- Email: [email protected]
NEW TREATMENT OF CHOLERA: ITS ORIGIN AND CURE.
drooping. Soon after this, the reflex leg became completely abolished.
actions in the
paralysed scriptions
exceptional instances,
or
at least to
cause
it
in them the real
paralysing lesion existed (though perhaps overlooked or unappreciated) as usual in the opposite hemisphere. It may, perhaps, be urged that as in this case of mine a distinct lesion was found after death in the right half of the brain, therefore there is no need to suppose any exceptional direct,
October, he suffered from severe pain, without either or redness, in the right knee, which lasted several weeks, and was quite uninfluenced by remedies. In December, several spasmodic or convulsive seizures occurred, and in one of them he was found stretched across the In
swelling
state of oepisthotonos. His mind had now beand he had a distinct attack of n gouty inflammation in the left elbow. In January, 1857, he continued to become more and more
bed almost in
in these
to be inferred that
even
instead of
crossed, nervous influence. But it appears to me that, although such an explanation of the phenomena is possibly the true one, yet that the whole train of symptoms during life, as well as of the morbid appearances after death, are entirely childish. The sphincters were only imperfectly under control. opposed to such a supposition; for 1. The primary seizure was one of acute disease, apparently He had a slight cough, and was observed to be losing flesh fast. In February, the flexor muscles of the paralysed arm had be- haemorrhage, with either active congestion or inflammation, and probably of a gouty character. come very tense and rigid, so that attempts to strighten the limb caused very great pain. Voluntary power over the leg 2. The paralysis came on suddenly, and was doubtless due to come
much
a
enfeebled,
the clot found
much increased. He died in April,
was
on
the outer side of the left corpus striatum. This
sinking gradually from exhaustion, death clot was small, (thus accounting for the slight affection of conbeing preceded by expiratory puffing of the cheeks, frequent sciousness,) and had not the appearance of being a haemorrhage - convulsive tremors of the muscles of the neck and face, apathy, resulting from softened brain substance; for although not disand imperfect coma. tinctly encysted, the cerebral matter immediately around it Dissection, April 25th, l857, twenty-four hours after death.- was sufficiently dense, and it was only externally to this that
Head : The parietal and frontal bones marked on their outer it became very soft and diffluent. 3. The amount and degree of softening were infinitely greater surface by several pits or depressions, the largest as big as a shilling, evidently cicatrices of old ulcerations. At these on the left side than on the right. 4. The mass of tumour in the left hemisphere was as large as places, the bone was found to be quite thin and translucent; and to the inner surface of one, situated in the centre of the a good-sized walnut; that in the right scarcely bigger than a left parietal bone, the dura mater was adherent by an old pea, and utterly insignificant in comparison with the other. 5. The paralysis of the eye and eyelid, a few days after that organized patch of lymph. The arachnoid milky nearly everywhere, and quite opaque where it covered the right hemi- of the limbs, was on the left side. 6. There was no atheromatous disease of the eerebral arteries. sphere and the base of the brain. A large elongated patch of 7. It is worthy of remark, that the former attack of paralysis bodies on internal Pacchionian the enormously-developed edge of right hemisphere, to which the dura mater adhered inti- of the arm was on the left side, and that the morbid appearmately. At the base of the skull, in one small spot upon the ance which best accounted for this-viz., an old organized posterior part of the right petrous bone, the dura mater was patch of lymph on the inner surface of the centre of the almost absorbed, leaving only the transparent arachnoid mem- parietal bbne, was on the left side also. - P*or all’; these reasons, I incline strongly to the opinion that brane. The anterior surface of both petrous portions of the temporal bones so much thinned by absorption as to leave the the paralysing lesion existed in the left hemisphere, that the slightest possible covering of areolated bone to the internal ear. disease found in the right was secondary in point of time, and Pia mater vascular; the cerebral substance somewhat con- that the influence exerted upon the limbs was direct instead gested ; no apparent disease of the arterial system. On open- of crossed. And much do I regret not to have examined ing the left lateral ventric!e, the corpus striatum and adjacent minutely the medulla oblongata, with a view to the possibility part of hemisphere were seen to be more prominent than of the existence of an abnormal arrangement of the fibres of its natural, and had a gelatinous appearance, as if both oedema.- anterior pyramids, (a possibility suggested by Dr. Bright,) tous and softened. At the junction of the left corpus striatum which, if present, would form a ready explanation of the direct with the hemisphere was found the remains of an old clot, the influence exerted in the two attacks of paralysis. This case is highly interesting in other respects, such as size of a horse-bean, the blood being semi-fluid, and like to ina coincidence in the same individual of the syphilitic, spissated bile. The cerebral substance around it was softened, showingand scrofulous materies morbi; but as my object in rediscoloured; the substance of the corpus striatum itself gouty, was infiltrated with serum, and softened, and occupying its cording it has been simply to call attention to the exceptional outer and anterior part was a firm greenish-yellow tumour of character of the nervous disorder, I shall forbear to enlarge irregularly-elongated form, about equal in bulk to a walnut, upon its other salient points. and surrounded by softened and discoloured brain. On the Norwich, July, 1857. right side, situated in the hemisphere, just external to the corpus striatum and optic thalamus, was a small mass similar in appearance to that found on the other side, consisting of NEW TREATMENT OF CHOLERA: two small rounded nodules, the size of swan-shot, adhering toITS ORIGIN AND CURE. gether by a sort of pedicle, and surrounded by softened cerebral substance.