1854.]

PATHOLOGY OF CHOLERA.

at the present juncture. It succinctly reviews what is at present known regarding cholera, and is not deficient in novelty. For instance, it is pointed out that typhus fever generally increases in any country, as cholera approaches, and acquires a greater tendency to abdominal complication. It is therefore advanced hypothetically, that under the influence of the particular poison, typhus fever becomes a virulent remittent, the cold stage of which is algide cholera, and that this form is preceded, and in part induced, by an action causing alvine disturbance. The difference, in reality, between intermittent, remittent, and continued fevers, is very small; so slight, that in the same climate and in the same malaria, a difference of temperature as to season will change the aspect of the disease from one to the other. The relation of algide cholera to intermittent fever is thus further pointed out.

"In the cold stages of a regular intermittent, ague for instance, the blood leaves the surface of the body, causing contraction and shrinking of the face and hands, and a peculiar rough sensation of the skin; and in cholera, the blood leaves the surface and remains pent up in the internal cavities; the body is cold in both in time, if all goes well, warmth returns, which soon becomes heat and fever. The difference of this symptom, in fact, is more in degree than kind. The cholera patient often dies before the hot stage comes on, and never lives, as far as my experience goes, through a second cold fit to the next hot; the ague patient survives very many. Thus, though no one could say, with an approach to truth, that cholera is merely a deadly form of ague, yet it apIn all pears true, that it is a peculiarly deadly disorder with a decided remittent type, and that the sufferer is apt to die in the cold stage, or before the circulation, disturbed by the great power of this chill, can become fully restored. cases of cholera which live beyond the algide stage, a consecutive fever supervenes. In the three cases given above, and in four others at St Thomas's Hospital, the notes of which are now by me, the changes from one to the other, and back again to the cold stage, are well marked.

"As in the cold stage of ague, the blood remains in the internal parts, so does it in cholera; but apparently a certain disorder, either of the intestines or of the blood, causes a tendency to the secretion of fluid therefrom, the congestion and the stagnation in the larger vessels, during the cold stage, increase this tendency, and the serum of the blood constantly runs off into the intestine.

"Drs Reinhardt and Leubuscher, who published in 1849, their observations on cholera, give a most detailed and elaborate account of the appearances found in those dying in all stages of the disease. In those who died in the algide stage it appears, that most internal organs suffered from venous congestion, situated, not so much in the venules, as in the large veins of the part. Thus, the lungs and the liver are empty of blood; but all the right side of the heart and the vessels leading to it are gorged therewith, as Dr Parkes also has observed. The mucous membranes generally, but those of the chylo-poietic and of the urinary system in particular, are congested, even to the venules; the left side of the heart and its vessels are comparatively devoid of blood. Indeed, to state the facts broadly and in few words, there was a universal internal congestion, which appeared, as though beginning in obstruction about the right side of the heart, for all in its neighbourhood was full, and the left side of this organ was empty, as though it had, through life, retained power to pump away what little blood entered its cavities. The same condition of surface and the internal congestion, but in a less degree, takes place also in the cold stage of ague, and the comparison between the two diseases is assisted by the morbid anatomy of each.

"However, as in all fevers of the remittent type, irregularities not unfre

quently occur, so also in cholera ; for the consecutive fever, or the febrile stage of cholera, which is analogous to the hot fit of an ague, may be very slight and evanescent, in comparison to the intensity of the algide symptoms, or the cold stage may be short and slight, in proportion to the great amount of consecutive fever there may even be no cold stage, no rice water purging, but simply violent bilious cholerine, with vomiting and suppression of urine, followed by so great an amount of febrile disturbance, that, together with the entire disappearance of that secretion, it carries off the patient. Now, it cannot be said, that these irregularities militate against the truth of the hypothesis; for I contend, that they rather aid in its establishment, showing, as they do, that even the unmistakeable cold stage is not a necessary part of Asiatic cholera; but only one phase in the disease,-a very fatal one it is true, still, perhaps, not much more so, than the consecutive fever, and it is not so essential a portion as that fever, since no case that lives beyond the cold stage escapes the hot one." -Pp. 70-74.

Dr Barwell then gives three cases which had no, or a very slight, algide stage, but glided almost at once from the premonitory diarrhoea into consecutive fever. Hence, according to him, cholera is a malarious disease, of an irregular intermittent type, the cold fit being so virulent, as to form the most fatal part of the malady, and to take the most prominent place in all descriptions and all our ideas of the disease. With the algide symptoms is combined, more or less, morbid action of the stomach and bowels, which action appears an essential part of the malady, and is seldom absent.

