- Email: [email protected]
MEMORANDA ON CHOLERA.
235
mulants, such asvapour or hot hip-bath, va- ment, that cholera is not a disease of the ginal injections of ammonia, &c. Intlietrent- brain ; but we know that the secretive and mentcf amenorrbaa, however, the distinction motific
nerves
frequently
continue theit
necessary to be made in so many other functions when the sensifio nerves have diseases is also uffessatv. Should there be lost their influence, and vice 1’eTsa. The fulness, aloetic turpentine, &c., ideot, for the most part, has but littte sense will be useless ; the inflammatory state or of pain, and can bear intense heat and cold congestion of it must be first removed, and with impunity. His senses are blunted, but then diese will come into play beneficially, hnving still the motific power in all his musor, perhaps, not be required. On the other cles, and, what is more to our present purin those of respiration, life, in him, not hand, if there is debility, it is in vain to think of stimulating it until the strength, unfrequently proceeds to longevity. The is sensible and likewise a due quantity of good blood, patient, ou the is restored; and again, when this is done,of pain to the last ; he complains of the the uterus will frequeutly resume its func-’ weight of a blanket, and in a bath at 1000, he feels the heat insunnortable, but his mustions without the aid of these stimuli. powers are prostrate, his stomach and bowels become palsied, and the respiratory organs are unable to continue their function?. Cholera, then, is a disease of neuralgia, and MEMORANDA ON THE the immediate cause of neuralgic disorders EPIDEMIC CHOLERA OF INDIA. is, a diminution of nervous power, as is ob. vious from the little control which the ceBy S. DICKSON, Esq., Assistant Surgeonrebro-spintil organs possess even over volunto the 30th Foot. tary muscles. This decrease of energy may be the effect of a thousand causes. The aetion of the marsh noison is the common. To the Editor of TnE LANCET. cause of agues; but a stricture of thè SIR,—The disease which foms the sub- urethra is sometimes attended with ague ject of the accompanyingpaper, having fits ; and the introduction of an armed bouswept away a number of men of H. M. 30th gie into the same passage, is occasionally Foot, while under mv charge, 1 have been followed by a similar paroxysm. Epilepsy led to pay a more than ordinary degree of at- is as often the effect of irritation of the alitention to ita symptoms. Several of my me- mentary canal, as of direct cerebral disease. dical friends, to whom I have submitted myIt may be produced, also, by various poisons. views of the disorder, think I haveaccounted We see a fall, the prick of a thorn, and the satisfactorily for its phenomena, and havepoison of nux vomica, followed by tetanus. hssured me of their willingness, as opportu- You may simulate this disease hv puncturing titv offers, to my proposed method ofthe spinal chord with a small stilet. treatment to the test of experience. May I Like every other neuralgic affection, charequest the favour of your insertmg my pa- lera, I apprehend, may have its origin in per in your widely circulated pages. many causes; although when epidemic, as I remain your obedient servant, in India, we shall find it more frequently S. DICKSON, Ai’sisf. from a vitiated atmosphere. 1 know Assist. Surg. Surg. H. M. 30th Foot. shadow ofa difference betwixt the train of induced by the action of Bangalore, July 13th, 1829. arsenic when injected into a vein, and thosa observed in this disease. The bite of cer. MEMORANDA ON CHOLERA. tain snakes, concussion of the stomach from I cannot conceive why the learned Mason a blow, and, occasionally, surgical operations, Good should have placed cholera under his nrf followed bya similar disorder Tt la a order ofceeliaca, and that, too, even when ac- frequent result of gun-shot wounds even of knowledging that the nhole nervous energy the extremities. The bydrocyanic and ox. constituting life is frequently in an instant ahc* acids will produce it in its most fatal by this disease, as a Leyden jar form ; so will a stroke of ligbtning or elecis deprived of its eleetricitp by touching it tricity. 1n short, whatever directly or inwith a brass rod. The that the by immediate contact or by symweakens the nervous energy, will, alimentary canal is the original seat of disto its violence and rapidity, proease, seems to have arisen from the circumstance, that vomiting and purging show particular affections, more or less ap themselves at an early period of the disorder; I but both these symptoms may be induced by See paper by Drs. Christison and Coin. fear, which none would on that account call a coeliac affection. The complete rationality det, in the Edinburgh Medical and Surgical of the patieut is brought forward as an argu- Journal for April, SJ
purgatives,
pose,
, cholera
contrary,
cular
arising not the symptoms
supposition,
dpathy,irectly,
according
duce
___________________________.
1823.
236
proaching to’ this terrific disease.t When death is an immediate consequence, we shall not be able, perhaps, to detect a single morbid appearance on dissection ; but where the fatality shall have been slow, we have congestion, and if still more slowly induced, we have inflammation and even gangrene Jt has been the subject of remark, that no two cases of cholera are precisely alike in all their symptoms. The reason is far fiom obscure. The brain and spinal chord hold a control over an extensive system of nerves, and it only depends upon the situation and degree of their derangement, whether any or all of these nerves be implicated when those organs are diseased. In cholera, the muscles of the toes and fingers first act irregularly, then those of the legs and arms. Were the brain and spine to lose their influence only over those distant parts, life would not be in danger ; but when the nerves of respiration and secretion also escape from their control, then, and then only, the dis-
approaches to fatality.
It seems difficult, at first view, to account for the secretions in one patient ceasing entirely, while in another they continue to be carried on with preternatural activity. Some cholera patients, for example, vomit up bile to the very last; the greater number, however, have this secretion stopped. To explain this, it is only necessarv to observe, that the various functions of muscle, and viscus, immediately terminate when the nerves that supply them are cut off from their. connexions with the brain or spine ; that, on the other hand, when this connexion is only partially interrupted, which may be
gland,
.
well-that this
were
the
only secretion
that ceased in cholera. But in the most fatal cases of this disease, the liver secretes no bile—the kidneys no urine ; there is no moisture on the skin, or if there be, it is the cold clammy sweat that exudes from the atonic vessels of the moribund. It is not
what Dr.
supervening.
ease
were
Johnston
terms
it-a sweat
squeezed out by spasms, for in this stage of the disease, a spasmodic action has ceased to exist.
