OBSERVATIONS UPON THE NATURE, CAUSES, AND TREATMENT OF SPASMODIC CHOLERA.

478 2nd. To arrest the serous haemorrhage. 3rd. To restore the suspended secretions. The first indication is effected by the exhibition of an emetic; and this is principally of advantage in the early stage, BY J. RANDOLPH, ESQ., M.R.C.S., Westminster. when it will frequently arrest its progress, and change the I HAVE thrown together a, few desultory remarks upon the entire aspect of the case. The choice of emetics must be a mature, causes, and treatment of spasmodic cholera, in the matter of consideration, selecting such as will not depress the hope that somewhat may thence be deduced to aid the im- vital powers; and the best our materia medica offers is ipeportant object of arriving at some definite mode of viewing cacuanha, in doses of one scruple or twenty-five grains, which and combating this formidable malady, which, there is no should be followed with a dose of two to four grains of doubt, will be found, when clearly comprehended, to be as much calomel, and six or eight of powdered rhubarb. within the power of medical aid, if promptly and watchfully The second indication belongs to the second stage, when the given, as any epidemic disease with which we are acquainted. disease is fully developed, and the bowels are freed from all Having in the earlier part of my professional life resided in faeculent matter, the frequent evacuations having assumed the a marshy district, and treated during the autumnal periods of 46 rice-water" appearance, the vital powers rapidly declining, the years 1825-6-T and 1828, diseases peculiar to such localities, the heart’s action limited, extremities cold, and almost pulseat those seasons when the atmosphere is subject to great less, breath of the same distinctive character, voice reduced variations, and more or less loaded with miasmatic exhalations, to a whisper, muscular cramps more or less severe, and the I have been forcibly reminded of the apparent identity, to a constitutional powers wholly prostrate. The critical moment limited extent, in the character of the present epidemic and has now arrived when all our tact, science, and watchful some of those affections. energies must be exercised, or the patient will be inevitably If we examine the excellent statistical tables prepared by lost. The greatest discrimination will be required in our the registrar-general, we discover that cholera and diarrhoea selection of remedies, more especially the use of diffusible of the most concentrated and malignant character are met stimulants and narcotics, lest a consecutive fever be induced, with in low and damp localities, the houses of the inhabitants incontrollable in its course; they are most important auxiliaries, being imperfectly drained and badly ventilated, and the atmo- if used with discretion, in supporting the strength, those to be sphere of the neighbourhood polluted by gases emanating from preferred being the compound sulphuric ether and brandy. Chief reliance must be placed upon the internal administraoffensive trades, drains, and other abominable nuisances. Among many of the lower classes occupying houses thus tion of refrigerants, as ice, iced water, effervescent draughts; rendered miserable and unwholesome, their wretchedness is &c., given in small quantities frequently repeated, not in large, further increased by falling into habits of uncleanliness and which the stomach will reject, it being an important object to intemperance; poverty induces them oftentimes to purchase soothe and quiet, not oppress, that organ, which is in a state of food that is innutritious; ignorance also condemns them to vascular excitement; sinapisms to the epigastrium, or extended imposition in this respect; and from their bodies being thus over the abdomen; the external application of warmth to the rendered susceptible of disease, they become its earliest and extremities, through the medium of bladders filled with hot chief victims. water, or bags of heated sand placed along the thighs, legs, Cholera spasmodica may be viewed as a disease generated and soles of the feet, and the free admission of atmospheric by atmospheric influences on the nervous system, exciting air by throwing the windows of the apartment open. Our morbific secretions from the mucous membrane of the stomach object may be further aided by simultaneously attempting the and intestines, which, acting as an irritant poison, produces third indication, the restoration of the suspended secretions: ’those symptoms constituting this affection, and in a milder this is effected by the exhibition of small doses of calomel, form, diarrhoea; this being generally preceded by a sense of two grains every ten or fifteen minutes, combining the first nausea and uneasiness of the stomach and bowels. The deve- four doses with a quarter of a grain of opium, closely watching lopment is hastened by the predisposition induced by excesses every evacuation that follows the administration, the patient of every kind, whether in food, drink, the character also of not being permitted to exhaust his strength and keep up the ’these aliments; bodily and mental fatigue, anxiety, fear, and haemorrhage by getting out of bed on these occasions, but, all the co nmon causes of fever. whenever practicable, the use of a bed-pan should be enforced. The violent action set up is an effort on the part of Nature Upon the discovery of the slightest odour or colour in the to rid the system of its immediate cause of such disturbance; evacuations, it is an evidence of the treatment having been and the great determination of blood to these organs thus in- brought to bear upon the case, and gives encouragement duced, becoming further augmented as disease advances, a steadily to persist, progressively extending the intervals of serous hemorrhage from the bowels ensues, carrying with it the administration of the calomel. Reaction may now be exsmall shreds, resembling patches of coagulated lymph, forming pected to advance; the evacuations will assume an increasing what is termed rice-water evacuations." tinge of bile, and after a short time become of a fseculent. In proportion to the loss of this fluid, the vital powers character. become diminished; the blood retained in the system is overA mixture containing bicarbonate of soda and hydrocyanic charged with carbon; and the patient as ardently desires the acid may now be prescribed, or the refrigerants before alluded free admission of atmospheric air, for its oxygen, as he does to continued, supporting the strength with beef-tea or chickenthe refreshing beverages of cold water, effervescent draughts, broth, in small quantities. The condition of the bladder should always be attended to; &c., to alleviate an intolerable thirst. If this view of the subject be admitted, the remedial means for although it is generally discovered empty, the contrary is within our power resolve themselves into two classes-pre- sometimes found to be the case; the occasional introduction of a catheter should therefore not be omitted. Common tea ventive and curative. The preventive measures consist in the removal of all those as a beverage should be avoided in every stage of the disease: causes which destroy the healthy state of the atmosphere, it frequently increases the disturbance of the stomach and whether existing within or around our dwellings; the posses- bowels, and occasions much griping pain; cofree, on the other sion of a constant and ample supply of pure water; a free and hand, will soothe, and is less likely to be rejected. -uninterrupted house and sewer drainage;’ a sufficiency of Acting upon these premises, and strictly following this plan wholesome food; and the wearing of warm clothing, &c. of treatment, I have succeeded in the recovery of thirty-nine Too much importance cannot be attached to daily house- cases out of forty-eight that came under my care. Eight patients visitation, during the prevalence of the epidemic. A sympathy died of consecutive fever between the third and sixth day, refor the poor, and a greater intercourse between them and the action having taken place in each. The ninth case terminated higher classes of society, would be a medium of infusing into in four hours after my first visit, the patient having been three the former a feeling of self-respect, which, from neglect and hours and a half in collapse before medical assistance was obcontempt, is too often abandoned. It would also lead to a tained. In one case of recovery, the evacuations were uncontrollable grateful reception of religious and moral instruction ; and wherever Christianity, in its pure and gospel form, prevails, until super-acetate of lead and opium had been given; and if humanity is raised, happiness and prosperity follow, the soul the opinion entertained in these remarks be correct, I can becomes informed of a future existence, and will seek to quite understand the occasional advantage to be obtained from secure that which is the reward of faith, and virtuous actions the application of the cold wet sheet. based upon it. It is an entertained opinion that an excess of one secretion The curative treatment may be reduced to the following will diminish another; and hence it has been inferred, that indications:the total absence of urine in this disease may be accounted for 1st. To free the svstem of the noxious matter contained in by the urinary elements passing off by the bowels. a certhe alimentary canal. tain extent this may be admitted; but should wenot rather