This being the theory, the practice must be directed so to act on the circulation, that the blood may be attracted to the surface, the great internal vessels unloaded, and the heart enabled to act. Such efforts can only be produced by external remedies, since we possess no internal medicines which act primarily on the circulation. The one recommended is external warmth, by means of the hot wet-sheet. Of this he says :—

"The hot-wet-sheet, one of the most powerful instruments for imparting warmth that can be imagined, was frequently very successful in dispelling the collapse, and was so grateful to the patient, that they always spoke of it with thankful expressions. All the world knows that a sheet dipped in cold water and wrapped round the body soon causes great warmth; and this is even the case with a cholera patient, although his body may appear to have lost all power of generating heat; but the hot wet-sheet is better, as it brings at once the requisite warmth. The water, out of which the sheet is wrung, should be boiling, and therefore some implement for wringing it without scalding the hands is required. A strong piece of canvass, half a yard broad and rather more than one yard long, has, sewn across at each of its end, a strong staff, which projects at either side beyond the canvass. The sheet is placed in this, in a bucket, and boiling water poured on to saturation, then two persons turn the stick, one one way, one the other, till the canvass, being tightly twisted, squeezes the sheet sufficiently dry. The patient having been stripped, is now wrapped in this, laid on a bed or mattress, and covered closely with five or six thick blankets, and in this he is kept for one hour.

"One of the most marked effects of the hot-sheet is the disappearance of cramp. Patients will come suffering from these in a very distressful manner, and after having been in the sheet for ten minutes or a quarter of an hour, will be perfectly relieved; the body, which before was cold, will often come out glowing and red; the tongue, too, is often warmed. Now, during the application of this remedy, the face and tongue are the only means of judging if it be

as beneficial, as can be wished, since the hands and wrists are enclosed; the cheeks will sometimes be found to become warm in about a quarter of an hour, and the face loses its choleraic aspect in about half an hour; if these changes take place, and the tongue also become warm, we may be tolerably confident that the patient will live through the stage of collapse, and that time will be allowed for the application of other remedies,-always a great point gained. Another occasional consequence of this external warmth is the checking of the rice-water purging; true, I have never tried this remedy alone to the exclusion of internal ones, such as brandy and wine, and therefore it cannot be directly proved, that the wet sheet, and not the other means, stopped the intestinal action; but, as many patients have, after the application, never had another rice-water dejection, although before this, they occurred every ten or twenty minutes, and as in this time, he had only taken one dose of medicine, wine, or brandy, it seems fair to conclude that the external warmth, whose action is immediate, was the cause of this sudden check to the morbid action of the intestines, particularly as the same internal means had before been so eminently unsuccessful, while warmth to the surface was neglected. One of the worst cases of collapse I ever saw, with constant purging, was also a case of the most rapid recovery, and the patient never had a drop of medicine of any description while in the hospital. The patient seemed afterwards to look upon that hour on the sheet with a mystic veneration, as though there were something magical in the whole performance."-Pp. 111-114.

The purging should be checked by the means appropriate for choleraic diarrhoea, by mustard poultices on the abdomen, starch and opium enemata of very small bulk, but when it continues, and is accompanied by vomiting and thirst, he recommends that large quantities of water should not be allowed :—

"Everything he drinks should be cold, iced, and in the smallest quantities at a time. Two table-spoonfuls of iced water at a time, is enough for ten minutes, and then another such quantity, or rather a fragment of clear ice, about as big as a hazel-nut, may be given, and in two minutes more another such piece; when the patient, as he soon will do, finds the value of pursuing this plan, that thereby he is not made sick, and that his thirst is much better relieved, he will be content to continue the same method of his own accord. Thus he may have a teaspoonful of brandy, and half a wine-glassful of soda-water every five or ten minutes, or, which is sometimes useful, ten minims of laudanum in the same quantity of soda-water, either with or without brandy, as best may suit the stomach. Hydrocyanic acid is not generally of much benefit in this form of vomiting; but still should be tried with small quantities of soda-water; and creasote generally fails. Combined with the plan of management, however, a pill of four grains of calomel, or of the chalk and mercury, with one grain of opium, often appears beneficial; but, after all, the sheet anchor is the internal cold, the small, but frequently renewed blocks of ice, and the very sinall bulk of all ingesta. The great benefit derived from internal cold in this complaint, is, indeed, what we should expect, if we admit that it is this congested condition of the internal parts which is, in a great measure, the originator of the stomacho-intestinal disturbance, when ice, applied as directly as possible to the viscera, would be just the best adapted remedy for that particular state.

"There is, however, a mode of using the mineral acids, which often has a marked effect in checking both the purging and the vomiting, whether chiefly by their constringent or by their antiseptic qualities cannot be determined, though both have probably their share in the result. This acid is a mixture of the strong nitric and hydrochloric acids, three drachms of the former to five of the latter. On mixing, a quantity of chlorine is set free, and detained in the fluid, and it may be partially to this chlorine that the medicine owes its

