ON A CASE OF CHOLERA SUCCESSFULLY TREATED.

505 As in syncope consequent upon extreme haemorrhage, so in rationale of its operation. In rapid deasths, occurring in the cyanic stage, the materies morbi would seem to operate, cyanosis, when the discharges cease, a reactional tendency primarily, through the sentient structure of the stomach and sets in, and if the powers of life are not too far prostrated, the efforts will succeed in restoring the circulation. small intestines upon the ganglionic nervous centres. The In aiding the natural efforts by external agents, their availaction appears to be reflex, and is either general or partial. That mysterious connexion between the nervous and sangui- ableness would seem to depend not so much upon their nature ,

spontaneous

neous

systems, displayed by

turbed ;

and in

proportion

as

their reciprocal action, is disthe virus acts mildly or malig-

nantly, nervous energy is diminished or suspended. By some inexplicable action of the virus upon the mucous membrane of the alimentary canal, combinedly with loss of vital power,

copious aqueous transudations occur.* The effect upon the capillaries is immediate, and the blood is arrested in its circulation, and speedily congested.. The blood, thus obstructed in the capillaries, rapidly accumulates in the vessels of the mesentery; its lacteals and lymphatics are soon implicated, and the function of absorption is entirely arrested. In proportion as the aqueous discharges are rapidly profuse, venous congestion and vital depression increase, until the various viscera become functionally disturbed and their secretions suspended. The blood, thus arrested in its course, collects in the ascending cava and right ventricle of the heart. The sequence is clear-pulmonary congestion, defective decarbonization, and coma, rapidly ensue, and the heart’s action gradually ceases-asphyxiated. Assuming, then, the foregoing to be the true rationale of its operation, the indications of cure are clearly obvious, and necessarily threefold-viz., to neutralize the morbific agent, re-establish nervous influence, and restore the blood to its due and healthy proportions. In the practice of therapeutics, we are taught by daily observation and experience, that in the employment of remedies for the removal of disease, our efforts will prove abortive, unless the condition of the organism is such as to render it susceptible to the influence of remedial agents. In no instance is this truism better illustrated than in the treatment of this disease by the much-vaunted remedy-calomel. Notwithstanding the gravity of the occasion, it is difficult to repress a smile, to see an individual, watch in hand, sedulously seated by the side of the sick, administering with praiseworthy perseverance, and chronometrical exactness, one or two grains of calomel, every five or ten minutes, for the purpose of resuscitating prostrated vitality to renewed health and action ! As readily might we hope, by mercurial friction, to arouse a person from a state of frozen torpor, or even expect calomel to vitalize the vial from which it is taken, as hope, by the exhibition of this drug, to restore latent life from the lethargy of the algide form of the disease. It is said that in the collapsed stage, five hundred and eighty grains of calomel have been taken, and, what is undeniably true, that pending this stage no calomel is absorbed; if, then, we submit this quantity, and what is usually required

the mode in which they are employed. Sinapisms applied, not merely to the scrobiculus cordis, but comprising the entire extent of the thorax and abdomen, with earthenware bottles of hot water laid parallel with the longissimi dorsi; or blankets wrung out in hot water, and tucked closely around the patient, are amongst the best available aids in promoting a determination to the surface. A tablespoonful or two of a mixture composed of chloric-ether, turpentine, and camphor mixture, suspended in the yolk of an egg, and administered every quarter of an hour, . may be an useful adjunct. In the majority of cases, however, the term cyanosis seems synonymous with death, and the most unwearied efforts to induce reaction will prove unavailing. In the reactionary stage, with a full, bounding pulse, and hot skin, I have abstracted blood,* with the view of relieving congestion, with decided advantage. Calomel, or what is better, blue pill, in two or three grain doses every three or four hours, may now be given, for the purpose of facilitating absorption. Diarrhoea, dysentery, and extreme irritability of the stomach, with grass-green vomiting, frequently follow the reactionary stage, which are attributable to loss of power in the intestinal canal, the bile flowing mechanically through the pylorus. For the former, a combination of opium and sulphate of copper, with a decoction of cinchona; and for the latter, an emetic, followed by au effervescent saline, I have found un. exceptionably beneficial. In the consecutive fever, the surface presents considerablevariety of temperature. In one case the patient was nearly universally exanthematous, and perfectly pulseless, ninety-six hours immediately preceding death. Cerebral congestion, with great physical prostration, prevail. The treatment applies equally in these cases as in fevers of a low typhoid type.

as

Hull, November, 1849. ON A

CASE OF CHOLERA SUCCESSFULLY TREATED.