Having
granted
once
symptom of cerebral
or
that spasm is a spinal weakness
that it is the frequent forerunof death in typhus, and precedes palsy in almost, indeed, every instance, shall we doubt it 1), all the symptoms of cholera may be easily accounted for. The pneumo-gastric nerve, as its name denotes, supplies the stomach and lungs with the cerebral energy-a partial inter. ruptiou of its connexion with the hiain
(and seeing
ner
spasmodic vomiting and precordial anxiety; when this connexion is completely cau-es
dissolved
(which it is
in every fatal
case
of
paralysis of both organs. In this instance, there. is no longer violent vomiting—whatever is now taken by the mouth is retained. The stomach is palsied and passive, equally unconscious of the pre. cholera),
sence
there is
of stimulant and diluent fluids. The
breathing for a time is carried on by the diaphragm and intercostal muscles, but these
in the universal unable to continue their functions, and the lungs, consequently, collapse. The sufferer now coughs occasionally, complains ofcutting of bis breath, and the almost inaudible tone in artificially produced by puncturing a nerve, which he answers your questions, shows the functions of either become morbidly ac. that the recurrent branch of the eighth pair tive. Tetanus, I have said, may be pro. is also paralysed; he speaks like a persou duced by puncturing the spinal marrow, who has cut this nerve in an attempt at The function of a muscle is to contract, and suicide. The more the lungs collapse, with in this disease the muscles are in morbid greater difficulty the blood finds its way contraction. Divide the spinal chord en. to the left side of the heart. The little that tirely, and there will be complete palsy. does pass is black and viscid-it is more The passion of grief affords another exam- carbonised than healthy venous blood. The ple : the tears flow profusely in sorrow, but greater portion of this fluid is now collected when the feelings of the sufferer are corn- in the right auricle and ventricle ; it is ill pletely absorbed in this depressing passion, vain that the anxious patient draws, in the the lachrymal secretion ceases, the eye is shape of along sigh, his deepest inspiration dry, like a dead person’s ; it is the glazed to relieve his loaded heart. The blood can. eye of ehoiera unmoistened by a tear. It not pass through the lungs; it must seek new channels. The valves of the external t If fear amount to tC1TO1’, we shall have, veins prevent its regurgitating into them according to the degree of constitutional but the veins of the brain, and abdominal irritability present, ague, hysteria, epilepsy, viscera, having no valves, these are the tetanus, cholera. In the course of our voy- channels into which the superfluity of blood after experien- is naturally sent. These veins, then, must nrie from England to India, cing a severe hurricane off the Cape, thir- be in a state of congestion ; and the super. teen of a pack of thirty dogs which was on ficial veins receiving but a small supply from board, died of a disease extremely resem- the ill-fed arteries, contract in their calibre bling cholera : here it was indubitably the upon this diminished quantity, as they urge it on. Is not this, then, the cause of the effect of terror. -
soon
become
involved
prostration, they
are
237
extremities becoming shrunk and bloodless ;I who have died of cholera, we ehalt nnd them that they are cold and livid, is owing to’ precisely the same as.are observed on open. their not being supplied with red blood. In ing an animal that has been drowned, the puer ceruleas (the greater part of whose strangled, or poisoned by noxious vapours ; blood passes through the open foramen ovale viz. a colldpsed and engorged state of the dlrectlv to the left side of the heart, with- lungs ; a loaded condition of the brain, the out being acted upon by the atmosphere), right side of the heart, and, in a word, of all the extremities are cold and blue, but they the internal veins ; the arterial blood is are not shrunk as in cholera, for they are black ; the colon and urinary bladder are sufficiently supplied with blood, though that empty and contracted in all. Blood drawn blond, from its carbonised state, is unequal before death, is found to be uncoagulable in to the production of heat. We have ac- each and every of these diseases. Professor Coleman, on repeated experi. counted, then, for almost every but the watery purging. Having shown observed that all the air of the lungs how the internal veins are all completely was nearly exhausted in animals killed as congested, we have only to remark, in ad- above described ; but when he passed a ditiun, that wherever there is a great vis a ligature round the trachea, so as to keep the tergo, the bowels, during life, seek to re- lungs distended, lie found that the blood lieve themselves by means of their nume- could pass to the left side of the heart with rous excretories in those watery discharges, ease. The proportion of blood in the left which consist of the more pellucid portion of side was, in such cases, to that of the right, the blood. as nine to seven ; nay, when he distended Let us examine the condition of a person the lungs by water, he obtained a similar rewhose lungscollapse from an artificial cause, sult. When the animal was destroyed with.’ the effusion of blood from a wound in the out this precaution, it was the reverse. The thorax for example :-" You will find him," right side of the heart, the veins of the says Mr. John Bell,with bloody foam at his brain and of the abdomen, were completely his face, pale in the cheeks, and livid loaded. The lungs were then in a state ofround the lips and eyes, heaving the breast collapse or complete expiration. " Expirawith intolerable anguish, tossing side tion (says Haller) wiil, therefore, stop the to side in bed, the bloody foam increasing, easy passage of the blood. through the lungs, the breathing becoming more difficult, and and when the whole thorax is compressed the blood and air rattling in the throat; together, repels the venous blood into the then the pulse flutters, and the extremities veins of the head, and fills the brain and its’ constantly grow colder, till, struggling in sinuses..In this manner, a fresh necessity something like a convulsion, he expires." follows for repeating the respiration, beStllp this description of a few accidental cause the collapsed vessels of the lungs resymptoms, and you have before you a case sist the blood repeatedly expelled from the of Indian cholera. In such a case, there is right ventricle of the heart, and this makes always that dreadful thirst which forms not another cause of death in those animals the least of the cholera patient’s sufferings. which expire in vessels exhausted of air.’ This thirst is common to every disease in Such lungs having the air entirely drawn which there is a difficulty of respiring. It out of them, appear dense, solid, and are is one of the symptoms of phthisis, and is heavier than water, whence they are renderpresent in the passion of grief, where also ed impervious to the blood. Of the same the sighing and anxiety show the inability kind is the death of those who are killed by to breathe freely ; wherever the brain has lightning, and, perhaps, by the noxious valost its perfect control over the respiratory pours of caverns." The treatment of diseases so nearly re-’ nerves,we have this burning thirst. It adds to the sufferings of the wounded in a field of sembling each other, ought, to a certain exbattle, and of all who have lost much blood. tent, to be similar; and, first, as to stimu-’ Almost all the symptoms of cholera may be lants. Having already clearly, I hope,’ induced by loss of blood. Take them in the proved the disorder to be one of cerebro-’ words of Dr. Blundell :—" A certain ghast- spinal weakness, stimulants, I need hardly liness of the countenance, a restless dispo- say, are the remedies chiefly to be depended sition to change posture, a long-continued upon. Ammonia, brandy, camphor, &c., cessation of the pulse at the wrist, a gasping ought to be administered in large doses, the’ respiration like that produced by running, moment the symptoms of the disease appear. jactitation of the arms and legs, joined with Opium, at the commencement, is extramely a feelmg of’ most oppressive anguish." To beneticial ; but I fear I have seen it haestcn these add irritability of the and death in the latter stages. With regard to cold sweats" and ’° cold extre- calomel, 1 hesitate not to say, that I believe it to be totally useless, if not hurtful ; nor mities," and, lastly, .y, asphyxia." If we turn to the post-mortem appear- can I place reliance on any mercurial aaces discovered on examination of those remedy, when I know that the disorder has’
symptom
ments,
mouth,
from
°
’
.
‘
’ _
-
!
z t
t
t
.