efficacy. The dose is eight minims, and it is given with one drachm of syrup of poppies, and with one ounce of water. This medicine is to be administered as soon as the patient is wrapped in the wet sheet, and continued every hour. It often has the effect, combined with the management above described, of checking the vomiting and purging, and even where the absence of algide symptoms rendered the use of the hot sheet unnecessary, this acid was often found to be thus beneficial, and was often given to the exclusion of all other medicines whatever. Great dependence, therefore, may be placed on this combination for subduing the vomiting, if it be administered early enough in the disease, and it has the same effect upon the purging, five doses being sometimes sufficient to put an entire stop to both symptoms. When all these remedies, and the management of the iced and cold drinks fail, as they sometimes will, the vomiting runs on to another, and even more distressing, stage, which will be hereafter shortly described. One circumstance should not, however, go unnoticed, viz., the desirability, when opium in the solid form is to be administered, of giving, not the soap and opium, but simply crude opium, since the soap certainly appears to induce vomiting in this particularly irritable state of the stomach. And here it may be advisable to say a few words with regard to the use and abuse of opium in this disease. As a remedy for choleraic diarrhoea this medicine, combined with stimulating astringents, is, as has been said, extremely useful, when given in moderation; but it is vain, and indeed injurious, to attempt to cut short the disease entirely by its means; there is, in the collapsed state, and in the subsequent stages of cholera, a tendency to apathy and to heavy sleep, almost amounting to stupor, which this remedy only increases, and it, moreover, when given in excess, masks the nervous symptoms and perplexes the treatment. In the collapsed stage of cholera, while the patient is actually cold, almost pulseless, and when one sound of the heart is already lost, the medicine can only be hurtful; and, as far as my experience goes, does not subdue cramp, even when given in quantities sufficient to produce most decided and injurious effects on the nervous system. One patient, a captain of a small trader, had taken, I believe, from the medicine chest of his vessel, so large a quantity of opium, that it was impossible to say whether he died of the remedy or the disease, and yet, for the short time during which he lived under our observation, cramps in the calf of the legs were continual, the only sign of suffering being referable to that cause.

"After the collapse has entirely subsided, a small dose of opium, in the solid form and crude, has sometimes, however, a beneficial effect in checking the remaining disposition to vomit and to purging, and in subduing a restless state of the patient, which is occasionally present, and during which he often rolls himself about, throws off the bedclothes, and exposes his body to the cold air, which has, as before said, a most injurious effect. Laudanum is also useful in the same way, but more so as a remedy for purging than for vomiting, since a pill is often retained and allowed to act when fluids are rejected; it should be given in a small quantity of soda-water, if there be vomiting, and if, as is sometimes the case, it excite this action, either solid opium may be substituted, or another remedy tried. The drug, however, can only be recommended in a few instances, when the collapse, passing away, leaves the patient fretful and restless, but without the pulse becoming hard, or the skin hot, and when there is no fulness of head."-Pp. 119-24.

Should the patient struggle through the algide stage, then reaction occurs and the febrile stage commences. If he pass urine within thirty-six hours after the disappearance of the algide symptoms, recovery from the consecutive fever is, according to the experience of the author, shortly established. But if the secretion be absent for

three days, recovery will be longer; and if four days go by, there is great reason to dread a fatal termination. Indeed no patient can

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1854.] DR TOOGOOD'S REMINISCENCES OF A MEDICAL LIFE. sympbe considered safe until he have passed urine. Again, if within the sixth day after the entire disappearance of collapse, the febrile toms do not begin somewhat to abate, or if the oppression and lowness of spirits become greater and the pulse weaker, the probability is that the patient sinks into a far worse state by gradual and slow degrees; this constitutes, according to the author, choleraiç typhus, and closely resembles ordinary typhus with brain congestion, and its treatment is the same. Wines, light nourishment, leeches to the head, in to the shaven scalp, effervescing saline draughts, and small doses of chloride of potass.

The chapter on the morbid anatomy of cholera, translated from the paper of Messrs Reinhardt and Leubeuscher, is the best account of it yet published.

We shall not venture to criticise either the theory or the practice of our author. The former must be allowed to be plausible, and the latter as good as any yet brought forward. Experience alone can decide on its merits. Hence we have contented ourselves with giving an analysis of this, the most recent book on cholera, and have allowed Dr Barwell to speak, to a considerable extent, for himself.

Reminiscences of a Medical Life, with Cases and Practical Illustrations. By JONATHAN TOOGOOD, L.R.C.P.L. Taunton, 1853. IT is a common belief that medical men write books at one or other of two epochs in their history. The young doctor writes from the fulness of his faith and love of medicine, and in the fulness of his leisure. The old doctor takes up the pen under similar motives, but his faith in medicine is purified from much dross, and is fortified by having had many storms and struggles to encounter; his leisure also is the otium cum dignitate. The book before us is by an old and accomplished practitioner, whose enthusiasm for his art has certainly never been surpassed, and whose interest in practice has in no way been abated by increasing years. It should be read by professional men as the history of a long journey, presenting numerous incidents, marvellous or instructive, with general reflections by the pilgrim during his progress.

Our author, in introducing his reminiscences to us very properly says, that he is not about to repine-quite the reverse. He has had his share of hardships and trials, involving the sacrifice sometimes of time, health, and convenience; but he gratefully adds,

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"I am thankful to enjoy good health, after forty years most laborious country practice, and gratefully acknowledge that my profession has enabled me to educate, and establish in respectable positions in life, eight sons, and that it has introduced me to a large circle of acquaintances, and secured many valued friends."-P. vi.

Dr Johnson characterises the work of our profession as a "me