-Chest: Old adhesions of pleurae, chiefly on BY A. C. BOATE, ESQ., L.R.C.S.I., the left side. At apex of the left lung were some small tuberLATE ONE OF THE SURGEONS TO HER MAJESTY’S 6TH DRAGOONS, cular masses, some of them in a state of incipient calcification. (INNISKILLENS.) - abdomen : Liver large, adherent by old false membranes to the peritoneum, its structure granular and almost nutmeggy WHAT is cholera ?-or what is the nature of this terrible diskidneys large and congested; a little purulent fluid in the pelvis of the left. ease, so sudden in its attack, and in many instances equally so The cerebral tumours appeared to be composed of a low form in its fatal termination? of fibrinous exudation, and showed, as their microscopical eleIn the autumn of 1853, at Newcastle-on-Tyne, where I was ments, a granular blastema, containing a large quantity of free oily-looking dots and granules, and corpuscles of various sizes quartered with part of my regiment, the cholera prevailed to a and shapes containing granular matter, and the same bright- fearful extent, so much so that the deaths of the inhabitants in the town and adjoining the barracks were from 100 to 150 looking dots, so many of which were seen floating free. For the preceding case (a brief notice of which I a few weeks daily, and, although the numerical strength of the garrison ago brought before the Norwich Pathological Society) I venture was nearly 500 men, exclusive of women and children, not a to ask a place in the pages of THE LANCET, believing it to be death occurred. The treatment adopted I will give in worthy of record as a genuine example of that very rare condi- single tion of disease, in which the paralysing lesion exists on the detail. same side of the body as the paralysis itself. So rare is it, that At Newcastle-on-Tyne in 1853,I gave this epidemic my most Dr. Watson (" Lectures on Physic," vol. i.) refers to only two attentive consideration. Afterwards in Varna, in Turkey, in such cases, Dr. Todd (article Paralysis in "Cyclopaedia of 1854, (where the troops were nearly decimated,) at which Medicine’’) to only four, and Dr. Bennett (in " Library of Medi- period I became confirmed in an opinion,--which before I cine" speaks of being acquainted with only twenty-one similar had some doubts of, not having had sufficient experience,ones as having ever been published. Moreover, the tone of all that cholera is originated in the brain and spine by some the authors whom I have consulted on this subject is such as to magnetic or electrical condition of the earth and atmosphere, imply a doubt of the authenticity or trustworthiness of the de- withdrawing or suspending their influence over the various ’
but not
I
135
nerves of the body, but more particularly from the pneumc gastric nerves, those nerves that preside over the stomach lungs, and vocal organs, and which are essentially necessary t the functions of respiration and digestion. Take, for example a dog or a rabbit, divide or paralyze by artificial means it pneumogastric nerves, and you produce the identical symptom
of cholera.
In the Appendix to the Report of the Committee for Scientifi in relation to the cholera epidemic, 1854, Tabl XXXVII., showing the electricity of the atmosphere at th, several stations, is most interesting, and affords a great l( for further study and observation. I maintain that it is th negative electricity that acts on the sympathetic brain an( spine, and produces cholera. On turning to page 103 of th, same Report, I find a passage which strongly bears me outv’iz.: "I much regret that the electrometer observations begal to" late to afford any decided results. They would, however seem to show that a deficiency of electricity prevailed durinl the time when the disease was at its height, and that at loa stations, as compared with higher, a deficiency was likewise t< be observed, which fully accounts for the prevalence of cholen in low districts." There are two forms of this direful malady : Cholera Mitior, ataalogous to English cholera; and Cholera Asphyxia, or suffo cative cholera, the latter being the most dangerous. Complete paralysis or suspension of the brain’s influence over the various nerves of the body, particularly of the pneumogastric nerves, exists in this special form of the disease. The lungs do not perform their proper functions; the vitality of the blood is not maintained; connsequently the duration of the disease depends upon the complete or incomplete paralysis of these nerves. While, in certain localities, the electrical condition of the earth and atmosphere is pred’Í8po8Í1/[J only, the immediately exciting causes are many and various, effluvia being amongst the most prominent; 2nd, excesses of any kind; 3rd, evaporation arising from damp floors, cesspools, &c.; 4th, purgatives taken for some other complaint. I cannot give a better example of immunity from the cholera epidemic than the Newcastle Garrison when I was in charge, and I attribute it solely to guarding the soldiers against the exciting causes, and, by a strict surveillance over their habits, doing away with effluvia; and cautioning them against the danger of not making immediate application on the appearance of diarrhoea,. The first symptoms are vomiting and purging-exactly what takes place when the brain is injured; but I have frequently noticed that patients generally complain of a tightness of the chest, sometimes amounting to pain, with a difficulty of respiration, and occasionally uneasy sensations in the head previous to these; after which come cramp, loss of voice, &c. &c. Having briefly stated what the predisposing and exciting causes are, I beg to add a, few observations, as well as my experience, relative to its treatmeiit. What can this be, in a disease in which the door to medication is in most instances closed by the early paralysis of the gastric nerves ? The physician must have recourse to a remedy possessing an instantaneous effect over the brain and nerves. Now, everyone knows the effect of an emetic, acting directly on the brain, exciting a more vigorous action of the powers of the constitution, as is proved by the amendment of the pulse, and other favourable appearances, immediately after vomiting. Although produced by