Reported by

G. BELLASIS

MASFEN, ESQ.

HOUSE-SURGEON TO THE STAFFORDSHIRE GENERAL INFIRMARY.

ON Monday, the 18th of August, 1834, about noon, Mr. Walton was called to J. J-, cordwainer of Stafford, a man’ of spare habit and sound constitution, aged about twenty-four. He found him in bed, extended at full length on his back,without rigidity or spasms, his arms lying listlessly by his side, outside the clothes, the eyes shrunk in their orbits, the face elongated, deathly cold, and mottled with a livid hue, and the whole countenance expressive of the most hopeless despair. The other parts of the body, which were equally cold, and bedewed with cold clammy perspiration, partook of the livid hue, yet not to the same extent; the respiration was short and irregular, and at times a little laborious, relieved by an occasional prolonged sigh; the pulse at the wrist scarcely if at all perceptible. Copious inodorous evacuations, of the consistence of thin, lumpy gruel, were voided every two or three minutes. The mind, despite this disturbance, was clear and quick, and seemed in no manner affected. He was first attacked at three o’clock A.M., with a feeling of weight at the stomach which awoke him. This he attributed to an apple and a glass of ale, which he had taken on the evening before. These symptoms progressed till six o’clock, when profuse vomiting and purging came on, the latter attended with excruciating pain and general spasms, the ejected matters being described by his wife as "pink water." He became completely prostrated, and at noon was unable to leave his bed, his motions being voided as he lay. He had taken, glass after glass, about a quart of brandy; each glassful, however, came back as soon as it was taken. The renal secretion had been entirely checked since the commencement of the attack. Mr. Walton immediately covered him with an additional blanket, applied large mustard plasters to the stomach and bowels, and gave him a wineglassful of brandy with the follow-

to produce ptyalism, to a common rule in arithmetic, it follows, that where no evidence of absorption exists, five hundred and sixty-eight grains at least must be utterly use-

less.

Notwithstanding, calomel is totally inert in cases where collapse is fully confirmed; on the contrary, it is undoubtedly an useful adjunct, if administered under circum-

the

stances favourable to its absorption. In the premonitory diarrhoea, my experience in the efficacy of opium fully confirms that of others; it is, indeed, our sheetanchor ; in fact, the only remedy upon which reliance can be placed. Given in the solid form, in half-grain doses, according to the urgency of the symptoms, with a mixture composed of the compound aromatic powder, and a little chloric ether. I have found it efficacious, not only in restraining simple diarrhoea, but the bilio-aqueous also, even when these discharges haveappeared to be rapidly approximating the pathognomonic. Its efficacy, however, in the premonitory diarrhoea, has, I am convinced, its limitation. In cases where, from the susceptibility of the patient, and the intensity of the morbific cause, the diarrhceal discharges run rapidly into the "rice-watery," opium, however early administered, may be totally inert. In cases of collapse induced by discharges exceedingly profuse, and exclusively intestinal, the stomach retains its sensibility to some extent, and opium, injudiciously given, may readily narcotize, and thus considerably increase congestion. Indeed, remedies appear of little avail in arresting the purelyaqueous discharges, which always cease as the cyanosis becomes confirmed.