I
,
t
stomach
bowels,"
238
attached, and proved fatal to, men in a state every symptom of cholera, this very con. of ptyalism. Blisters. only torture, and, gestion is presentThis congestion causes consequently, weaken the already debili- no cerebral oppression, at least when the c disease first shows itself, and that is the pe. tated patient.
Some of my eastern brethren will ask me, riod when bleeding has its most numerous I have omitted bleeding. If Mr. Cole- advocates. Every body,at all conversant with man’s remarks upon the analogous diseases the disease, will acknowledge, that the pa. already alluded to, be not sufficiently cogenttient sinks more rapidly when raised from against bleeding in cholera, I have others inthe horizontal position. Does this argue an store, which may.be still more convincing.oppressed state of the brain ? Does it not " Were it possible (says Mr. Coleman) toshow, rather, how necessary the blood is to take blood from the part where weknow it the cerebral arteries? Is the rational state superabounds, bleeding would prove one ofof the patient a sin of apoplexy’! When the most efficacious means of recovery. Thecholera ends in coma—when the pupil is right side of the heart has been found to becontracted or dilated, and the patient has loaded with blood ; this universally obtainsstertorous breathing, then, most certaiuly, in the disease ; and I mentioned one or two there is apoplexy. But will bleeding reinstances in particular, where we had an op- move this?—Will it give sufficient portunity of observing that the heart ceased to the respiratory muscles to distend the to act from over distention ; but when re- collapsed lungs ? Assuredly not. To those lieved. from a part of its burden, its contrac- who argue for venesection, on the plea that tions were immediately renewed. If, there- it subdues spasm, I answer, that while it fore, from the right side of the heart, while robs the affected muscles of the little cere. thus in a state of violent plethora, a small bral energy the spasms show they possess, q.uu2ttaty of blood could be taken, experi- it weakens the powers of the respiratory ment and observation tell us, that its power muscles also, and consequently hastens asand action would be instantaneously ii-ivigo- phyxia. The blood is in this case the life, rated ; but as this lies beyond the reach of for without blood a muscle cannot contract, art, the taking of blood from any other part nor a gland secrete ; many die of cholera of the body can rarely be productive of any who, from the first, have never suffered considerable benefit. from spasm. In the last stage of the disease If a ligature be placed upon an inferior there is no spasmodic action ; the internal extremitv, you may bleed your patient in parts are palsied, and the external strength the arm to syncope, but you will not thereby is laid prostrate. If it be boasted that remove the existing below the liga- bleeding has been sometimes followed by ture ; on the contrary, the limb will run success, I believe the reason to be, that the sooner into a state of gangrene. It is ex- irritating cause in such cases has not been actly the same in cholera, where venesec- so great; the, atmospheric poison has not tion must do additional harm, by robbing been so deeply inhaled ; and the records of tJte patient of the little arterial blood so ree- our science bear witness to a successful recessary to the existenee of the brain’s, al- sult in other dangerous diseases, where the practice has been confessedly erroneous. ready too diminished, energy. If you ask three practilioners why they But if it be proved (which it has been by bleed in cholera, one will tell you, to relieve Magendie), that the action of poison is fa. cerebral congestion ; a second, to unload voured by bleeding and retarded by an arti the engorged lungs and abdominal viscera ; ficial plethora, why should we bleed in a while a third will inform you, it is.to subdue disease which arises, indubitably, from an spasm. These practitioners, nevertheless, empoisoued atmosphere? Misled by the regive, at the very moment they detract blood, lations of. authors, and the encomiums they a. diffusable stimulus. They sE:e that the have given to bleeding in- this disease, I disease is one of debility, but they cannot gave it a trial to an extent which I never divest their minds ot the theories about çon- can sufficiently regret. I should have beet gestion, &c., and so they bleed, blister, and more successful had .1 transfused hlood into give brandy, in one and the same breath. my patient’s veius, instead of depewing Is this not blowing hot and cold ? It is the them of this fluid, so necessary to their very same as if they were to order a hot poultice existence. to a bubo with a cold wash above it. Of all the various modes of treatment Let us answer each in order. The same reply resott.dto in nervous diseases, is not will, perhaps, satisfy the two first. it ancounter-irritation the most generally efficaanimal be allowed to bleed 11 low from lifeC;ous!? Zinc, arsenic, and copper, are called away," this very congestion of the brain, tonics ; may they not rather be termed irrilungs, and abdominal viscera, will be found tants, seeing that when they produce cures among the post-mortem appearances. Wouldi in ague, epilepsy, gout, palsv, &c., they do these gentlemen, then, bleed in a case ofso ouly by establishing an analagous disease uterine haemorrhage, wheie, in addition to act, m a word, by counter-irritation.
why
energy
B
°
plethora
they
I I
239 How instantaneously does cold water, dash- shortly after being attacked, .took drachm tdin the face, recall the neeting energy of doses of the arsenical solution, every twenty the brain in
syncope !
Dr. Currie
was,
I
minutes,
to the extent of four
drachms. Dr.
believe, the first who introduced the cold Perston, H.M.2bth, found her, in the bath in tetanus; he attributes its good effects solely to counter-irritation. On this principle the French physicians treat the disease with nux vomica, which, as we have already said, produces a similar disorder. The poi-
of the same
in her
day,
even-
collapsed state, and administered to brandy, with large doses of tinct. lytta, a remedy which, among his female patients, he has found very suc-
ing
a
cessful..