OBSERVATIONS UPON THE NATURE, CAUSES, AND TREATMENT OF SPASMODIC CHOLERA.

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To

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479 attribute it to the absence of nervous influence on the kidneys to eliminate the secretion from the circulation, or to a congested state of those organs? Patients die of consecutive fever in a comatose state, from the third to the sixth day, the biliary secretion having been restored, and the action of ’, the bowels arrested, but no urine secreted; we may therefore conclude that the elementary principles are thrown back upon the blood, and that this circumstance is the cause of death, which being the case, the excessive use of stimulants and narcotics, too often resorted to, should be carefully avoided.

In two most satisfactory cases of recovery that came under my care, the patients partook of nothing for two or three days but frequent sips of cold water, every other article being rejected, and with them the urinary secretion was speedily and

freely restored.

I have made these suggestions, in the hope that some of your correspondents who are engaged in physiological inquiries will give them their consideration. Marsham-street, Westminster, 1849. REMARKS ON

THE TREATMENT OF CHOLERA, SUBSEQUENT TO A FORMER COMMUNICATION. BY R. H.

PERY, L.A.H.I.,

RESIDENT MEDICAL OFFICER AND ACCOUCHEUR AT THE FEVER

HOSPITAL,

CORK-STREET, DUBLIN.

SINCE my communication which appeared in THE LANCET of the 25th of August, I beg to lay before the readers of this journal six additional cases of cholera (occurring here) which I have attended, and which are now completely convalescent. Three of the patients-namely, Mary Delahunt, Jane Adams, and John Heslan, were treated with the combination pi-eviously mentioned, each of the pills containing three grains of calomel, two grains of camphor, half a grain of opium, and a quarter of a grain of capsicum. The remaining three, Mary Foy, Catharine Neterville, and Mary Carroll, were treated on the same principle, with the exception that a quarter of a grain of opium, instead of half a grain, was given in each pill. The result of the experiment is as follows. I should perhaps remark, that in all these cases treatment commenced at the beginning of the second stage of the disease.