* Blood drawn from the arm at the commencement of reaction presents These effluxes are not secretions; they are the effect of a state the little alteration in its relative proportions, being probably chiefly abdominal. of active, which perhaps has its parallel in paralytic paroxysms, The chief change is in the crassamentum, which possesses diminished capaduring which the skin is suffused with copious exhalations./.bility of coagulation. *

reverse

I

506 carbonate of ammonia, four grains; camphor julep, two tablespoonfuls; followed in about fifteen minutes with five grains of calomel and one grain and a half of opium. His wife states that his stomach rejected the pills and draught in about half an hour, though Mr. Walton did not observe any vomiting while he was present. About one P.M. my father saw him; the man was then in a most complete state of collapse, of a blue colour, cold, and to all appearance dead, but that there was a slight steam on a looking-glass applied to his mouth, and a scarcely perceptible pulsation of the heart; the stools, which were then being carried away, he describes as having the smell of animal matter in the first stage of decomposition, looking like imperfectly made oatmeal gruel, with the addition of distinct fluid, resembling beefgravy. He ordered, first, friction generally of the trunk and extremities, the application of hot salt-bags to the sides, and hot bottles to the feet; and three grains of calomel with the

ing draught: laudanum, thirty drops;

of

and

to be

quantity opium yenne pepper, same the tip of hisoftongue half’hour. pepper, At to three be placed placed P.M. Mr. on quantity opium every andca-cayenne same

on

Walton and my father visited him, and found him better. The same remedies were ordered to be continued every hour. At seven o’clock a great improvement had taken place; the livid hue had disappeared, the countenance had assumed a serene and placid expression, the pulse had become full and soft, and a warm, glowing perspiration was beginning to be diffused His wife states, that after the third or fourth over the body. dose of the medicine, the purging had become materially lessened, and for the last hour no evacuation had taken place. The latter motions were certainly, though slightly, tinged with unhealthy bile. The medicines were now ordered to be repeated every two hours during the night. Towards bed-time he began to complain of the medicine "burning his inside out," and craved incessantly for cold water, of which he drank nearly a gallon during the course of the night. He perspired profusely, and early in the morning passed a little urine, which was the first for four-and-twenty hours. 19th.—This morning he was convalescent-in fact, well, though, of course, weakened by the tremendous nature of the attack. He drank several cupsof strong coffee during the day, and had the following mixture:-Powdered rhubarb, one drachm; carbonate of magnesia, a drachm and a half; oil of cinnamon, four drops; water, six ounces. Two tablespoonfuls to be taken every three hours. He kept his bed for a day or two after this, taking beef-tea and other light nutritious diet, and by the end of the week was able to resume his work. The opium, of which he took altogether more than two scruples, was tolerated, there being no narcotism or even sleep induced by it; nor was there the slightest symptom of

ptyalism present. The great thirst, though no doubt partly owing to the cayenne pepper, is also frequently attendant upon that stage of cholera as a part of the disease, and may probably be an effort of nature to supply the great deficiency of the liquor sanguinis, produced by the excessive purging; and if so, how very desirable to attend to the patient’s craving for drink by a supply of broth, gruel, whey, or even cold water. It may not be unimportant to state, that the patient is a native of Stafford, and had not been out of the town for three years

previously, and

that there were certainly not more than half dozen cases in the town, if there were even any other than the one I have narrated. For many of the particulars of this case I am indebted to Mr. Walton, now of Birmingham, and my father, Mr. Masfen, of Stafford. Infirmary, Stafford, 1849. a

ON THE TREATMENT OF UNHEALTHY INFLAMMATIONS. [STRICTURES ON THE OBSERVATIONS OF MR. BROKE GALLWEY.] BY JOHN

LANGLEY, ESQ., Surgeon, London. I TAKE it for granted, that what Mr. Gallwey means to convey by the expression of " unhealthy inflammations" is, inflammation, general or local, occurring in the systems of persons of cachectio or unhealthy constitutions; and he insists that the

treatment of such inflammatory diseases should be conducted upon principles and measures opposite to those indicated when the same character of disease attacks persons- of more robust and vigorous system, and also avows that he would not treat the same inflammatory disease in the same manner in a different locality, as in "Little France or Smithfield." Upon this most important professional point I beg to differ from him toto cœlo. I must first bring my mind to the absurd conclusion, that an engine of inferior power, a hose of smaller