debility of the brain in the first instance, it has the effect of reflecting strength back on the constitution. This is the groundwork of my treatment in every stage of cholera :-First begin with an emetic, followed (after the action of the emetic has ceased) by an opiate-say thirty to forty minims of tincture of opium, and thirty minims of sulphuric ether, to two ounces of water. If this does not rest on the stomach, a pill, composed of three grains of calomel and one grain of opium, is to be given. This will often remain on the stomach when nothing else will. But what is to be done in collapse, when the pulse is small and thready, resp ration almost suspended, and lividity pervading the whole system (the circulation being impeded owing to the contracted state of the lungs}? Chloroform is the grand remedy. But how does it act, or how should it be administered ? It is given by inhalation, carefully marking or watching the effect upon the pulse. Now the first effect of chloroform is a strong stimulant, the pulse becoming full and bounding, where beore its use it could hardly be felt. You must prolong its application as long as the pulse is full, and the moment it begins to sink, withdraw the chloroform; alternately repeating and withdrawing the stimulant until the patient lapses off to sleep. I may also add, that in a case of incessant vomiting, where nothing will remain on the stomach, a full opiate, say thirty or forty minims of tinc-
Inquiries
136
ture of opium in combination with half a drachm of
ether, may in a little water, and then the chloroform administered, which instantly checks the vomiting; and this action being kept up, the opiate becomes absorbed, and sleep very soon follows. This I maintain is a new treatment, and one which I in. variably adopted during the cholera epidemic at Varna, (where I was in charge of her Majesty’s 6th Dragoons,) and with su.eh success, as the medical return will show, (vide "Army Medical Board Returns,") that out of 62 cases of genuine Asiatic cholera, I only lost 9 patients (about 14 per cent.) I will illustrate this treatment by giving a few cases:Private ——, 6th Dragoons, was attacked in the night with severe diarrhoea, quickly followed by vomiting, great mental Did not make any application to medical depression, &c. officer until the next day. On the morning following his attack his comrades gave him brandy, pepper, &c. He allowed the disease to go on until the evening, when my hospital sergeant heard that he was ill, and reported the case to me. I visited the man’s tent, which was a small one, pitched at the back of his master’s ball-tent, only a few yards intervening. I found him in a state of extreme collapse, lividity pervading his whole system; incessant vomiting, with frequent diarrhoea, and pulse not to be felt. I ordered him to hospital instantly, administered a mustard emetic, which had the desired effect, and then applied the chloroform, having first given him a full opiate in conjunction with a stimulant. The pulse, which at first appeared small and thread-like, gradually became larger, stronger, and fuller. I kept up the action of the chloroform until the pulse began to diminish, and then withdrew it, again to repeat it after a short interBa]. The vomiting and diarrhoea ceased, and sleep followed. The patient remained asleep for about four hours, and awoke complaining of great thirst, which I have invariably remarked in all cases of cholera. I always kept a large quantity of solution of bicarbonate of soda with a little ginger, which I think makes the nearest approach to the saline ingredients of the blood, the ginger being merely to stimulate and warm the stomach and intestinal This I allowed the patient to partake of freely. canal, &c. He had slight consecutive fever, but was recovered and at his duty on the sixth day. Sergeant ——, 6th Dragoons; admitted into hospital, complaining of uneasy sensations in the head, slight pain, or tightness of the chest, as he termed it; vomited frequently during my examination of him; stated that he had suffered from diarrhoea, the greater part of the night; great mental depression; pupils much dilated; pulse very small, and with difficulty could be felt; in fact, the usual symptoms that characterize this hitherto formidable disease. Ordered, a mustard emetic; as soon as the action of the emetic ceased, a full opiate, with ether, in a little water. Vomiting and diarrhoea ceased, and sleep followed. At his duty on the third day. Sergeant Major ——, 6th Dragoons, (treated in his tent;). was attacked with diarrhoea in the middle of the night, quickly followed by vomiting; stated he drank a good deal of native This was a good wine (sheerah) on the previous evening. example of excess as an exciting cause. His countenance was shrunken and nearly livid; voice scarcely audible; pulse hardly to be felt. A mustard emetic was administered, which did not act for some time, but when it did, it was effectual, a large quantity of bilious secretion coming away. A full opiate, with sulphuric ether, was administered, and immediately followed by the inhalation of the chloroform, to prevent the rejection of the opiate and stimulant. The pulse rose full and bounding, lividity disappeared, and I had the gratification to find my patient in a slumber after a few minutes. Ultimately he did well, and was quite restored to health in a few days. I could add several other cases, more or less severe than these, but I think it would be superfluous. I did not take any notes of the number of dicrlaceal cases, which were very frequent; as many as fifty or sixty patients (in my regiment) made application daily to hospital for medicine to check this disease. The most successful formula I found to stay it was a mixture composed of the following ingredients:= Prepared chalk, aromatic confection, tincture of catechu,. tincture of kino, gum Arabic mucilage, tincture of opium3 distilled water. Also a pill composed of three grains of calomel, one grain of opium, and one grain of aromatic confection. These were the formulee which I also used at Newcastle-onTyne in 1853, when there were nearly 500 cases of diarrhoea admitted into hospital, and not a single death. Compare this with the report of the London hospitals in 1854, and truth-will speak for itself. In Dr. Babington’s Report on the Cholera amongst the Blaok be
given
!
.