’

Now, on an examination of the foregoing cases, it certainly appears that reaction set in sooner in those to whom the halfgrain doses of opium were given in combination than in those to whom merely quarter-grain doses were administered. However, I must confess that medicine in general acts on different constitutions differently at different periods; so, if I had tried the large doses of calomel by itself, in the cases of Adams and Carroll, I might have been led to suppose that calomel alone was the remedy to be preferred; the same, would have been my opinion if the combination with perhaps,was tried, and calomel only in the other cases; but as opium I have had so much experience in the combination which I have recommended, and as this experience has been guaranteed by such happy results, I feel it would be a difficult task to alter my peculiar views respecting the line of treatment I have adopted. I am sorry to perceive that a correspondent in the LANCET, signed "A. I3..L," should have misunderstood my meaning when speaking of opium. The passage in my prior communication alluded to is as follows:The consecutive fever in all my cases were merely nominal, although so much opium had been used, which clearly prove3 that the drug may be administered freely in this disease." I should have said, that the drug may be administered freely in the combination which I employ in the treatment of the disease. Now if "A. B. M." will have the kindness to refer to the case of Lool, given in your number of the 25th of August, he will there see that it is on the mercurial preparation I placed my chief reliance; for on visiting him on the 16th, I ordered five grains of mercury with chalk every eighth hour, merely to keep up a mercurial action, although so much calomel had been previously taken; whereas, had I placed my entire hopes of success on opium alone, as "A. B. M." would seem to

infer, should have administered half-a-grain, or a grain of opium every eighth hour, in place of the mercury with chalk,

which I did not. With regard to the prescribing of opium in the treatment of cholera, some place their chief reliance on it; others, on the contrary, entirely deprecate its use. These opposite views of its usefulness altogether depend, I fancy, on the modes of its administration. As for my part, I consider that opium, in combination with camphor, calomel, and capsicum, is a most valuable adjunct in the treatment of the disease. The theoretical view I take of the combination I employ is this:-The camphor first stimulates the nervous centre, and relaxes the spasmodic stricture of the duodenum and common biliary duct, while the opium, primarily assisting the stimulating effect of the camphor, exerts a direct sedative influence on the system in general, protracting, as it were, the relaxations until such time that the calomel will be conveyed through the circulation, to cause the secretory organs to secrete and pour out, not only what has been secreted before, but also that which is secreted anew, in order that a continued action should be kept up until health is restored. The opium, also, undoubtedly produces sleep, which is of itself a most favourable indication of a future convalescence. Although this view of the subject may appear theoretical, the results of my cases tend very much to substantiate the theory. I regret exceedingly that I see so many opposed to the calomel treatment, and so few (comparatively speaking) duly appreciating this valuable remedy in cholera. It matters not whether it is used alone or in combination, I feel perfectly confident that is the only means that we possess, fully competent to contend with this fatal malady. The advocates for treating cholera by acetate of lead and opium combined, vegetable astringents, cretaceous preparations, brandy and laudanum, &c., will for the most part find that their cases either prove directly fatal, or pass into a low consecutive fever, out of which the recoveries will be few. Some time since I was called upon to see a case, treated on the acetate-of-lead-and-opium plan for fourteen hours. The patient was lying on his back; eyes turned, and fixed in his head; breathing stertorous. He died in a very short time after my arrival. Whether it was the acetate of lead and opium injudiciously administered, or the disease itself, that caused the patient’s death, I leave it to my readers to judge. I may here mention a very singular case of cholera that has occurred within these last few days. The patient had been attacked with cholera of a very severe character on the 18th of last July, and had recovered. She remained perfectly well until about two o’clock on Sunday, the 2nd of September, when she was again attacked with vomiting and purging, which terminated in as severe a case of Asiatic cholera as has at any time come under my notice. She is now perfectly convalescent. From this case, it appears that the same individual is liable to be attacked more than once with cholera during the prevalence of the epidemic. Dublin, September, 1849.

practical

REPORT OF AN INSTANCE OF

EXTENSIVE DISEASE OF THE HEART, AND POST-MORTEM EXAMINATION. By C. M. MILLER, M.D., Stoke Newington.

delicate

MRS. M-, aged thirty-five, a woman, had been, for the L)st two years, subject to violent palpitation of the heart, which she attributed to a bad miscarriage of twins. She had been under several medical men, some of eminence, none of whom had been able to discover any lesion about the heart, and every one gave it as his opinion that it was irritability of the heart from disordered state of the stomach. When I first saw her, I had the same opinion. Antispasmodies, tonics, and brandy-and-water, generally relieved her, but nothing so much as the supine position. I saw her occasionally, but never for a continuance, until the 27th of July, 1848, when I was called to her for a very severe attack which confined her to her bed. On examining the region of the heart, no bruit was discoverable, but there was excessive palpitation and gasping. I at first gave her a tonic, as I had been accustomed to do; but I found on the next day she was no better, and I therefore substituted an andspasmodic, with digitalis. There was,however, a great deal of pain in the region of the heart, and a blister was applied on the 1st of August, with a slight alleviation of suffering. On the 8th, jaundice made its appearance, with tenderness and slight enlargement of the liver. Mercury in small doses was given but as this caused great exhaustion, the