calibre, and fluid of a less extinguishing character than water, should be used and applied to subdue the flame of a burning edifice in Little France or Smithfield, to that used for the If thirty same purpose to a mansion in St. James’s-square. years’ practice and experience in my profession have taught me anything, it is this, that, figuratively speaking, the weaker and more fragile the tenement, the more decisive, prompt, and vigorous should be the means used to destroy and an-

nihilate the destructive element, and in tenapore, which is the omnium primum, before the nervous system and general vital energy is destroyed by continued inflammatory and insidious febrile action. I would here presume to ask Mr. Broke Gallwey what he really means by " unhealthy inflammation" ? Does he use the term in contradistinction to healthy inflammation ? If so, I beg to observe that I consider no inflammation healthy, for whenever action is morbidly carried to such a height as to induce inflammation, whenever the friction of the circulating molecules has so far increased in intensity as to generate morbid heat or inflammation, then such a condition can never be healthy, excepting only the instance where the vis medicatrix naturœ establishes a limited inflammatory action to promote the union of divided parts in incised wounds, through the intermediate agency of coagulable lymph, Nature’s size, or glue, for that purpose. But, even in that instance, I have much doubt whether the action set up does not fall short of the inflammatory point, as wefind high inflammatory action frustrates the design, and converts the-adhesive lymph into a sera-purulent fluid, incompatible with the promotion of union by the-first intention. Where and whenever the phenomena of inflammation, the

rubor, tumor, et calor, cum dolore," exist, organic disease has commenced, and will progress, and insidiously increase in intensity, until the structure or organ attacked is functionally or substantially destroyed, by ulceration, effusion, or adhesion, and consequent obliteration of parts, to the impediment or destruction of natural function, as in trachealt peritonæal, pleural, or cardial inflammations, or if not fatal, a most serious impairment of health follows, entailing misery throughout future existence. I

_

aware that Mr. Gallwey is supporting the of his professional brethren in general, and arguing opinions in accordance with the present fashion of medical practice ; for I have been replied to, when advocating full depletion in fevers and inflammatory diseases, and also in acute local inflammations of large joints, as the hip and knee joints-" I never bleed in London; that practice may do in the country, but not here." But my firm belief, and that founded upon long and considerable experience, is, that where the " rubor, tumor, et calor cum dolore" exist, the only efficient and controlling power, and if I may be allowed the expression, the sheet-anchor of the surgeon, is his lancet, if timely, properly, and perseveringly used, until the goal aimed at is attained, ever steadily keeping in view the object which determined him to resort to it, with this motto encouraging him in his good .course" Tu ne cede malis sed contra audentior ito." The disrepute into which active general depletion has fallen has arisen in consequence of its not having been carried to a determinate curative point. A first, second, and third bleeding have been audaciously resorted to by some practitioners, at distant intervals, and without relief; the cause which induced such treatment remaining in statu q2co, a conclusion is erroneously arrived at, that bleeding is of no use; the disease advances, and the patient dies. Much attention has been paid, much medicine administered, much unnecessary pain and suffering endured, and everything is believed to have been done: and it is well if these repeated small bleedings have not been charged with the production of the fatal result, for whoever reads, or has read, the Dicksonian fallacies of the profession, a pamphlet written ad captandum vulgus,—an ocean of unscientific and erroneous dogmas, through which an occasional rivulet of sense and reason runs-must attribute the unfortunate issue of all the ills that flesh is heir to" to the use of the lancet; while I, unless mentally and physically blind to. the reflection of my scalpel, aver, that among the,numerous post-mortem researches I have read of, and my own frequent autopsies in search of the cause of death, in scarcely a single instance could I attribute it to other than organic disease of the brain, lungs, or heart, which three primary organs, the late Dr. Beddoes, in his usual elegant style of writing, designated the " Tripod of Life," or of some other important structure, caused unequivocally by unsubdued inflammation. I fear I am trespassing too deeply upon the space of your valuable columns, but briefly wish to remark upon one of the grave absurdities, urged even by medical men, and very lately to me by a physician of great repute and notoriety,’ that the am

quite