If in some instances of poisoning from duces a train of symptoms analogous to cho- opium, life has been restored by blowing )era. The natives of India treat the bite’ into the lungs with bellows, after apparent Qf the cobra de capello successfully with death had taken place by the cessation of rsenic. Ought not this to be an induce- respiration, this practice ought not to be ment to give it a fair trial in cholera1 In neglected under similar circumstances in the case of a Sepoy who came under my cholera. Might it not be uselul, moreover, care, I administered to the extent of 5ij of to expand the patient-’s lungs in- this man< Fowler’s solution at a dose; the patient re- ner when we observe the respiration to becovered. In several European cases, I tried come difficult 1 :, the fumes of arsenic,by making them inhale Ilaving already glanced at several of the the remedy from a common tobacco-pipe, nervous diseases which owe their origin to and in the majority of instances with suc- particular passi-ons and’poisons, it may no£ cess. I attribute the deaths that occurred be out of place to remark that all these irritomy having, unfortunately, bled the pa- tating causes, when long localised, are capaother forms of disease very tients at the same time. In one instance, ble of 1I’hele re-aetlcm had taken place after the analogous to each other. Thus the various exhibition of the remedy, 1 believe a fatal poisons of lead, arsenic, and mercury, when termination to have been produced by the slowly accumulated in the system, exhibit ealiaastion of a long confession, and the their effects in disorders, similar to those additional fear of extreme unction. which, uader the name of scurvy, abound in I apprehend, that the usual practice of a marshy country; and these, again, are covering up the patient with a blanket in daily mistaken for syphilitic diseases. If cholera is decidedly hurtful, inasmuch as the patient have at any period had venereal the skin is thus kept from absorbing oxygen disorder, not a doubt is entertained. If he from the atmosphere, which, in this dis- have not, his physician is sceptical as to the ease, ithas the power of doing to a greater truth of his assertion ; and if he cure him extent than at any other time ; for the exter- with mercury, he prides himself upon such nal veins being neariy empty, absorption scepticism, forgetting that many scorbutic goes on rapidly, as we see in the sudden diseases yield to this mineral. eyes, disappearance of the fat of the eyes and spongy gums, cutaneous eruptious, diseased lips, Frictions of the legs and arms are bones and liver, dysentery, colic, epilepsy, powerful auxiliaries in every case of dimi. tetanus, tremblings of the muscles, and wished vitality, and consequently prove palsy, are the common diseases of a malaria luglily beneficial in cholera. I have seen district. To these might be added, intracttoo many patients expire from the debility able ulcers, elephantiasis, idiotcy, diabetes, induced by the warm-bath, to recommend it consumption, and malignant tumours, such in cholera, In the commencement of the as cancer and fungus. Does not the fact, that disease the cold-bath, I have no doubt, all these diseases are benefited by arsenic, mi;ht be serviceable, from the good I have go far to bring them under one family. Do seen done by cold ablution in the more ad. ,not many of them too frequently embitter vanced stages; the patients, one and all, the lot of those whose constitutions have declared it to be extreinely grateful. Dr, been broken up by corroding grief, and by Stephenson, of H. M. 15th Dragoons, has long courses of mercury for fancied syphilitic the merit of first-putting the coid-bath to disorders. We find them in miners long the test of experience, and he reports very exposed to the fumes of arsenic or copper, highly in its favour..and in those who work in lead, such am It is the common custom to deny the plumbers, glaziers, and painters. When patient cold drinks in the disease ; on what these diseases arise from poisons, analogous account I am at a loss to conceive. Ou a poisons are the medicines, perhaps, most to late occasion I indulged a female with a be depeiideduvon ; iodine, arsenic, mercury, deep draught of the coldest water, and she and silver, are highly successful in the dissaid it restored her strength. To the same eases of malaria ; while many mercurial patient I gave half a bottle of beer when she disorders yield to mercury itself. called forot, and obtained a similar declaraNote.-In some cases of cholera, patients tion. The woman recovered. This woman, suffer from- trismus. The only ditrereuce son
of
arsenic, and of certain snakes, pro-
producing
Sore
.
! ,
240 which seems to- me to subsist betwixt cholera present, and remained in suspension in the and tetanus is this, viz. that while in cholera urine. Mr. R--- at first consulted two very the nerves of both the brain and spine become almost at once inadequate to the per- respectable practitioners of Limeriok. Of formance of their respective functions, in these Mr. Carroll assured him that the symp. tetanus for some days the nerves arising toms left no doubt as to the existence of from the spinal chord only, are affected ; stone in the bladder, but that catheterism hence the eighth pair deriving its origin did not justify this conclusion. Having
un- called Mr. Thwaites into consultation, he and the blood circulates proceeded to’ a careful examination, but freely. Where this disease terminates in neither of these gentlemen could satisfy death the eighth pair becomes also involved. himselfof the presence of the foreign body. The patient, therefore, dies the same death According to the advice of these gentle. as those who die of cholera, viz. of asphyxia. men the patient came to London and con. sulted that eminent surgeon Mr. Green, who could discover no stone. He was sent by Mr. Green to Mr. Brodie, by whom he was sounded, and a sensation experienced suffi. LITHOTRITY. ciently plain to convince him of the existence of a calculous body. Afterwards Messrs. Brodie and Green consulted together, and CASE OF STONE IN THE BLADDER TREATED carefully explored the bladder, but did not WITH THE BRISE-COQUE, succeed in detecting a stone. Mr. Rthen went to Mr. Lawrence, who was also By BARON HEURTELOUP. unsuccessful in his researches. (Communicated by D. O. EDWARDS, Esq. Mr. Green now brought the patient to Westminster Hospital.) I practised catheterism according to me. Mr. R--, ag-ed 60; good constitution ; my system, and immediately ascertained the presence of a foreign body. 1 deter. slight cala?-rlt of the bladder ; a smooth mined in two days’ time to resume my exand flat unic-acid calculus, from about ten to twelùe lines in diameter-Difficulty ploration, with a view of learning the nature and state of the calculus, in order to proceed of recognising the existence of this stone to its destruction. its the -Employment of perce-pierre ; Green and Mr. Brodie being present, insufficiency-Employment of the brise- andMr. the patient conveniently placed on the coque- New " sonde exploratrice"rectangle-bed, I first performed catbeterism Cure. with the recto-curvilineal sound, and I be. Mn. R-,a merchant of Limerick, about came conscious of the presence of a body sixty years of age, of a sanguineous tempera- which 1 judged was sufficiently small to be ment and good constitution, having always destroyed with a perce-pierre. * The enjoyed excellent health, and having never bladder was injected with a suitable quantity experienced the least pain in the region of of water, and the sound withdrawn. I inthe kidneys nor voided gravelly particles, troduced the instrument, the stone was im. was about a year since, conscious, for the mediately seized, and submitted to the action first time, of a sensation of lieat at the ex- of the lithotritor, but before its action was tremity of the penis, and which soon dege- completed the calculus escaped from the nerated into a sense of pinching when the claws; being retaken several times, it as bladder was quiet, and of vivid and lancinat- often escaped, and the instrument could ing pain during the expulsion of the urine. make no impression upon it in consequence. A stumble, the act of sitting down, or the A second application of the perce-pierre, entering a carriage, increased the intensity was nearly as fruitless as the first, the stone of these painful sensations ; but Mr. R—— as soon as taken slipped away from the immediately experienced relief on placing grasp of the instrument. Some sabulous himself on his side. Notwithstanding vari- particles brought away in the teeth of the otis symptoms indicative of stone, the urine drill, and a few small fragments ejaculated flowed in a full stream, and wa-3 not suddenly * arrested in its course; the desire of urining M. Heurteloup has given the appellawas not of frequent occurrence, and was less tion of " perce-pierre, or stone-piercer," to frequent at night than in the day-time. the instrument Drs. Leroy and Clviale, During the former period the patient did , because the action of that instrument consists lrot feel the want more than three or four only in boring a hole in the stone, each times, and during the latter, in spite of the I time it is fniily presented to the drill. Dr. abstinence from exercise which he under- I Civiale admitted to me in conversation that went,he was obliged to make water every his instrument was not applicable to a stone half hour. A mucose deposit was constantly I of larger diameter than 20 lines.-D. 0. E.