quite
furnished to the Board of Health, a great deal of less instances in which unusual sensitiveness exists to alas ! after comparing the reports of both warm and cold substances, depending upon a variety almost all the medical officers of the Black Sea fleet, he con- of causes: such as exposure of the necks; or arising from cludes thus: "But no measure of success seems to have fol- chipping and fracture of the tooth from brittleness or some lowed any mode of treatment, so as to recommend it emphati- other cause ; or, again, where the tooth has been filed, cally beyond the rest." Some of the suggestions in Dr. cut, or accidentally broken. A very striking instance of this Babington’s compilation are, he states, very valuable, and it kind-that is, unusually great suffering from taking either affords much food for reflection on a disease, the nature of warm or cold liquids into the mouth-came under my care but the other day, in which permanent and complete relief was which remains so obscure. In putting these few notes together, I have carefully afforded from the electric cautery. If a tooth is snapped off avoided enlarging this little treatise, or adding any superfluous at the neck, and the pulp-cavity becomes exposed and painful, matter, thereby making it easily comprehended. Already the it can be destroyed, and an artificial tooth may be fastened to symptoms are, I am confident, but too evident to those who the stump, in the same manner as when the tooth is intentionever-once saw cholera; and besides, they are so elaborately deally removed for this purpose. Sometimes, also, bleeding will scribed by so many authors. My object is merely to introduce occur from the rupture of some minute capillary vessels during a new treat1nent for this hitherto formidable disease, and which the removal of caries from a cavity which may have become has-been so far successful, that I deem it but right to make it morbidly vascular, without the presence of actual pain or even hmown for humanity’s sake. - sensitiveness; it is equally serviceable here as in other forms z1 think a great deal of useful information may yet be derived I of disease, and stops the haemorrhage, which is inconvenient from carefully-made observations with the electrometer at ’, and -troublesome, from its interference with the progress of the tooth. I have -also applied it in sensitiveness night, for invariably every case of cholera that I had to deal with in my extensive field of practice occurred between twelve arising from the wearing away or grooving of a tooth, from the and three o’clock at night. Not having an electrometer in my , constant pressure of the spring clasp of a plate, which has, possession, either at Newcastle-on-Tyne or at Varna, in Turkey, caused the destruction of the dentine ; mechanical friction, in Pmade no observations. fact, producing this condition. As a general rule, the electric cautery may be used with Composition of chloroform: C2 H Clg. It is improperly called a tes·cleloa°ide of formyl, its real composition being as I decided advantage in almost every case of diseased tooth, with have stated above. Its action is stimulant, sedative, and anti- very few exceptions. But the commonest affection constantly 6pa6modic, the identical three objects essentially necessary to requiring its use, I again repeat, is ordinary toothache, not recover a cholera patient. unfrequently most agonizing in its character, and depending upon the presence of a cavity from caries, which has laid bare 3u1’, 1857. the delicate nervous pulp contained in it, which, so long as it likely to come into contact with the liquids and solids of the THE ELECTRIC CAUTERY AND ITS APPLI- mouth, will continue in this condition. Destruction of ,the pulp and subsequent stopping prove the remedy; the nerve is CATION TO DENTAL SURGERY. destroyed,! the pain disappears, and the tooth remains -for BY THOS. H. HARDING, ESQ. years, and answers a,s well as if it had been filled without,exposure and destruction of the pulp. (Concluded from p.82.) The electric cautery therefore saves many a tooth which, without its would be otherwise totally lost. It is preOf the opemtion in partiwla1..-The great object of this ope- served for aid, and years, perhaps it is not saying too much, that, if ration, which I am endeavouring so strongly to recommend in ordinary care and precaution are used, it will most probably the present communication, is to destroy the irritable ulcer in last the life-time of the individual. This, perhaps, may seem the membrane of the tooth which permits the nerve to be ex- to be problematical, as many dentists would declare that, if posed, and which is often associated with the presence and the nerve is destroyed, the tooth is dead; it is a foreign body, and will last but a few years, ultimately decay, and require even protrusion of minute granulations, not dissimilar to what extract,ion. The certainly destroys either a portion-or the surgeon meets with as protruding from an ulcer situated the whole of the cautery dental or nervous pulp; I will say, for arguover a carious or necrosed bone in some other part of the body. ment’s sake, that it does completely and effectually destroy This condition is accompanied with a certain amount of inflam- the nerve of the tooth. The tooth, however, receives nourishmation and tumefaction. The cautery, as I have said before, ment from the periosteum covering its -fang, as well as from lining its socket, and it would seem that there may even completely destroys the affected parts, and there is no time that be minute nervous twigs accompanying the equally minute left to produce a new surface; nor do I think that could be capillary bloodvessels which afford life and sustenance to the accomplished after the destruction of the pulp; nor, again, is plugged tooth. It cannot therefore be looked upon as a foreign it a necessary measure, as no particular good could be derived body, as it possesses and retains its vitality, .which is derived from it, were it to be permitted to occur. The cavity is at through its fang, or, in other words, from without, and is thus capable, from the reasons mentioned, of lasting with proper once plugged and the admission of air to the tooth prevented, Mr. Nasmyth has beautifully care, the patient’s lifetime. and the sensitiveness and carious condition are shown that a tooth is supplied with a large number of minute removed. nervous twigs and bloodvessels. I must also speak of another form of affection which has Now, of the proper cases in which the electric cautery may be used, the most important and common is that known as ’, been relieved by it- namely, neuralgia of the face-a form of severe ordinary toothache, especially that form of tooth affee- ’, tic douloureux, supposed to depend upon some other cause-than tion arising from a cavity with exposure of the tooth-pulp. InI a carious tooth. On examining the mouth, however, I have cases also of cavities requiring filling, in which too great a sendetected an affected tooth, on destroying the pulp