branches, the altered or disorganized
condition of the blood, the impaired or obstructed circulation, and
the early and direct tendency to congestion. These are the prominent
and essential features to be observed in the treatment. They are too
intimate, dependent and inseparable, to warrant any attempt to mark the
precise order of their development. They are the essential phenomena,
proceeding equally and directly together from the primary cause and
disease action, and strictly constitute the complex character of the
cholera, and exhibit its main, distinguishing features, which must
necessarily govern and dictate the maxims of rational practice in
the treatment of this disease. The object, then, of first importance
is to restore the lost temperature, the caloric already eliminated,
and prevent its further depression; to restore, at the same time,
the lost nerve-power to the nerves again; to arrest the process of
disorganization of the blood, and equalize the circulation; to relieve
and suspend the congestion; and then, according to all the experiments
which have been made, the consequent and dependent phenomena of the
cramps and the vomiting and the purging will disappear.