from the
brain, continues its functions
disturbed for days
;
.
of
mulants, such asvapour or hot hip-bath, va- ment, that cholera is not a disease of the ginal injections of ammonia, &c. Intlietrent- brain ; but we know that the secretive and mentcf amenorrbaa, however, the distinction motific
nerves
frequently
continue theit
necessary to be made in so many other functions when the sensifio nerves have diseases is also uffessatv. Should there be lost their influence, and vice 1’eTsa. The fulness, aloetic turpentine, &c., ideot, for the most part, has but littte sense will be useless ; the inflammatory state or of pain, and can bear intense heat and cold congestion of it must be first removed, and with impunity. His senses are blunted, but then diese will come into play beneficially, hnving still the motific power in all his musor, perhaps, not be required. On the other cles, and, what is more to our present purin those of respiration, life, in him, not hand, if there is debility, it is in vain to think of stimulating it until the strength, unfrequently proceeds to longevity. The is sensible and likewise a due quantity of good blood, patient, ou the is restored; and again, when this is done,of pain to the last ; he complains of the the uterus will frequeutly resume its func-’ weight of a blanket, and in a bath at 1000, he feels the heat insunnortable, but his mustions without the aid of these stimuli. powers are prostrate, his stomach and bowels become palsied, and the respiratory organs are unable to continue their function?. Cholera, then, is a disease of neuralgia, and MEMORANDA ON THE the immediate cause of neuralgic disorders EPIDEMIC CHOLERA OF INDIA. is, a diminution of nervous power, as is ob. vious from the little control which the ceBy S. DICKSON, Esq., Assistant Surgeonrebro-spintil organs possess even over volunto the 30th Foot. tary muscles. This decrease of energy may be the effect of a thousand causes. The aetion of the marsh noison is the common. To the Editor of TnE LANCET. cause of agues; but a stricture of thè SIR,—The disease which foms the sub- urethra is sometimes attended with ague ject of the accompanyingpaper, having fits ; and the introduction of an armed bouswept away a number of men of H. M. 30th gie into the same passage, is occasionally Foot, while under mv charge, 1 have been followed by a similar paroxysm. Epilepsy led to pay a more than ordinary degree of at- is as often the effect of irritation of the alitention to ita symptoms. Several of my me- mentary canal, as of direct cerebral disease. dical friends, to whom I have submitted myIt may be produced, also, by various poisons. views of the disorder, think I haveaccounted We see a fall, the prick of a thorn, and the satisfactorily for its phenomena, and havepoison of nux vomica, followed by tetanus. hssured me of their willingness, as opportu- You may simulate this disease hv puncturing titv offers, to my proposed method ofthe spinal chord with a small stilet. treatment to the test of experience. May I Like every other neuralgic affection, charequest the favour of your insertmg my pa- lera, I apprehend, may have its origin in per in your widely circulated pages. many causes; although when epidemic, as I remain your obedient servant, in India, we shall find it more frequently S. DICKSON, Ai’sisf. from a vitiated atmosphere. 1 know Assist. Surg. Surg. H. M. 30th Foot. shadow ofa difference betwixt the train of induced by the action of Bangalore, July 13th, 1829. arsenic when injected into a vein, and thosa observed in this disease. The bite of cer. MEMORANDA ON CHOLERA. tain snakes, concussion of the stomach from I cannot conceive why the learned Mason a blow, and, occasionally, surgical operations, Good should have placed cholera under his nrf followed bya similar disorder Tt la a order ofceeliaca, and that, too, even when ac- frequent result of gun-shot wounds even of knowledging that the nhole nervous energy the extremities. The bydrocyanic and ox. constituting life is frequently in an instant ahc* acids will produce it in its most fatal by this disease, as a Leyden jar form ; so will a stroke of ligbtning or elecis deprived of its eleetricitp by touching it tricity. 1n short, whatever directly or inwith a brass rod. The that the by immediate contact or by symweakens the nervous energy, will, alimentary canal is the original seat of disto its violence and rapidity, proease, seems to have arisen from the circumstance, that vomiting and purging show particular affections, more or less ap themselves at an early period of the disorder; I but both these symptoms may be induced by See paper by Drs. Christison and Coin. fear, which none would on that account call a coeliac affection. The complete rationality det, in the Edinburgh Medical and Surgical of the patieut is brought forward as an argu- Journal for April, SJ
purgatives,
pose,
, cholera
contrary,
cular
arising not the symptoms
supposition,
dpathy,irectly,
according
duce
___________________________.
1823.
236
proaching to’ this terrific disease.t When death is an immediate consequence, we shall not be able, perhaps, to detect a single morbid appearance on dissection ; but where the fatality shall have been slow, we have congestion, and if still more slowly induced, we have inflammation and even gangrene Jt has been the subject of remark, that no two cases of cholera are precisely alike in all their symptoms. The reason is far fiom obscure. The brain and spinal chord hold a control over an extensive system of nerves, and it only depends upon the situation and degree of their derangement, whether any or all of these nerves be implicated when those organs are diseased. In cholera, the muscles of the toes and fingers first act irregularly, then those of the legs and arms. Were the brain and spine to lose their influence only over those distant parts, life would not be in danger ; but when the nerves of respiration and secretion also escape from their control, then, and then only, the dis-
approaches to fatality.
It seems difficult, at first view, to account for the secretions in one patient ceasing entirely, while in another they continue to be carried on with preternatural activity. Some cholera patients, for example, vomit up bile to the very last; the greater number, however, have this secretion stopped. To explain this, it is only necessarv to observe, that the various functions of muscle, and viscus, immediately terminate when the nerves that supply them are cut off from their. connexions with the brain or spine ; that, on the other hand, when this connexion is only partially interrupted, which may be
gland,
.
well-that this
were
the
only secretion
that ceased in cholera. But in the most fatal cases of this disease, the liver secretes no bile—the kidneys no urine ; there is no moisture on the skin, or if there be, it is the cold clammy sweat that exudes from the atonic vessels of the moribund. It is not
what Dr.
supervening.
ease
were
Johnston
terms
it-a sweat
squeezed out by spasms, for in this stage of the disease, a spasmodic action has ceased to exist.