of which sitiveness is present, thus preventing the satisfactory removal with the cautery, and subsequently stopping it, a permanent of the carious portions of the tooth, it is equally valuable. It cure has been effected. is useful also in cases where the gums have receded, with exIt may be recommended as admirably suited to destroy posure of a -part of the neck of a tooth, which .is extremely fungous growths springing from the internal pulp, which often sensitive and oftentimes very painful to the touch; in these it bleed very profusely on the slightest touch. It will thus be seen that the application of the electric is necessary merely to touch the exposed necks, to remove the sensitiveness. It is not less serviceable in its application to cautery is wide and extensive, in the number and variety of tender, sensitive, and bleeding gums, producing a new and the oases of tooth disease. The following, however, are unfit for it, as it would not only healthy action, which permits them to become firmly attached again to the necks of the previously-exposed teeth. Sometimes produce no good, but harm might result from its use :it’is merely necessary to hold the heated wire near a sensitive When a tooth is loose, with its external aspect sound, but neck, without actual contact, to remove the tenderness. I have the pain depending upon the presence of a fungous growth or with the greatest ease and rapidity, the pulps of small abscess developed at the end of one or more of the fangs. destroyed, incisor teeth which have been cut off for the purpose of being In such a case extraction only will afford relief. It will prove of no avail, in an attack of inflammation of the ,pivoted. Every dentist is aware of the sensitiveness which sometimes exists in a pivoted incisor tooth, depending upon pulp, which may sometimes affect a tooth that is otherthe vitality of the stump; this is completely obviated by the wise apparently sound. This may be known by the severe, 4iF,e of the cautery. I have employed it also in number- heavy, throbbing pain which _it occasion?, running up to the
Sea
Fleet,
ingenuity is shown, but,
I
stopping
_________________
permanently
I
I central
137
actions in the
paralysed scriptions
exceptional instances,
or
at least to
cause
it
in them the real
paralysing lesion existed (though perhaps overlooked or unappreciated) as usual in the opposite hemisphere. It may, perhaps, be urged that as in this case of mine a distinct lesion was found after death in the right half of the brain, therefore there is no need to suppose any exceptional direct,
October, he suffered from severe pain, without either or redness, in the right knee, which lasted several weeks, and was quite uninfluenced by remedies. In December, several spasmodic or convulsive seizures occurred, and in one of them he was found stretched across the In
swelling
state of oepisthotonos. His mind had now beand he had a distinct attack of n gouty inflammation in the left elbow. In January, 1857, he continued to become more and more
bed almost in
in these
to be inferred that
even
instead of
crossed, nervous influence. But it appears to me that, although such an explanation of the phenomena is possibly the true one, yet that the whole train of symptoms during life, as well as of the morbid appearances after death, are entirely childish. The sphincters were only imperfectly under control. opposed to such a supposition; for 1. The primary seizure was one of acute disease, apparently He had a slight cough, and was observed to be losing flesh fast. In February, the flexor muscles of the paralysed arm had be- haemorrhage, with either active congestion or inflammation, and probably of a gouty character. come very tense and rigid, so that attempts to strighten the limb caused very great pain. Voluntary power over the leg 2. The paralysis came on suddenly, and was doubtless due to come
much
a
enfeebled,
the clot found
much increased. He died in April,
was
on
the outer side of the left corpus striatum. This
sinking gradually from exhaustion, death clot was small, (thus accounting for the slight affection of conbeing preceded by expiratory puffing of the cheeks, frequent sciousness,) and had not the appearance of being a haemorrhage - convulsive tremors of the muscles of the neck and face, apathy, resulting from softened brain substance; for although not disand imperfect coma. tinctly encysted, the cerebral matter immediately around it Dissection, April 25th, l857, twenty-four hours after death.- was sufficiently dense, and it was only externally to this that
Head : The parietal and frontal bones marked on their outer it became very soft and diffluent. 3. The amount and degree of softening were infinitely greater surface by several pits or depressions, the largest as big as a shilling, evidently cicatrices of old ulcerations. At these on the left side than on the right. 4. The mass of tumour in the left hemisphere was as large as places, the bone was found to be quite thin and translucent; and to the inner surface of one, situated in the centre of the a good-sized walnut; that in the right scarcely bigger than a left parietal bone, the dura mater was adherent by an old pea, and utterly insignificant in comparison with the other. 5. The paralysis of the eye and eyelid, a few days after that organized patch of lymph. The arachnoid milky nearly everywhere, and quite opaque where it covered the right hemi- of the limbs, was on the left side. 6. There was no atheromatous disease of the eerebral arteries. sphere and the base of the brain. A large elongated patch of 7. It is worthy of remark, that the former attack of paralysis bodies on internal Pacchionian the enormously-developed edge of right hemisphere, to which the dura mater adhered inti- of the arm was on the left side, and that the morbid appearmately. At the base of the skull, in one small spot upon the ance which best accounted for this-viz., an old organized posterior part of the right petrous bone, the dura mater was patch of lymph on the inner surface of the centre of the almost absorbed, leaving only the transparent arachnoid mem- parietal bbne, was on the left side also. - P*or all’; these reasons, I incline strongly to the opinion that brane. The anterior surface of both petrous portions of the temporal bones so much thinned by absorption as to leave the the paralysing lesion existed in the left hemisphere, that the slightest possible covering of areolated bone to the internal ear. disease found in the right was secondary in point of time, and Pia mater vascular; the cerebral substance somewhat con- that the influence exerted upon the limbs was direct instead gested ; no apparent disease of the arterial system. On open- of crossed. And much do I regret not to have examined ing the left lateral ventric!e, the corpus striatum and adjacent minutely the medulla oblongata, with a view to the possibility part of hemisphere were seen to be more prominent than of the existence of an abnormal arrangement of the fibres of its natural, and had a gelatinous appearance, as if both oedema.- anterior pyramids, (a possibility suggested by Dr. Bright,) tous and softened. At the junction of the left corpus striatum which, if present, would form a ready explanation of the direct with the hemisphere was found the remains of an old clot, the influence exerted in the two attacks of paralysis. This case is highly interesting in other respects, such as size of a horse-bean, the blood being semi-fluid, and like to ina coincidence in the same individual of the syphilitic, spissated bile. The cerebral substance around it was softened, showingand scrofulous materies morbi; but as my object in rediscoloured; the substance of the corpus striatum itself gouty, was infiltrated with serum, and softened, and occupying its cording it has been simply to call attention to the exceptional outer and anterior part was a firm greenish-yellow tumour of character of the nervous disorder, I shall forbear to enlarge irregularly-elongated form, about equal in bulk to a walnut, upon its other salient points. and surrounded by softened and discoloured brain. On the Norwich, July, 1857. right side, situated in the hemisphere, just external to the corpus striatum and optic thalamus, was a small mass similar in appearance to that found on the other side, consisting of NEW TREATMENT OF CHOLERA: two small rounded nodules, the size of swan-shot, adhering toITS ORIGIN AND CURE. gether by a sort of pedicle, and surrounded by softened cerebral substance.-Chest: Old adhesions of pleurae, chiefly on BY A. C. BOATE, ESQ., L.R.C.S.I., the left side. At apex of the left lung were some small tuberLATE ONE OF THE SURGEONS TO HER MAJESTY’S 6TH DRAGOONS, cular masses, some of them in a state of incipient calcification. (INNISKILLENS.) - abdomen : Liver large, adherent by old false membranes to the peritoneum, its structure granular and almost nutmeggy WHAT is cholera ?-or what is the nature of this terrible diskidneys large and congested; a little purulent fluid in the pelvis of the left. ease, so sudden in its attack, and in many instances equally so The cerebral tumours appeared to be composed of a low form in its fatal termination? of fibrinous exudation, and showed, as their microscopical eleIn the autumn of 1853, at Newcastle-on-Tyne, where I was ments, a granular blastema, containing a large quantity of free oily-looking dots and granules, and corpuscles of various sizes quartered with part of my regiment, the cholera prevailed to a and shapes containing granular matter, and the same bright- fearful extent, so much so that the deaths of the inhabitants in the town and adjoining the barracks were from 100 to 150 looking dots, so many of which were seen floating free. For the preceding case (a brief notice of which I a few weeks daily, and, although the numerical strength of the garrison ago brought before the Norwich Pathological Society) I venture was nearly 500 men, exclusive of women and children, not a to ask a place in the pages of THE LANCET, believing it to be death occurred. The treatment adopted I will give in worthy of record as a genuine example of that very rare condi- single tion of disease, in which the paralysing lesion exists on the detail. same side of the body as the paralysis itself. So rare is it, that At Newcastle-on-Tyne in 1853,I gave this epidemic my most Dr. Watson (" Lectures on Physic," vol. i.) refers to only two attentive consideration. Afterwards in Varna, in Turkey, in such cases, Dr. Todd (article Paralysis in "Cyclopaedia of 1854, (where the troops were nearly decimated,) at which Medicine’’) to only four, and Dr. Bennett (in " Library of Medi- period I became confirmed in an opinion,--which before I cine" speaks of being acquainted with only twenty-one similar had some doubts of, not having had sufficient experience,ones as having ever been published. Moreover, the tone of all that cholera is originated in the brain and spine by some the authors whom I have consulted on this subject is such as to magnetic or electrical condition of the earth and atmosphere, imply a doubt of the authenticity or trustworthiness of the de- withdrawing or suspending their influence over the various ’
but not
I
135
nerves of the body, but more particularly from the pneumc gastric nerves, those nerves that preside over the stomach lungs, and vocal organs, and which are essentially necessary t the functions of respiration and digestion. Take, for example a dog or a rabbit, divide or paralyze by artificial means it pneumogastric nerves, and you produce the identical symptom
of cholera.
In the Appendix to the Report of the Committee for Scientifi in relation to the cholera epidemic, 1854, Tabl XXXVII., showing the electricity of the atmosphere at th, several stations, is most interesting, and affords a great l( for further study and observation. I maintain that it is th negative electricity that acts on the sympathetic brain an( spine, and produces cholera. On turning to page 103 of th, same Report, I find a passage which strongly bears me outv’iz.: "I much regret that the electrometer observations begal to" late to afford any decided results. They would, however seem to show that a deficiency of electricity prevailed durinl the time when the disease was at its height, and that at loa stations, as compared with higher, a deficiency was likewise t< be observed, which fully accounts for the prevalence of cholen in low districts." There are two forms of this direful malady : Cholera Mitior, ataalogous to English cholera; and Cholera Asphyxia, or suffo cative cholera, the latter being the most dangerous. Complete paralysis or suspension of the brain’s influence over the various nerves of the body, particularly of the pneumogastric nerves, exists in this special form of the disease. The lungs do not perform their proper functions; the vitality of the blood is not maintained; connsequently the duration of the disease depends upon the complete or incomplete paralysis of these nerves. While, in certain localities, the electrical condition of the earth and atmosphere is pred’Í8po8Í1/[J only, the immediately exciting causes are many and various, effluvia being amongst the most prominent; 2nd, excesses of any kind; 3rd, evaporation arising from damp floors, cesspools, &c.; 4th, purgatives taken for some other complaint. I cannot give a better example of immunity from the cholera epidemic than the Newcastle Garrison when I was in charge, and I attribute it solely to guarding the soldiers against the exciting causes, and, by a strict surveillance over their habits, doing away with effluvia; and cautioning them against the danger of not making immediate application on the appearance of diarrhoea,. The first symptoms are vomiting and purging-exactly what takes place when the brain is injured; but I have frequently noticed that patients generally complain of a tightness of the chest, sometimes amounting to pain, with a difficulty of respiration, and occasionally uneasy sensations in the head previous to these; after which come cramp, loss of