Having
granted
once
symptom of cerebral
or
that spasm is a spinal weakness
that it is the frequent forerunof death in typhus, and precedes palsy in almost, indeed, every instance, shall we doubt it 1), all the symptoms of cholera may be easily accounted for. The pneumo-gastric nerve, as its name denotes, supplies the stomach and lungs with the cerebral energy-a partial inter. ruptiou of its connexion with the hiain
(and seeing
ner
spasmodic vomiting and precordial anxiety; when this connexion is completely cau-es
dissolved
(which it is
in every fatal
case
of
paralysis of both organs. In this instance, there. is no longer violent vomiting—whatever is now taken by the mouth is retained. The stomach is palsied and passive, equally unconscious of the pre. cholera),
sence
there is
of stimulant and diluent fluids. The
breathing for a time is carried on by the diaphragm and intercostal muscles, but these
in the universal unable to continue their functions, and the lungs, consequently, collapse. The sufferer now coughs occasionally, complains ofcutting of bis breath, and the almost inaudible tone in artificially produced by puncturing a nerve, which he answers your questions, shows the functions of either become morbidly ac. that the recurrent branch of the eighth pair tive. Tetanus, I have said, may be pro. is also paralysed; he speaks like a persou duced by puncturing the spinal marrow, who has cut this nerve in an attempt at The function of a muscle is to contract, and suicide. The more the lungs collapse, with in this disease the muscles are in morbid greater difficulty the blood finds its way contraction. Divide the spinal chord en. to the left side of the heart. The little that tirely, and there will be complete palsy. does pass is black and viscid-it is more The passion of grief affords another exam- carbonised than healthy venous blood. The ple : the tears flow profusely in sorrow, but greater portion of this fluid is now collected when the feelings of the sufferer are corn- in the right auricle and ventricle ; it is ill pletely absorbed in this depressing passion, vain that the anxious patient draws, in the the lachrymal secretion ceases, the eye is shape of along sigh, his deepest inspiration dry, like a dead person’s ; it is the glazed to relieve his loaded heart. The blood can. eye of ehoiera unmoistened by a tear. It not pass through the lungs; it must seek new channels. The valves of the external t If fear amount to tC1TO1’, we shall have, veins prevent its regurgitating into them according to the degree of constitutional but the veins of the brain, and abdominal irritability present, ague, hysteria, epilepsy, viscera, having no valves, these are the tetanus, cholera. In the course of our voy- channels into which the superfluity of blood after experien- is naturally sent. These veins, then, must nrie from England to India, cing a severe hurricane off the Cape, thir- be in a state of congestion ; and the super. teen of a pack of thirty dogs which was on ficial veins receiving but a small supply from board, died of a disease extremely resem- the ill-fed arteries, contract in their calibre bling cholera : here it was indubitably the upon this diminished quantity, as they urge it on. Is not this, then, the cause of the effect of terror. -
soon
become
involved
prostration, they
are
237
extremities becoming shrunk and bloodless ;I who have died of cholera, we ehalt nnd them that they are cold and livid, is owing to’ precisely the same as.are observed on open. their not being supplied with red blood. In ing an animal that has been drowned, the puer ceruleas (the greater part of whose strangled, or poisoned by noxious vapours ; blood passes through the open foramen ovale viz. a colldpsed and engorged state of the dlrectlv to the left side of the heart, with- lungs ; a loaded condition of the brain, the out being acted upon by the atmosphere), right side of the heart, and, in a word, of all the extremities are cold and blue, but they the internal veins ; the arterial blood is are not shrunk as in cholera, for they are black ; the colon and urinary bladder are sufficiently supplied with blood, though that empty and contracted in all. Blood drawn blond, from its carbonised state, is unequal before death, is found to be uncoagulable in to the production of heat. We have ac- each and every of these diseases. Professor Coleman, on repeated experi. counted, then, for almost every but the watery purging. Having shown observed that all the air of the lungs how the internal veins are all completely was nearly exhausted in animals killed as congested, we have only to remark, in ad- above described ; but when he passed a ditiun, that wherever there is a great vis a ligature round the trachea, so as to keep the tergo, the bowels, during life, seek to re- lungs distended, lie found that the blood lieve themselves by means of their nume- could pass to the left side of the heart with rous excretories in those watery discharges, ease. The proportion of blood in the left which consist of the more pellucid portion of side was, in such cases, to that of the right, the blood. as nine to seven ; nay, when he distended Let us examine the condition of a person the lungs by water, he obtained a similar rewhose lungscollapse from an artificial cause, sult. When the animal was destroyed with.’ the effusion of blood from a wound in the out this precaution, it was the reverse. The thorax for example :-" You will find him," right side of the heart, the veins of the says Mr. John Bell,with bloody foam at his brain and of the abdomen, were completely his face, pale in the cheeks, and livid loaded. The lungs were then in a state ofround the lips and eyes, heaving the breast collapse or complete expiration. " Expirawith intolerable anguish, tossing side tion (says Haller) wiil, therefore, stop the to side in bed, the bloody foam increasing, easy passage of the blood. through the lungs, the breathing becoming more difficult, and and when the whole thorax is compressed the blood and air rattling in the throat; together, repels the venous blood into the then the pulse flutters, and the extremities veins of the head, and fills the brain and its’ constantly grow colder, till, struggling in sinuses..In this manner, a fresh necessity something like a convulsion, he expires." follows for repeating the respiration, beStllp this description of a few accidental cause the collapsed vessels of the lungs resymptoms, and you have before you a case sist the blood repeatedly expelled from the of Indian cholera. In such a case, there is right ventricle of the heart, and this makes always that dreadful thirst which forms not another cause of death in those animals the least of the cholera patient’s sufferings. which expire in vessels exhausted of air.’ This thirst is common to every disease in Such lungs having the air entirely drawn which there is a difficulty of respiring. It out of them, appear dense, solid, and are is one of the symptoms of phthisis, and is heavier than water, whence they are renderpresent in the passion of grief, where also ed impervious to the blood. Of the same the sighing and anxiety show the inability kind is the death of those who are killed by to breathe freely ; wherever the brain has lightning, and, perhaps, by the noxious valost its perfect control over the respiratory pours of caverns." The treatment of diseases so nearly re-’ nerves,we have this burning thirst. It adds to the sufferings of the wounded in a field of sembling each other, ought, to a certain exbattle, and of all who have lost much blood. tent, to be similar; and, first, as to stimu-’ Almost all the symptoms of cholera may be lants. Having already clearly, I hope,’ induced by loss of blood. Take them in the proved the disorder to be one of cerebro-’ words of Dr. Blundell :—" A certain ghast- spinal weakness, stimulants, I need hardly liness of the countenance, a restless dispo- say, are the remedies chiefly to be depended sition to change posture, a long-continued upon. Ammonia, brandy, camphor, &c., cessation of the pulse at the wrist, a gasping ought to be administered in large doses, the’ respiration like that produced by running, moment the symptoms of the disease appear. jactitation of the arms and legs, joined with Opium, at the commencement, is extramely a feelmg of’ most oppressive anguish." To beneticial ; but I fear I have seen it haestcn these add irritability of the and death in the latter stages. With regard to cold sweats" and ’° cold extre- calomel, 1 hesitate not to say, that I believe it to be totally useless, if not hurtful ; nor mities," and, lastly, .y, asphyxia." If we turn to the post-mortem appear- can I place reliance on any mercurial aaces discovered on examination of those remedy, when I know that the disorder has’
symptom
ments,
mouth,
from
°
’
.
‘
’ _
-
!
z t
t
t
.
I
,
t
stomach
bowels,"
238
attached, and proved fatal to, men in a state every symptom of cholera, this very con. of ptyalism. Blisters. only torture, and, gestion is presentThis congestion causes consequently, weaken the already debili- no cerebral oppression, at least when the c disease first shows itself, and that is the pe. tated patient.
Some of my eastern brethren will ask me, riod when bleeding has its most numerous I have omitted bleeding. If Mr. Cole- advocates. Every body,at all conversant with man’s remarks upon the analogous diseases the disease, will acknowledge, that the pa. already alluded to, be not sufficiently cogenttient sinks more rapidly when raised from against bleeding in cholera, I have others inthe horizontal position. Does this argue an store, which may.be still more convincing.oppressed state of the brain ? Does it not " Were it possible (says Mr. Coleman) toshow, rather, how necessary the blood is to take blood from the part where weknow it the cerebral arteries? Is the rational state superabounds, bleeding would prove one ofof the patient a sin of apoplexy’! When the most efficacious means of recovery. Thecholera ends in coma—when the pupil is right side of the heart has been found to becontracted or dilated, and the patient has loaded with blood ; this universally obtainsstertorous breathing, then, most certaiuly, in the disease ; and I mentioned one or two there is apoplexy. But will bleeding reinstances in particular, where we had an op- move this?—Will it give sufficient portunity of observing that the heart ceased to the respiratory muscles to distend the to act from over distention ; but when re- collapsed lungs ? Assuredly not. To those lieved. from a part of its burden, its contrac- who argue for venesection, on the plea that tions were immediately renewed. If, there- it subdues spasm, I answer, that while it fore, from the right side of the heart, while robs the affected muscles of the little cere. thus in a state of violent plethora, a small bral energy the spasms show they possess, q.uu2ttaty of blood could be taken, experi- it weakens the powers of the respiratory ment and observation tell us, that its power muscles also, and consequently hastens asand action would be instantaneously ii-ivigo- phyxia. The blood is in this case the life, rated ; but as this lies beyond the reach of for without blood a muscle cannot contract, art, the taking of blood from any other part nor a gland secrete ; many die of cholera of the body can rarely be productive of any who, from the first, have never suffered considerable benefit. from spasm. In the last stage of the disease If a ligature be placed upon an inferior there is no spasmodic action ; the internal extremitv, you may bleed your patient in parts are palsied, and the external strength the arm to syncope, but you will not thereby is laid prostrate. If it be boasted that remove the existing below the liga- bleeding has been sometimes followed by ture ; on the contrary, the limb will run success, I believe the reason to be, that the sooner into a state of gangrene. It is ex- irritating cause in such cases has not been actly the same in cholera, where venesec- so great; the, atmospheric poison has not tion must do additional harm, by robbing been so deeply inhaled ; and the records of tJte patient of the little arterial blood so ree- our science bear witness to a successful recessary to the existenee of the brain’s, al- sult in other dangerous diseases, where the practice has been confessedly erroneous. ready too diminished, energy. If you ask three practilioners why they But if it be proved (which it has been by bleed in cholera, one will tell you, to relieve Magendie), that the action of poison is fa. cerebral congestion ; a second, to unload voured by bleeding and retarded by an arti the engorged lungs and abdominal viscera ; ficial plethora, why should we bleed in a while a third will inform you, it is.to subdue disease which arises, indubitably, from an spasm. These practitioners, nevertheless, empoisoued atmosphere? Misled by the regive, at the very moment they detract blood, lations of. authors, and the encomiums they a. diffusable stimulus. They sE:e that the have given to bleeding in- this disease, I disease is one of debility, but they cannot gave it a trial to an extent which I never divest their minds ot the theories about çon- can sufficiently regret. I should have beet gestion, &c., and so they bleed, blister, and more successful had .1 transfused hlood into give brandy, in one and the same breath. my patient’s veius, instead of depewing Is this not blowing hot and cold ? It is the them of this fluid, so necessary to their very same as if they were to order a hot poultice existence. to a bubo with a cold wash above it. Of all the various modes of treatment Let us answer each in order. The same reply resott.dto in nervous diseases, is not will, perhaps, satisfy the two first. it ancounter-irritation the most generally efficaanimal be allowed to bleed 11 low from lifeC;ous!? Zinc, arsenic, and copper, are called away," this very congestion of the brain, tonics ; may they not rather be termed irrilungs, and abdominal viscera, will be found tants, seeing that when they produce cures among the post-mortem appearances. Wouldi in ague, epilepsy, gout, palsv, &c., they do these gentlemen, then, bleed in a case ofso ouly by establishing an analagous disease uterine haemorrhage, wheie, in addition to act, m a word, by counter-irritation.
why
energy
B
°
plethora
they
I I
239 How instantaneously does cold water, dash- shortly after being attacked, .took drachm tdin the face, recall the neeting energy of doses of the arsenical solution, every twenty the brain in
syncope !
Dr. Currie
was,
I
minutes,
to the extent of four
drachms. Dr.
believe, the first who introduced the cold Perston, H.M.2bth, found her, in the bath in tetanus; he attributes its good effects solely to counter-irritation. On this principle the French physicians treat the disease with nux vomica, which, as we have already said, produces a similar disorder. The poi-
of the same
in her
day,
even-
collapsed state, and administered to brandy, with large doses of tinct. lytta, a remedy which, among his female patients, he has found very suc-
ing
a
cessful..