voice, &c. &c. Having briefly stated what the predisposing and exciting causes are, I beg to add a, few observations, as well as my experience, relative to its treatmeiit. What can this be, in a disease in which the door to medication is in most instances closed by the early paralysis of the gastric nerves ? The physician must have recourse to a remedy possessing an instantaneous effect over the brain and nerves. Now, everyone knows the effect of an emetic, acting directly on the brain, exciting a more vigorous action of the powers of the constitution, as is proved by the amendment of the pulse, and other favourable appearances, immediately after vomiting. Although produced by debility of the brain in the first instance, it has the effect of reflecting strength back on the constitution. This is the groundwork of my treatment in every stage of cholera :-First begin with an emetic, followed (after the action of the emetic has ceased) by an opiate-say thirty to forty minims of tincture of opium, and thirty minims of sulphuric ether, to two ounces of water. If this does not rest on the stomach, a pill, composed of three grains of calomel and one grain of opium, is to be given. This will often remain on the stomach when nothing else will. But what is to be done in collapse, when the pulse is small and thready, resp ration almost suspended, and lividity pervading the whole system (the circulation being impeded owing to the contracted state of the lungs}? Chloroform is the grand remedy. But how does it act, or how should it be administered ? It is given by inhalation, carefully marking or watching the effect upon the pulse. Now the first effect of chloroform is a strong stimulant, the pulse becoming full and bounding, where beore its use it could hardly be felt. You must prolong its application as long as the pulse is full, and the moment it begins to sink, withdraw the chloroform; alternately repeating and withdrawing the stimulant until the patient lapses off to sleep. I may also add, that in a case of incessant vomiting, where nothing will remain on the stomach, a full opiate, say thirty or forty minims of tinc-
Inquiries
136
ture of opium in combination with half a drachm of
ether, may in a little water, and then the chloroform administered, which instantly checks the vomiting; and this action being kept up, the opiate becomes absorbed, and sleep very soon follows. This I maintain is a new treatment, and one which I in. variably adopted during the cholera epidemic at Varna, (where I was in charge of her Majesty’s 6th Dragoons,) and with su.eh success, as the medical return will show, (vide "Army Medical Board Returns,") that out of 62 cases of genuine Asiatic cholera, I only lost 9 patients (about 14 per cent.) I will illustrate this treatment by giving a few cases:Private ——, 6th Dragoons, was attacked in the night with severe diarrhoea, quickly followed by vomiting, great mental Did not make any application to medical depression, &c. officer until the next day. On the morning following his attack his comrades gave him brandy, pepper, &c. He allowed the disease to go on until the evening, when my hospital sergeant heard that he was ill, and reported the case to me. I visited the man’s tent, which was a small one, pitched at the back of his master’s ball-tent, only a few yards intervening. I found him in a state of extreme collapse, lividity pervading his whole system; incessant vomiting, with frequent diarrhoea, and pulse not to be felt. I ordered him to hospital instantly, administered a mustard emetic, which had the desired effect, and then applied the chloroform, having first given him a full opiate in conjunction with a stimulant. The pulse, which at first appeared small and thread-like, gradually became larger, stronger, and fuller. I kept up the action of the chloroform until the pulse began to diminish, and then withdrew it, again to repeat it after a short interBa]. The vomiting and diarrhoea ceased, and sleep followed. The patient remained asleep for about four hours, and awoke complaining of great thirst, which I have invariably remarked in all cases of cholera. I always kept a large quantity of solution of bicarbonate of soda with a little ginger, which I think makes the nearest approach to the saline ingredients of the blood, the ginger being merely to stimulate and warm the stomach and intestinal This I allowed the patient to partake of freely. canal, &c. He had slight consecutive fever, but was recovered and at his duty on the sixth day. Sergeant ——, 6th Dragoons; admitted into hospital, complaining of uneasy sensations in the head, slight pain, or tightness of the chest, as he termed it; vomited frequently during my examination of him; stated that he had suffered from diarrhoea, the greater part of the night; great mental depression; pupils much dilated; pulse very small, and with difficulty could be felt; in fact, the usual symptoms that characterize this hitherto formidable disease. Ordered, a mustard emetic; as soon as the action of the emetic ceased, a full opiate, with ether, in a little water. Vomiting and diarrhoea ceased, and sleep followed. At his duty on the third day. Sergeant Major ——, 6th Dragoons, (treated in his tent;). was attacked with diarrhoea in the middle of the night, quickly followed by vomiting; stated he drank a good deal of native This was a good wine (sheerah) on the previous evening. example of excess as an exciting cause. His countenance was shrunken and nearly livid; voice scarcely audible; pulse hardly to be felt. A mustard emetic was administered, which did not act for some time, but when it did, it was effectual, a large quantity of bilious secretion coming away. A full opiate, with sulphuric ether, was administered, and immediately followed by the inhalation of the chloroform, to prevent the rejection of the opiate and stimulant. The pulse rose full and bounding, lividity disappeared, and I had the gratification to find my patient in a slumber after a few minutes. Ultimately he did well, and was quite restored to health in a few days. I could add several other cases, more or less severe than these, but I think it would be superfluous. I did not take any notes of the number of dicrlaceal cases, which were very frequent; as many as fifty or sixty patients (in my regiment) made application daily to hospital for medicine to check this disease. The most successful formula I found to stay it was a mixture composed of the following ingredients:= Prepared chalk, aromatic confection, tincture of catechu,. tincture of kino, gum Arabic mucilage, tincture of opium3 distilled water. Also a pill composed of three grains of calomel, one grain of opium, and one grain of aromatic confection. These were the formulee which I also used at Newcastle-onTyne in 1853, when there were nearly 500 cases of diarrhoea admitted into hospital, and not a single death. Compare this with the report of the London hospitals in 1854, and truth-will speak for itself. In Dr. Babington’s Report on the Cholera amongst the Blaok be
given
!
.