If in some instances of poisoning from duces a train of symptoms analogous to cho- opium, life has been restored by blowing )era. The natives of India treat the bite’ into the lungs with bellows, after apparent Qf the cobra de capello successfully with death had taken place by the cessation of rsenic. Ought not this to be an induce- respiration, this practice ought not to be ment to give it a fair trial in cholera1 In neglected under similar circumstances in the case of a Sepoy who came under my cholera. Might it not be uselul, moreover, care, I administered to the extent of 5ij of to expand the patient-’s lungs in- this man< Fowler’s solution at a dose; the patient re- ner when we observe the respiration to becovered. In several European cases, I tried come difficult 1 :, the fumes of arsenic,by making them inhale Ilaving already glanced at several of the the remedy from a common tobacco-pipe, nervous diseases which owe their origin to and in the majority of instances with suc- particular passi-ons and’poisons, it may no£ cess. I attribute the deaths that occurred be out of place to remark that all these irritomy having, unfortunately, bled the pa- tating causes, when long localised, are capaother forms of disease very tients at the same time. In one instance, ble of 1I’hele re-aetlcm had taken place after the analogous to each other. Thus the various exhibition of the remedy, 1 believe a fatal poisons of lead, arsenic, and mercury, when termination to have been produced by the slowly accumulated in the system, exhibit ealiaastion of a long confession, and the their effects in disorders, similar to those additional fear of extreme unction. which, uader the name of scurvy, abound in I apprehend, that the usual practice of a marshy country; and these, again, are covering up the patient with a blanket in daily mistaken for syphilitic diseases. If cholera is decidedly hurtful, inasmuch as the patient have at any period had venereal the skin is thus kept from absorbing oxygen disorder, not a doubt is entertained. If he from the atmosphere, which, in this dis- have not, his physician is sceptical as to the ease, ithas the power of doing to a greater truth of his assertion ; and if he cure him extent than at any other time ; for the exter- with mercury, he prides himself upon such nal veins being neariy empty, absorption scepticism, forgetting that many scorbutic goes on rapidly, as we see in the sudden diseases yield to this mineral. eyes, disappearance of the fat of the eyes and spongy gums, cutaneous eruptious, diseased lips, Frictions of the legs and arms are bones and liver, dysentery, colic, epilepsy, powerful auxiliaries in every case of dimi. tetanus, tremblings of the muscles, and wished vitality, and consequently prove palsy, are the common diseases of a malaria luglily beneficial in cholera. I have seen district. To these might be added, intracttoo many patients expire from the debility able ulcers, elephantiasis, idiotcy, diabetes, induced by the warm-bath, to recommend it consumption, and malignant tumours, such in cholera, In the commencement of the as cancer and fungus. Does not the fact, that disease the cold-bath, I have no doubt, all these diseases are benefited by arsenic, mi;ht be serviceable, from the good I have go far to bring them under one family. Do seen done by cold ablution in the more ad. ,not many of them too frequently embitter vanced stages; the patients, one and all, the lot of those whose constitutions have declared it to be extreinely grateful. Dr, been broken up by corroding grief, and by Stephenson, of H. M. 15th Dragoons, has long courses of mercury for fancied syphilitic the merit of first-putting the coid-bath to disorders. We find them in miners long the test of experience, and he reports very exposed to the fumes of arsenic or copper, highly in its favour..and in those who work in lead, such am It is the common custom to deny the plumbers, glaziers, and painters. When patient cold drinks in the disease ; on what these diseases arise from poisons, analogous account I am at a loss to conceive. Ou a poisons are the medicines, perhaps, most to late occasion I indulged a female with a be depeiideduvon ; iodine, arsenic, mercury, deep draught of the coldest water, and she and silver, are highly successful in the dissaid it restored her strength. To the same eases of malaria ; while many mercurial patient I gave half a bottle of beer when she disorders yield to mercury itself. called forot, and obtained a similar declaraNote.-In some cases of cholera, patients tion. The woman recovered. This woman, suffer from- trismus. The only ditrereuce son
of
arsenic, and of certain snakes, pro-
producing
Sore
.
! ,
240 which seems to- me to subsist betwixt cholera present, and remained in suspension in the and tetanus is this, viz. that while in cholera urine. Mr. R--- at first consulted two very the nerves of both the brain and spine become almost at once inadequate to the per- respectable practitioners of Limeriok. Of formance of their respective functions, in these Mr. Carroll assured him that the symp. tetanus for some days the nerves arising toms left no doubt as to the existence of from the spinal chord only, are affected ; stone in the bladder, but that catheterism hence the eighth pair deriving its origin did not justify this conclusion. Having
un- called Mr. Thwaites into consultation, he and the blood circulates proceeded to’ a careful examination, but freely. Where this disease terminates in neither of these gentlemen could satisfy death the eighth pair becomes also involved. himselfof the presence of the foreign body. The patient, therefore, dies the same death According to the advice of these gentle. as those who die of cholera, viz. of asphyxia. men the patient came to London and con. sulted that eminent surgeon Mr. Green, who could discover no stone. He was sent by Mr. Green to Mr. Brodie, by whom he was sounded, and a sensation experienced suffi. LITHOTRITY. ciently plain to convince him of the existence of a calculous body. Afterwards Messrs. Brodie and Green consulted together, and CASE OF STONE IN THE BLADDER TREATED carefully explored the bladder, but did not WITH THE BRISE-COQUE, succeed in detecting a stone. Mr. Rthen went to Mr. Lawrence, who was also By BARON HEURTELOUP. unsuccessful in his researches. (Communicated by D. O. EDWARDS, Esq. Mr. Green now brought the patient to Westminster Hospital.) I practised catheterism according to me. Mr. R--, ag-ed 60; good constitution ; my system, and immediately ascertained the presence of a foreign body. 1 deter. slight cala?-rlt of the bladder ; a smooth mined in two days’ time to resume my exand flat unic-acid calculus, from about ten to twelùe lines in diameter-Difficulty ploration, with a view of learning the nature and state of the calculus, in order to proceed of recognising the existence of this stone to its destruction. its the -Employment of perce-pierre ; Green and Mr. Brodie being present, insufficiency-Employment of the brise- andMr. the patient conveniently placed on the coque- New " sonde exploratrice"rectangle-bed, I first performed catbeterism Cure. with the recto-curvilineal sound, and I be. Mn. R-,a merchant of Limerick, about came conscious of the presence of a body sixty years of age, of a sanguineous tempera- which 1 judged was sufficiently small to be ment and good constitution, having always destroyed with a perce-pierre. * The enjoyed excellent health, and having never bladder was injected with a suitable quantity experienced the least pain in the region of of water, and the sound withdrawn. I inthe kidneys nor voided gravelly particles, troduced the instrument, the stone was im. was about a year since, conscious, for the mediately seized, and submitted to the action first time, of a sensation of lieat at the ex- of the lithotritor, but before its action was tremity of the penis, and which soon dege- completed the calculus escaped from the nerated into a sense of pinching when the claws; being retaken several times, it as bladder was quiet, and of vivid and lancinat- often escaped, and the instrument could ing pain during the expulsion of the urine. make no impression upon it in consequence. A stumble, the act of sitting down, or the A second application of the perce-pierre, entering a carriage, increased the intensity was nearly as fruitless as the first, the stone of these painful sensations ; but Mr. R—— as soon as taken slipped away from the immediately experienced relief on placing grasp of the instrument. Some sabulous himself on his side. Notwithstanding vari- particles brought away in the teeth of the otis symptoms indicative of stone, the urine drill, and a few small fragments ejaculated flowed in a full stream, and wa-3 not suddenly * arrested in its course; the desire of urining M. Heurteloup has given the appellawas not of frequent occurrence, and was less tion of " perce-pierre, or stone-piercer," to frequent at night than in the day-time. the instrument Drs. Leroy and Clviale, During the former period the patient did , because the action of that instrument consists lrot feel the want more than three or four only in boring a hole in the stone, each times, and during the latter, in spite of the I time it is fniily presented to the drill. Dr. abstinence from exercise which he under- I Civiale admitted to me in conversation that went,he was obliged to make water every his instrument was not applicable to a stone half hour. A mucose deposit was constantly I of larger diameter than 20 lines.-D. 0. E.
from the
brain, continues its functions
disturbed for days
;
.
of