quite
furnished to the Board of Health, a great deal of less instances in which unusual sensitiveness exists to alas ! after comparing the reports of both warm and cold substances, depending upon a variety almost all the medical officers of the Black Sea fleet, he con- of causes: such as exposure of the necks; or arising from cludes thus: "But no measure of success seems to have fol- chipping and fracture of the tooth from brittleness or some lowed any mode of treatment, so as to recommend it emphati- other cause ; or, again, where the tooth has been filed, cally beyond the rest." Some of the suggestions in Dr. cut, or accidentally broken. A very striking instance of this Babington’s compilation are, he states, very valuable, and it kind-that is, unusually great suffering from taking either affords much food for reflection on a disease, the nature of warm or cold liquids into the mouth-came under my care but the other day, in which permanent and complete relief was which remains so obscure. In putting these few notes together, I have carefully afforded from the electric cautery. If a tooth is snapped off avoided enlarging this little treatise, or adding any superfluous at the neck, and the pulp-cavity becomes exposed and painful, matter, thereby making it easily comprehended. Already the it can be destroyed, and an artificial tooth may be fastened to symptoms are, I am confident, but too evident to those who the stump, in the same manner as when the tooth is intentionever-once saw cholera; and besides, they are so elaborately deally removed for this purpose. Sometimes, also, bleeding will scribed by so many authors. My object is merely to introduce occur from the rupture of some minute capillary vessels during a new treat1nent for this hitherto formidable disease, and which the removal of caries from a cavity which may have become has-been so far successful, that I deem it but right to make it morbidly vascular, without the presence of actual pain or even hmown for humanity’s sake. - sensitiveness; it is equally serviceable here as in other forms z1 think a great deal of useful information may yet be derived I of disease, and stops the haemorrhage, which is inconvenient from carefully-made observations with the electrometer at ’, and -troublesome, from its interference with the progress of the tooth. I have -also applied it in sensitiveness night, for invariably every case of cholera that I had to deal with in my extensive field of practice occurred between twelve arising from the wearing away or grooving of a tooth, from the and three o’clock at night. Not having an electrometer in my , constant pressure of the spring clasp of a plate, which has, possession, either at Newcastle-on-Tyne or at Varna, in Turkey, caused the destruction of the dentine ; mechanical friction, in Pmade no observations. fact, producing this condition. As a general rule, the electric cautery may be used with Composition of chloroform: C2 H Clg. It is improperly called a tes·cleloa°ide of formyl, its real composition being as I decided advantage in almost every case of diseased tooth, with have stated above. Its action is stimulant, sedative, and anti- very few exceptions. But the commonest affection constantly 6pa6modic, the identical three objects essentially necessary to requiring its use, I again repeat, is ordinary toothache, not recover a cholera patient. unfrequently most agonizing in its character, and depending upon the presence of a cavity from caries, which has laid bare 3u1’, 1857. the delicate nervous pulp contained in it, which, so long as it likely to come into contact with the liquids and solids of the THE ELECTRIC CAUTERY AND ITS APPLI- mouth, will continue in this condition. Destruction of ,the pulp and subsequent stopping prove the remedy; the nerve is CATION TO DENTAL SURGERY. destroyed,! the pain disappears, and the tooth remains -for BY THOS. H. HARDING, ESQ. years, and answers a,s well as if it had been filled without,exposure and destruction of the pulp. (Concluded from p.82.) The electric cautery therefore saves many a tooth which, without its would be otherwise totally lost. It is preOf the opemtion in partiwla1..-The great object of this ope- served for aid, and years, perhaps it is not saying too much, that, if ration, which I am endeavouring so strongly to recommend in ordinary care and precaution are used, it will most probably the present communication, is to destroy the irritable ulcer in last the life-time of the individual. This, perhaps, may seem the membrane of the tooth which permits the nerve to be ex- to be problematical, as many dentists would declare that, if posed, and which is often associated with the presence and the nerve is destroyed, the tooth is dead; it is a foreign body, and will last but a few years, ultimately decay, and require even protrusion of minute granulations, not dissimilar to what extract,ion. The certainly destroys either a portion-or the surgeon meets with as protruding from an ulcer situated the whole of the cautery dental or nervous pulp; I will say, for arguover a carious or necrosed bone in some other part of the body. ment’s sake, that it does completely and effectually destroy This condition is accompanied with a certain amount of inflam- the nerve of the tooth. The tooth, however, receives nourishmation and tumefaction. The cautery, as I have said before, ment from the periosteum covering its -fang, as well as from lining its socket, and it would seem that there may even completely destroys the affected parts, and there is no time that be minute nervous twigs accompanying the equally minute left to produce a new surface; nor do I think that could be capillary bloodvessels which afford life and sustenance to the accomplished after the destruction of the pulp; nor, again, is plugged tooth. It cannot therefore be looked upon as a foreign it a necessary measure, as no particular good could be derived body, as it possesses and retains its vitality, .which is derived from it, were it to be permitted to occur. The cavity is at through its fang, or, in other words, from without, and is thus capable, from the reasons mentioned, of lasting with proper once plugged and the admission of air to the tooth prevented, Mr. Nasmyth has beautifully care, the patient’s lifetime. and the sensitiveness and carious condition are shown that a tooth is supplied with a large number of minute removed. nervous twigs and bloodvessels. I must also speak of another form of affection which has Now, of the proper cases in which the electric cautery may be used, the most important and common is that known as ’, been relieved by it- namely, neuralgia of the face-a form of severe ordinary toothache, especially that form of tooth affee- ’, tic douloureux, supposed to depend upon some other cause-than tion arising from a cavity with exposure of the tooth-pulp. InI a carious tooth. On examining the mouth, however, I have cases also of cavities requiring filling, in which too great a sendetected an affected tooth, on destroying the pulp of which sitiveness is present, thus preventing the satisfactory removal with the cautery, and subsequently stopping it, a permanent of the carious portions of the tooth, it is equally valuable. It cure has been effected. is useful also in cases where the gums have receded, with exIt may be recommended as admirably suited to destroy posure of a -part of the neck of a tooth, which .is extremely fungous growths springing from the internal pulp, which often sensitive and oftentimes very painful to the touch; in these it bleed very profusely on the slightest touch. It will thus be seen that the application of the electric is necessary merely to touch the exposed necks, to remove the sensitiveness. It is not less serviceable in its application to cautery is wide and extensive, in the number and variety of tender, sensitive, and bleeding gums, producing a new and the oases of tooth disease. The following, however, are unfit for it, as it would not only healthy action, which permits them to become firmly attached again to the necks of the previously-exposed teeth. Sometimes produce no good, but harm might result from its use :it’is merely necessary to hold the heated wire near a sensitive When a tooth is loose, with its external aspect sound, but neck, without actual contact, to remove the tenderness. I have the pain depending upon the presence of a fungous growth or with the greatest ease and rapidity, the pulps of small abscess developed at the end of one or more of the fangs. destroyed, incisor teeth which have been cut off for the purpose of being In such a case extraction only will afford relief. It will prove of no avail, in an attack of inflammation of the ,pivoted. Every dentist is aware of the sensitiveness which sometimes exists in a pivoted incisor tooth, depending upon pulp, which may sometimes affect a tooth that is otherthe vitality of the stump; this is completely obviated by the wise apparently sound. This may be known by the severe, 4iF,e of the cautery. I have employed it also in number- heavy, throbbing pain which _it occasion?, running up to the
Sea
Fleet,
ingenuity is shown, but,
I
stopping
_________________
permanently
I
I central
137